Researching COVID to enhance recovery (RECOVER) adult study protocol: Rationale, objectives and design (preprint)

Importance: SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. Methods: RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged [≥]18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. Discussion: RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.

Three Missed Critical Nursing Care Processes on Labor and Delivery Units During the COVID-19 Pandemic.

OBJECTIVE: To examine the relationships of three missed critical nursing care processes on labor and delivery units with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic in the United States. DESIGN: A cross-sectional survey. SETTING: Online distribution from January 14 to February 26, 2021. PARTICIPANTS: A national convenience sample (N = 836) of registered nurses employed on labor and delivery units. METHODS: We conducted descriptive analyses on respondent characteristics and critical missed care items adapted from the Perinatal Missed Care Survey. We conducted robust logistic regression analyses to assess the relationships of three missed critical nursing care processes (surveillance of fetal well-being, excessive uterine activity, and development of new maternal complications) with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic. RESULTS: Less nursing time at the bedside was associated with greater odds of missing any of the critical aspects of care, adjusted odds ratio = 1.77, 95% confidence interval [1.12, 2.80]. Adequate staffing greater than or equal to 75% of the time was associated with lower odds of missing any of the critical aspects of care compared to adequate staffing less than or equal to 50% of the time, adjusted odds ratio = 0.54, 95% confidence interval [0.36, 0.79]. CONCLUSION: Perinatal outcomes are dependent on the timely recognition of and response to abnormal maternal and fetal conditions during childbirth. In times of unexpected complexity in care and resource constraints, a focus on three critical aspects of perinatal nursing care is needed to maintain patient safety. Strategies that enable bedside presence of nurses, including maintaining adequate unit staffing, may help to mitigate missed care.

Challenges, Job Satisfiers, and Self-Care among Perinatal Nurses in the United States during the COVID-19 Pandemic.

PURPOSE: To explore the perceived challenges, job satisfiers, and self-care of perinatal nurses in the United States during the COVID-19 pandemic. STUDY DESIGN AND METHODS: In May of 2021, a cross-sectional survey was distributed online to members of the Association of Women's Health, Obstetric, and Neonatal Nurses and the National Association of Neonatal Nurses. We calculated descriptive statistics on respondent characteristics and applied conventional content analysis to free-text comments. RESULTS: Perinatal nurses ( N = 297) responded to three open-ended questions on their perceived challenges, job satisfiers, and self-care. Frequently reported challenges included changing guidelines and policies ( n = 101, 34%), personal protective equipment as a barrier ( n = 73, 24.6%), and visitor restrictions ( n = 64, 21.5%). Frequently reported job satisfiers were provision of high-quality care ( n = 137, 46.1%) and visitor restrictions ( n = 77, 25.9%). Respondents reported using mental ( n = 152, 51.2%) and physical ( n = 145, 48.8%) self-care strategies and 12.8% ( n = 38) reported using no self-care strategies. CLINICAL IMPLICATIONS: The ability to provide high-quality care was reported as a leading job satisfier. Poor communication of consistent, evidence-based guidelines, lack of personal protective equipment, and inadequate unit staffing were leading challenges. Visitor restrictions were a challenge and a job satisfier, suggesting opportunities to better include visitors as support people. Most respondents reported engaging in one or more types of self-care outside of the hospital setting. Future research is needed to examine strategies for self-care among perinatal nurses when at work in the hospital setting.

Enumeration of Public Health Nurses in the United States: Limits of Current Standards.

Recent national initiatives in nursing and public health have emphasized the need for a robust public health nursing (PHN) workforce. In this article, we analyze the extent to which recent national enumeration surveys base their counts of this workforce on the definitions, scope, and standards for practice and practice competencies of the PHN nursing specialty. By and large, enumeration surveys continue to rely on practice setting to define the PHN workforce, which is an insufficient approach for meeting the goals of major nursing and public health initiatives. We make recommendations for the development of new standards for PHN enumeration to strengthen the broader public health infrastructure and evaluate PHN contributions to population-level outcomes. (Am J Public Health. 2022;112(S3):S292-S297. https://doi.org/10.2105/AJPH.2022.306782).

Professional Quality of Life and Intention to Stay Among Perinatal Registered Nurses During the COVID-19 Pandemic...Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Convention, 25-29 June, 2022, Aurora, Colorado

The article offers information about the professional quality of life and intention to stay among perinatal registered nurses during the Covid-19 pandemic. It mentions that registered nurses make up the largest component of the health care workforce in the U.S., along with mentions that as direct patient care providers, they are affected by the Covid-19 pandemic.

Missed Critical Nursing Care Processes on Labor and Delivery Units During the COVID-19 Pandemic...Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Convention, 25-29 June, 2022, Aurora, Colorado

The article offers information about the missed critical nursing care processes on labor and delivery units during the Covid-19 pandemic. It mentions that study examined the rates of three critical nursing care processes on labor and delivery units and assessed the relationship with reports of reduced nursing time at the bedside and frequency of unit staffing adequacy during the Covid-19 pandemic in the U.S.

Alternatives to Opioids in the Emergency Department: The Henry Ford Health System Experience

Study Objectives: The aim of our Alternatives to Opiates (ALTO) program was to decrease opioid administration, measured in morphine milliequivalents (MME) per patient encounter, in all Henry Ford Health System (HFHS) emergency departments (EDs) by 15% in the 1-year period after program implementation as compared to the 3-year MME per patient encounter baseline prior to implementation. To our knowledge, this is the largest evaluation of an ALTO protocol completed. Methods: A multi-disciplinary group of ED providers, pharmacists, and nursing developed an ALTO program for HFHS using existing best practices and publications for implementation at all 9 HFHS EDs. This included 5 hospitals and 4 free-standing EDs, which see approximately 450,000 patient visits annually in total. Henry Ford Hospital (HFH) ED, a 100,000 annual patient visit quaternary care center, was amongst the 9 EDs included. After finalization of a protocol, we implemented an ALTO “Quicklist,” an organized section of non- opiate pain medications for indicated conditions, into our electronic medical record (EMR, Figure 1). Prior to implementation of our ALTO program in November 2019, we provided education surrounding the new tools and protocols to EM providers and nursing staff in different forums including staff meetings, grand rounds, nursing huddles and also email. Feedback was provided to all departments via system meetings and email communication at 4-month and 8-month intervals post-program kick off to monitor progress. A list of all opioids on HFHS pharmaceutical formularies was reviewed and a standard conversion factor to MME was applied to calculate a total number of MME administered per patient encounter (Figure 2). Only opiate medications administered in the ED were included. MME per patient encounter were compared in two groups: pre-intervention (November 2016 through October 2019;n=1, 317, 466) to the 1-year period post implementation (December 2019 through November 2020;n=366, 404). MME per patient encounter were compared for these time periods across HFHS EDs and for each department and the percentage change was calculated. Results: Opiate administration decreased across the entire HFHS from 2.76 MME per patient encounter to 2.62 MME per patient encounter, a 5.1% decrease overall. Only one of 9 EDs did not see any decrease. The other 8 EDs ranged from 0.5% to 29.4% decrease. Sub-analysis showed opiate administration at the HFH ED decreased from 4.60 MME per patient encounter to 4.28 MME per patient encounter, a 6.8% decrease. Conclusions: The HFHS ALTO program decreased opiate administration across the entire system, however, the goal of a 15% reduction in opiate administration was not met. The COVID-19 pandemic likely confounded these results with an increase in acuity and length of boarding in the ED juxtaposed against a decrease in patient volume seen across the country. Additionally, opiate administration was not stratified among discharged, admitted and intubated patients. Continued ALTO program education is ongoing as is further study with more nuanced data analysis, including specific ALTO medication utilization and provider level data. Other departments in the system, such as observation and surgical specialties, have expressed interest in developing similar protocols and QuickLists. [Formula presented] [Formula presented]

Roles and Experiences of Registered Nurses on Labor and Delivery Units in the United States During the COVID-19 Pandemic.

OBJECTIVE: To examine the roles and experiences of labor and delivery (LD) nurses during the COVID-19 pandemic. DESIGN: Cross-sectional survey. SETTING: Online distribution between the beginning of July and end of August 2020. PARTICIPANTS: LD nurses (N = 757) responded to an open-ended question about changes to their roles during the COVID-19 pandemic as part of a larger national survey. METHODS: We calculated descriptive statistics on respondents' characteristics and their hospitals' characteristics. We applied conventional content analysis to free-text comments. RESULTS: We derived four major categories from the responses: Changes in Roles and Responsibilities, Adaptations to Changes, Psychological Changes, and Perceived Effects on LaborSupport. Nearly half (n = 328) of respondents reported changes in their roles and responsibilities during the COVID-19 pandemic. They described adaptations and responses to these changes and perceived effects on patient care. Infection control policies and practices as well as the stress of a rapidly changing work environment affected the provision of labor support and personal well-being. CONCLUSION: The experiences described by respondents conveyed considerable changes in their roles and subsequent direct and indirect effects on quality of patient care and personal well-being. Policies and practices that can facilitate the ability of LD nurses to safely and securely remain at the bedside and provide high-touch, hands-on labor support are needed. The findings of our study can help facilitate the provision of labor support during times of disruption and foster the resiliency of the nursing workforce.

Machine learning application for the prediction of SARS-CoV-2 infection using blood tests and chest radiograph.

Triaging and prioritising patients for RT-PCR test had been essential in the management of COVID-19 in resource-scarce countries. In this study, we applied machine learning (ML) to the task of detection of SARS-CoV-2 infection using basic laboratory markers. We performed the statistical analysis and trained an ML model on a retrospective cohort of 5148 patients from 24 hospitals in Hong Kong to classify COVID-19 and other aetiology of pneumonia. We validated the model on three temporal validation sets from different waves of infection in Hong Kong. For predicting SARS-CoV-2 infection, the ML model achieved high AUCs and specificity but low sensitivity in all three validation sets (AUC: 89.9-95.8%; Sensitivity: 55.5-77.8%; Specificity: 91.5-98.3%). When used in adjunction with radiologist interpretations of chest radiographs, the sensitivity was over 90% while keeping moderate specificity. Our study showed that machine learning model based on readily available laboratory markers could achieve high accuracy in predicting SARS-CoV-2 infection.

Development of a simulation-based curriculum for paracentesis and thoracentesis

RATIONALE: Despite the decline in the number and variety of procedures performed by general internal medicine (IM) physicians, procedural training remains an integral part of IM residency training. With previous success in improving the education and comfort of central venous catheter (CVC) placement among graduating 3rd year IM residents due to the development of a robust simulation-based curriculum for CVC placement, we desired to also develop a similar curriculum for paracentesis and thoracentesis. The aim of this project was to develop a simulation-based curriculum for paracentesis and thoracentesis to adequately train residents to safely and independently perform these common bedside procedures. METHODS: Using the CVC simulation-based curriculum as a framework, review of simulation literature and local facility protocols, a comprehensive checklist, pre-learning document and instructional video were developed for each procedure. Each checklist included details for procedural planning (supplies, informed consent, imaging review, time out), sterile preparation and procedure steps. The checklists were submitted to IM, Hepatology, and Pulmonary content experts for review. Residents were provided with the checklists, pre-learning documents and videos prior to a scheduled point-ofcare ultrasound (POCUS) workshop. Residents were also asked to complete pre-and post-workshop knowledge assessments. The workshop allowed for direct application of the checklists to safely complete each procedure in a simulation environment under the instruction of experienced physicians. RESULTS: Thirteen IM residents (9 PGY-1s, 3 PGY-2s, and 1 PGY-3) attended the POCUS workshop in March 2020. Prior to the workshop, residents self-reported, on average, 3.4 observed paracenteses with 1.6 performed and 2 observed thoracenteses with 0.33 performed. Ten residents completed a 12-question pre-workshop knowledge assessment with an average score of 50.8%. Twelve residents completed the same assessment after the workshop, and the average score improved to 68.2%. Resident perceived skill rating in using ultrasound and in performing bedside paracentesis and thoracentesis improved after the workshop (Table 1). Due to COVID-19, the workshop scheduled for May 2020 was cancelled and transitioned to a virtual platform which limited further data collection. CONCLUSIONS: Structured, simulation-based procedural education that teaches best practice and allows for deliberate practice and feedback has consistently been shown to improve the procedural skills of trainees. After completion of the paracentesis and thoracentesis workshop, residents demonstrated improvement in procedure knowledge, ultrasound use, and procedural skills, and we believe that our structured curriculum will provide residents with the necessary framework to perform these procedures safely at the bedside.

Different approaches to encode and model 3D information in a MIA-QSAR perspective

Tridimensional information is a fundamental aspect for modelling and explaining biological/physicochemical properties. In this sense, the goal of this study was to explore different approaches for encoding this type of information into MIA-QSAR (Multivariate Image Analysis applied to Quantitative Structure-Activity Relationships) descriptors and to effectively model these new features. Originally, MIA-QSAR is a technique based on the treatment of 2D images of molecules. The approaches explored in this work were: (I) the use of 2D image projections of computationally optimized molecular geometries as a source of 3D information for a powerful machine learning method (support vector machine applied to regression);(II) the use of slice images obtained from the optimized molecules placed inside a theoretical box as a source of 3D descriptors for a multi-way regression method (trilinear PLS);and (III) the use of images viewed from different faces of the above box as an alternative source of 3D MIA-QSAR descriptors. These strategies were applied in three different data sets comprising anti-HCV, anti-SARS-CoV, and anti-HIV compounds. Satisfactory parameters for both internal and external validation were achieved in all three models, and the statistical results of correlation were at least similar to those earlier reported for these series of compounds. Nevertheless, the risk of chance correlation could not be excluded as demonstrated by y-randomization tests. Whereas the traditional MIA-QSAR method, that uses perfectly congruent, non-optimized geometries of pharmacophoric substructures as images, is more efficient than 3D MIA-QSAR, the latter uses tridimensional digital objects as descriptors for the first time in QSAR for regression purposes.

COVID-19 vaccines for patients with cancer: benefits likely outweigh risks.

Less than a year since the start of the COVID-19 pandemic, ten vaccines against SARS-CoV-2 have been approved for at least limited use, with over sixty others in clinical trials. This swift achievement has generated excitement and arrives at a time of great need, as the number of COVID-19 cases worldwide continues to rapidly increase. Two vaccines are currently approved for full use, both built on mRNA and lipid nanotechnology platforms, a success story of mRNA technology 20 years in the making. For patients with cancer, questions arise around the safety and efficacy of these vaccines in the setting of immune alterations engendered by their malignancy and/or therapies. We summarize the current data on leading COVID-19 vaccine candidates and vaccination of patients undergoing immunomodulatory cancer treatments. Most current cancer therapeutics should not prevent the generation of protective immunity. We call for more research in this area and recommend that the majority of patients with cancer receive COVID vaccinations when possible.

Collection of lower respiratory specimen by bronchoscopy for the diagnosis of COVID-19.

Bronchoscopy, as an aerosol-generating procedure, is not routinely performed in patients with high-risk of coronavirus disease-2019 (COVID-19) owing to potential transmission to healthcare workers. However, to obtain lower respiratory specimens from bronchoscopy with bronchoalveolar lavage (BAL) is necessary to confirm COVID-19 or other diagnosis that will change clinical management. We report a case of diagnostic difficulty with five negative SARS-CoV-2 RT-PCR testing in four upper respiratory tract and one stool samples following presentation with fever during the quarantine period and a strong epidemiological linkage to an index patient with COVID-19. The final diagnosis was confirmed by BAL. Special precautions to be taken when performing bronchoscopy in high-risk non-intubated patients were discussed.

280 Boucebacks during the Covid-19 Pandemic

Study Objectives: During the pandemic, emergency clinicians balanced the growing crisis of limited hospital bed availability with the risks of sending sick patients home. We sought to measure the rates of return visits during the pandemic and assess patient characteristics associated with higher rates of return. Methods: Cohort study of patients evaluated at 9 EDs within an integrated health system between March 13 and May 20, 2020 with clinical suspicion for Covid-19. We excluded patients who neither had testing for SARS-CoV-2 nor were designated with isolation precautions for Covid-19. We identified and collected data through a central dashboard that was established within the EHR. We defined confirmed Covid-19 cases as those with a positive PCR for SARS-CoV-2 infection. All patients had a minimum follow-up period of 14 days. The primary outcome was a return visit over the first 14 days. The analysis consisted of descriptive statistics and a multivariable proportional hazards model that was limited to patients discharged home on their index visit to assess the association between confirmed Covid-19 and bounceback. Results: There were 13,367 ED patients with clinical suspicion of Covid-19, of whom 7289 (54.5%) were female, 5225 (39.1%) black, non-Hispanic, and the mean age was 55.7 ±19.9 years. There were 12859 (96.2%) patients tested with PCR for SARS-CoV-2, 508 (3.8%) isolated for Covid-19 but never tested, and 3760 (28.1%) with confirmed Covid-19. The number of patients hospitalized was 7724 (57.8%). Return visits among those that were not hospitalized occurred 436 (7.7%) times within 14 days from the initial encounter and 546 (9.7%) times within 30 days. The median time to a return visit was 7 [IQR 3, 17] days. Of patients with a return visit in 14-days, 207 (46.1%) were hospitalized on their second visit. Patients who were discharged home that had confirmed Covid-19 had a return rate of 20.0% vs. 3.7% among patients without confirmed Covid-19 (see Figure 1). In multivariable analysis, factors not associated with the primary outcome were race, pulse oximetry, and sex. Factors significantly associated with 14-day returns were age >60 years (HR 1.34, 95% CI 1.03 - 1.67), each 1-point increase in the Charlson comorbidity index (HR 1.13, 95% CI 1.03 - 1.17), and confirmed Covid-19 (HR 5.25, 95% CI 4.29 - 6.42). Conclusions: Admission rates were high in patients with suspected Covid-19, and return rates over 14 days were 7.7%. Patients with confirmed Covid-19 had a 5-fold greater hazard of a 14-day return compared to those without confirmed Covid-19. [Formula presented]

Conformational fingerprints in the modelling performance of MIA-QSAR: a case for SARS-CoV protease inhibitors.

Multivariate image analysis applied to quantitative structure-activity relationships (MIA-QSAR) has proved to be a high-performance 2D tool for drug design purposes. Nonetheless, MIA-QSAR strategy does not efficiently incorporate conformational information. Therefore, understanding the implications of including this type of data into the MIA-QSAR model, in terms of predictability and interpretability, seems a crucial task. Conformational information was included considering the optimised geometries and the docked structures of a series of disulfide compounds potentially useful as SARS-CoV protease inhibitors. The traditional analysis (based on flat-shape molecules) proved itself as the most effective technique, which means that, despite the undeniable importance of conformation for biomolecular behaviour, this type of information did not bring relevant contributions for MIA-QSAR modelling. Consequently, promising drug candidates were proposed on the basis of MIA-plot analyses, which account for PLS regression coefficients and variable importance in projection scores of the MIA-QSAR model.