Respiratory support of adults in the emergency department: A protocol for a prospective, observational, multicenter point prevalence study

Background and AimsProviding respiratory support (RS) to patients may improve their oxygenation and ventilation, reducing the work of breathing. Emergency department (ED) patients often need RS;COVID-19 has heightened this need. Patients receiving RS may need escalation of their treatment;hence, studies considering the prevalence of escalation are warranted. MethodThis is a protocol for a prospective, observational, multicenter point prevalence study (PPS). Researchers will collect data over 2 days. All participants are adult ED patients needing RS. The setting is four EDs in New Zealand. The primary research question asks, "Which patients receiving RS require escalation of therapy in the ED?" For example, transitioning from conventional oxygen therapy (COT) to intubation is deemed an escalation of therapy. A sample size of 80 participants is required to resolve the primary research question. Secondary research questions: (1) Which patients receive nasal high flow (NHF) in the ED? (2) How is NHF therapy delivered in the ED? (3) What are the effects of NHF therapy on physiological and patient-centered outcomes? Research Electronic Data Capture (REDCap) will be used for data organization. Data will be imported for analysis from REDCap to IBM SPSS software (Statistics for Windows, Version 27.0). Data reporting on the primary outcome shall be considered by analysis of variance, regression modeling, and determination of two treatment effects: Odds Ratio and Number Needed to Treat. Statistical significance for inferential statistics shall use a two-sided alpha with p-values fixed at <= 0.05 level of significance and 95% confidence intervals. This protocol has ethical approval from Massey University, New Zealand. ConclusionThis novel PPS may reduce the evidence and clinical practice gap on RS delivery and ED patient outcomes, as evidenced by the emergence of COVID-19.

Poisoning-related Pediatric Emergency Department Visits During the COVID-19 Pandemic at Three Mid-atlantic Hospitals

Background: The COVID-19 pandemic restructured daily life for children and adolescents in the United States and may have altered injury risk patterns. Studies exploring a possible increase in pediatric poisoning events are equivocal, with some indicating increased calls to poison control centers but no increased pediatric emergency visits for poisoning. This study aimed to i) compare the proportion of Emergency Department (ED) visits related to poisoning for pediatric patients before and during the COVID-19 pandemic, and ii) describe the acuity and patient characteristics associated with these visits. Methods: This is a repeated cross-sectional study of ED health records for patients 0 to 18 years of age at three hospitals in the mid-Atlantic region from 2018 through 2020. Poisoning-related visits were identified through International Classification of Disease (ICD-10) code or chief complaint. Relevant ICD-10 codes included T36-50 “Poisoning by, adverse effect of and underdosing of drugs, medicaments and biological substances,” T51-65 “Toxic effect of substances chiefly nonmedical as to source,” and F10-19 “Mental and behavioral disorders due to psychoactive substance use.” Poisoning-related keywords in the chief complaint included “Poison/Poisoning,” “Ingestion,” “Overdose” and “Toxin.” These identifiers do not distinguish between intentional and unintentional poisonings. Patient demographic characteristics (age, sex, race, ethnicity), illness acuity, and disposition were reported. Data were analyzed using descriptive statistics and logistic regression on the odds of poisoning-related ED visits compared to ED visits for other reasons. Results: Of 147,736 total ED visits over the three-year study period, 2,478 (1.68%) were related to poisoning. There was a higher proportion of poisoning-related ED visits in 2020 (2.07% [721/34,835], 95%CI 1.92%-2.22%) compared to 2019 (1.49% [845/56,814], 95%CI 1.39%-1.59%) or 2018 (1.63% [912/56,087], 95% CI 1.52%-1.73%). The most common substances referenced in poisoning-related codes included cannabis (12.2%), non-opioid analgesics (7.7%), and alcohol (6.9%). The odds of poisoning-related ED visits increased for each increase in acuity along a 5-point scale (adjusted OR 2.18, 95%CI 1.90 - 2.50). The odds of poisoningrelated ED visits increased in 2020 compared to 2018 (OR 1.28, 95%CI 1.16 - 1.41) and to 2019 (OR 1.40, 95%CI 2.53 - 2.79), but results did not persist when adjusted for acuity and demographic characteristics. Teenagers and females displayed higher odds of poisoning-related ED visits (Table 1). Median acuity differed by year according to the Kruskal-Wallis test (X2(2) = 35, p<0.001). Post-hoc Dunn testing revealed median acuity differed in 2020 compared to 2018 (p<0.0001) or 2019 (p<0.0001), which suggests increased acuity of poison-related visits over time (Figure 1). Conclusion: Poisoning-related ED visits represented a higher proportion of total ED visits in 2020 compared to prior years;this was likely driven by the higher acuity of poisoning-related visits. Public health interventions should be targeted to decrease the frequency and acuity of pediatric poisoning events. Proportion of ED visits with a Triage Acuity Score of 1-2 for poisoning-related ED visits compared to ED visits for other reasons from 2018-2020. The number of poisoning-related ED visits with an acuity score of 1 or 2 was 432, 422, and 450 in 2018, 2019, and 2020, respectively. The number of other ED visits with an acuity score of 1 or 2 was 8,882, 9,489, and 6,656 in 2018, 2019, and 2020, respectively.

The Role of the Teacher as Assessor: Developing Student Teachers' Assessment Identity

The closure of schools across the globe due to the Covid-19 pandemic had the potential to have a catastrophic impact on a fundamental pillar of initial teacher education: school placement. This paper maps a new “site” of professional practice for “school placement” called “Teacher Online Programme” (TOP) using Xu and Brown's (2016) conceptual framework of teacher assessment literacy in practice. Its main focus lies in the integration of the assessment baseline knowledge into the programme under the seven elements proposed by the framework. A case study methodology informed the approach taken. Data was collected and analysed in three phases: the Teaching Online Programme Year 3 (TOP3) initiative;Student-teacher and Tutor Questionnaires and Student-teacher and Tutor focus group interviews. The findings highlight the complex and multifaceted process of building teacher assessment identity which nests in the larger purposes for education. They encourage an emergentist and collaborative approach to assessment knowledge and view working in communities of practice as a threshold for creativity and innovation. © 2021 Social Science Press. All rights reserved.

An Outbreak of Coronavirus Disease, 2019 (COVID-19) in a Skilled Nursing Facility - California, 2021: Description, Mitigation, Challenges, and Opportunities

Background. Skilled nursing facility (SNF) residents comprised 11% of all COVID-19 cases in the United States;however, they account for 43% of deaths with case fatality rates (CFR) of 26.0-33.7%. Methods. We report an outbreak of COVID-19, from June 15 to July 21, 2020 in a 159-bed SNF with a staff of 172 that resulted in an infection rate of 97% in residents and 23% in HCWs (Figure 1). A retroactive review outlined mitigation efforts, discussed challenges, identified risk factors among residents and health care workers (HCW) for acquisition of COVID-19, and reviewed opportunities for improvement (Figure 2). Results. Factors that contributed to the outbreak: delay in test results had an impact on cohorting;suboptimal adherence to the principles of infection prevention and control (IPC) and minimal adherence monitoring;strict criteria were used to screen for infection;the underappreciated transmissibility of COVID-19 from presymptomatic and asymptomatic persons;symptomatic HCWs who continued to work;the changing guidance on, the suboptimal use of, and an inadequate supply of personal protective equipment;poor indoor air quality due to ventilation challenges;and the important role of community/family/interfacility spread on the outbreak. Whole genome sequencing, performed in 52 samples, identified a common strain that was also found in clusters of 2 other facilities: 1 in the same geographic location, the other in a different geographic location but whose HCWs had the same zip codes as the facility (Figure 3). Certified nursing and restorative nursing assistants had the highest risk of infection with an odds ratio (OR) of 4.02 (confidence interval 1.29-12.55, p value: 0.02) when compared to registered and licensed vocational nurses. The residents' CFR was 24%. The OR for death was increased by 10.5 (10.20-11.00) for every decade of life as was morbid obesity (BMI > 35) with an OR of 8.50. BMI as a continuous variable increased risk of mortality for every additional unit, OR 1.07 (Tables 1, 2). Conclusion. While implementation of optimal IPC measures in the pre-COVID-19 vaccination era had no impact on the infections in residents who were likely already infected or exposed at the onset of the outbreak, these measures along with non-pharmacologic strategies were effective in halting the spread among HCWs.

Coronavirus Disease, 2019 (COVID-19) in Long-Term Care Facilities (LTCF): One Large County's Response, California 2020-2021

Background. The coronavirus-19 disease (COVID-19) outbreak has had a particularly devasting effect on skilled nursing facility (SNF) residents and healthcare workers (HCWs). While representing only 11% of COVID-19 cases, the residents accounted for 43% of deaths in the United States. Methods. We report a retrospective review of the support provided by our local health department (LHD) to long-term care facilities in response to the COVID-19 pandemic. This group comprised of staff from healthcare-associated infections (HAI);the Medical Operations Center (MOC);Testing, Tracing, and Treatment (T3);and the Healthcare Provider Status Taskforce (Table 1 outlines their functions). The HAI team with the State Public Health Department provided infection prevention and control (IPC) outbreak investigation, education, recommendations, and ongoing access to technical assistance. The T3 team focused on rapid response testing and tracing;the HPSTF team collected data and issued questionnaires;the MOC responded to staffing and PPE requests;and the Long-Term Care Facility sector presented routine telebriefings to update the facilities on public health guidance, share resources, and answer questions during and in between briefings. Table 1. Sectors and Function of Response Teams to COVID-19 Results. From March 2020 through May 2021, there were 504 outbreaks in LTCFs;the HAI team performed 281 outbreak investigations (Figure 1). In the same period, 308,264 molecular tests were performed using various platforms;laboratory services were outsourced during peak testing requests (Figure 2);"strike teams were deployed to facilitate testing on 404 occasions. Self-reported fully vaccination rate for SNF staff was 73% (March 2021) and 76% for residents (April 2021). There were 568 staff requested;total orders for PPE were 4,839 and 16,892,823 PPE items were fulfilled (Figure 3). In addition to knowledge gaps in IPC, other challenges included shifting IPC guidance, PPE shortages, timeliness of test results that impacted cohorting, community acquisition of disease with transmission to residents, interfacility spread among staff, staffing shortages, and vaccine hesitancy issues. Figure 1. Number of Outbreaks and Number of Outbreak Investigations Figure 2. Number of Tests Performed by the Public Health Laboratory and the Number of Visits by "Strike Teams" Figure 3. Personal Protective Equipment Fulfillment during COVID-19 Pandemic Conclusion. The management of the recent COVID-19 outbreaks required a multi-pronged approach. Lessons learned are applicable to other highly transmissible infectious diseases.

Canadian physician perspectives on the inclusion of pregnant women in trials of intervention for COVID-19

Objectives: Excluding pregnant persons from COVID-19 trials of intervention may lead to unintended harmful consequences. Beliefs and attitudes of clinicians have the potential to shape clinical research involving pregnant women. This study evaluates the current perspectives of Canadian physicians on the participation of pregnant women in COVID-19 clinical trials. Methods: An anonymous 22-item online questionnaire was sent to Canadian physicians belonging to four Canadian professional associations. Physicians were surveyed regarding the inclusion of pregnant women in COVID-19 trials using a semi-quantitative approach with multiple choice and open-ended questions. Descriptive statistics were performed. Themes from free-text answers were extracted using a semi-inductive approach. Results: 202 physicians agreed to participate, 168 of which completed the survey. The majority of respondents expressed support for including pregnant women in COVID-19 trials (119/165;72%), especially those investigating therapies with a prior safety record in pregnancy (139/164;85%). In addition, 66% (107/161) of physicians responded that including pregnant women in COVID-19 trials was urgent. The main barriers to including pregnant women in COVID-19 trials were perceived unwillingness of pregnant patients to take part in clinical trials, perceived unwillingness of treating teams to offer participation, burden of regulatory approval, and a general ‘culture of exclusion’ of pregnant women from clinical trials. Conclusions: Most physicians surveyed were supportive of the inclusion of pregnant women in COVID-19 trials of intervention. Importantly, we describe why some physicians may be reluctant to include pregnant women in clinical trials and identify important barriers to be addressed for the appropriate participation of pregnant women in clinical research.

Improving vitamin D content in pork meat by UV bio-enrichment

Given the marked variation in seasonally-induced cutaneous synthesis, habitually low dietary vitamin D intakes (2–4μg/day) and the generally low uptake of supplementation at the population level, identification of alternative food-based strategies are urgently warranted. Bio-enrichment is a growing area of research, with particular interest in the use of fortified animal feed and/or UV exposure to naturally increase vitamin D content in meat(2). Since meat contributes the highest percentage to total vitamin D intake(3), enriched pork meat may offer a plausible vehicle for bio-enrichment. In Study 1, UVB exposure significantly increased serum 25(OH)D3 concentrations in the pigs (mid and endpoint, p < 0.05) but did not alter total vitamin D activity, vitamin D3 nor 25(OH)D3 concentration in pork meat compared to control (p > 0.05).

COVID-19 vaccine hesitancy among rheumatology patients receiving influenza vaccine

Background: Adults with rheumatic diseases are a COVID-19 vulnerable population with potential increased risk for severe infection. COVID-19 vaccines are a key strategy to ending the pandemic. Unfortunately, fears about vaccines, some of which are propagated by misinformation, are common and may prevent or inappropriately delay vaccination. Refusal or uncertainty to get a vaccine despite its availability is known as vaccine hesitancy. Objectives: This study aims at defining causes of COVID-19 vaccine hesitancy among rheumatology patients. Methods: Between November and December 2020, a cross-sectional survey was completed by rheumatology patients presenting to a large Canadian tertiary-care center for influenza immunization. COVID-19 risk factors, previous COVID-19 infection, the likelihood of getting a future COVID-19 vaccine (scale 0-10), and contextual, individual, and vaccine-specific potential determinants of vaccine hesitancy were assessed. Patients were classified into 5 groups based on how likely they were to get a future COVID-19 vaccine (0= not likely at all;2.5= unlikely;5= intermediate;7.5= likely;10= highly likely). A machine learning approach (XgBoost) was used to fit univariate models for a multi-class correlation. Results: 157 rheumatology patients completed the survey. Most were females (n=112, 71%) with a mean age of 54.6 (standard deviation 17.9). The majority (73%) had tertiary-education, and 46% were employed at the time of the survey. The most common rheumatology diagnoses were rheumatoid arthritis (n=90, 58%), systemic lupus erythematosus/vasculitis (n=41, 26%) and spondyloarthropathies (n=39, 25%). Most patients were on immunosuppressors (n=93, 59%). Only half (n=85, 54%) were highly likely to accept a future COVID vaccine, 17% (n=26) likely, 19% (n=30) intermediate, 6% (n=10) unlikely, and 4% (n=6) not likely at all. One hundred thirty-five patients (86%) previously received the flu vaccine, whereas 6% (n=10) previously rejected it. Only three patients were previously diagnosed with COVID-19 (2%) one of whom was hospitalized. Eighty-seven patients (56%) considered that the COVID-19 vaccine should be mandatory, and 101 (65%) that they should receive it. Most respondents were somewhat concerned about receiving a future COVID-19 vaccine (n=116, 76%) despite that 65% believed that vaccines benefits outweighed their risks. Almost all, (n=145, 96%) believed that governmental decisions about vaccines are in the best interest of the population, while less than half (n=70, 45%) were confident that pharmaceutical companies would provide safe and effective vaccines. One hundred participants (65%) denied feeling social pressure to get the vaccine, and 55% (n=81) were willing to pay for the vaccine. Feeling social pressure about getting a COVID-19 vaccine, having severe concerns about receiving a future COVID-19 vaccine, distrust in pharmaceutical companies, lower education, and doubts of whether vaccines benefits outweigh their risks, were negatively associated with COVID vaccine acceptance. Conclusion: Forty six percent of rheumatology patients being immunized against influenza showed at least some hesitancy towards COVID-19 vaccination. Multiple contextual, individual, and vaccine-related factors may contribute. Targeted educational strategies, including producing and communicating data on vaccine safety, may help promote vaccine uptake in this potentially vulnerable population.

Vitamin D bio-enrichment of pork may offer a food-based strategy to increase vitamin D intakes in the UK population

Hypovitaminosis D is prevalent worldwide, with many failing to achieve the recommended nutrient intake (RNI) for vitamin D (10- 20μg/d)(1). Moreover, the COVID-19 pandemic has re-emphasised the need to avoid vitamin D deficiency to help maintain immune function(2) and the urgent need for food-based strategies to help address this(3). The aims of the current study were to 1) determine any changes to vitamin D intake and status over a 9-year period, and 2) apply dietary modelling to predict the impact of vitamin D bio-enrichment of pork and pork products on population intakes in the UK. Data from the National Diet and Nutrition Survey (NDNS) Rolling Programme Year 1-9 (2008/09-2016/17) were analysed using SPSS to determine nationally representative mean vitamin D intakes and 25(OH)D concentrations [a robust biomarker of vitamin D status]. Subgroup analysis investigating variance in sex, age and season was conducted. Informed by previous studies(4), four theoretical dietary modelling scenarios of vitamin D pork bio-enrichment were analysed (vitamin D content + 50/100/150/200% vs standard). Vitamin D intake in the UK population has not changed significantly from 2008 to 2017 yet, over the same period significant gender difference (M 2.66 ± 1.99μg/d and F 2.30 ± 1.66μg/d, p < 0.05) and seasonal variation in the mean 25(OH)D concentrations were evident. In 2016/17, across all age groups, 13.2% were considered insufficient (25(OH)D <25nmol/L). Across the whole group, theoretical modelling demonstrated an increase of 4.9, 10.1, 15.0 and 19.8% in daily vitamin D intake when vitamin D concentrations in bio-enriched pork were elevated by 50, 100, 150 and 200%, respectively. Based on the 200% modelling scenario, a greater relative change was observed in males (22.6%) compared to females (17.8%), and although older adults (65+ years) had significantly greater vitamin D intakes compared to other age categories (3.28 ± 2.27μg/day), this age group observed the smallest relative increase from the dietary modelling scenarios (14.3%). The greatest relative change was observed amongst 11-18-year olds, where 200% vitamin D bio- enrichment of pork and pork products would result in a 25.2% increase in mean daily vitamin D intakes. Vitamin D intakes have remained stable in the UK across almost a decade, and current results confirm that strategies are required to help the population achieve the RNI for vitamin D. These findings align with Irish data and provides incentive to pursue bio-enrichment practices. Specifically, bio-enrichment of pork meat provides a proof of concept, demonstrating that animal-based strategies may offer an important contribution to help to improve the vitamin D intakes of the UK population, particularly adolescents.