A Bleak Future Awaits Nurses in Traditional Employment Worldwide: Insights on Practice and Career Alternatives

The COVID-19 pandemic has tested world leaders' capacity to manage, and they have been found wanting. Traditional, institutionalised health services will shortly be unsustainable due to unconvincing leadership and inept managerial capacity to identify and alleviate risks to nurses and other workers on the pandemic front line. The aim of this paper is to share insights on nursing career and practice options to provide nursing services to our communities;and canvass anticipated resistance to nurses choosing autonomous practice models in independent business approaches to health care provision. From analysis of the evidence and literature, it was found that the systematic ill treatment and mismanagement of nurses during the COVID-19 pandemic is appalling. Nurses are exiting hospitals and health systems across the globe. Some are leaving nursing itself. On any measure, the situation is a wholesale disaster and a wanton waste of skilled and dedicated people. When hospital and health systems become too toxic for nurses and nursing services to function fully and thrive, and when government officials and politicians trivialise and disrespect the work and value of nursing, it is time for nurses to consider other employment and practice model options. In conclusion, A groundswell of support is needed for nurses to remove normalised policies that bind them to medical control, and to break medical monopoly on universal health insurance funding to permit access by nurses to sufficient specified items to earn a wage as independent practitioners. The implications for nursing and health policy makers are: nurse safety and practice integrity need to be central to policy deliberations that affect spending on risk management and reduction. Policies that put nurses and patients at increased risk encourage those with a choice, to abandon unsafe health system employment. Administrative accountability for staff and patient safety affected by their decisions has long been neglected in health systems around the world. It is time for a reckoning. © 2023, Thailand Nursing and Midwifery Council. All rights reserved.

Neutralising antibody potency against SARS-CoV-2 wild-type and Omicron BA.1 and BA.4/5 variants in infliximab and vedolizumab treated patients with Inflammatory Bowel Disease after three doses of COVID-19 vaccine: A prospective multicentre cohort study

Background: Anti-tumour necrosis factor drugs such as infliximab are associated with attenuated antibody responses after COVID-19 vaccination It is unknown how infliximab impacts vaccine-induced serological responses against highly transmissible Omicron variants, which possess the ability to evade host immunity and are now the dominating variants causing current waves of infection Methods: In this prospective, multicentre, observational cohort study we investigated neutralising antibody responses against SARS-CoV-2 wild-type and Omicron BA.1 and BA.4/5 variants after three doses of COVID-19 vaccination in 1288 patients with IBD without prior COVID-19 infection, who were established on either infliximab (n=871) or vedolizumab (n=417). Cox proportional hazards models were constructed to investigate the risk of breakthrough infection in relation to neutralising antibody titres Results: Following three doses of COVID-19 vaccine, neutralising titre NT50 (half-inhibitory neutralising titre) was significantly diminished in patients treated with infliximab as compared to patients treated with vedolizumab, against wild-type, BA.1 and BA.4/5 variants (Fig 1). Patients with Crohn's disease showed lower antibody NT50 compared to patients with ulcerative colitis against wild-type strain and BA.4/5 (Fig 2). Older age and thiopurine were independently associated with lower NT50 against wild-type strain and BA.4/5 (Fig 2). Non-white ethnicity was associated with higher NT50 compared to white ethnicity against wild-type strain, BA.1 and BA.4/5 (Fig 2). Breakthrough infection was significantly more frequent in patients treated with infliximab compared to patients treated with vedolizumab (Fig 3). Cox proportional hazards models of time to breakthrough infection after the third dose showed infliximab treatment to be associated with a higher hazard risk (HR) of 1.71 (95% CI [1.08 to 2.71], p=0.022) compared to vedolizumab (Fig 4). Higher neutralising antibody titres against BA.4/5 were associated with a lower hazard risk and a longer time to breakthrough infection (HR 0.87 [0.79 to 0.95] p=0.0028) (Fig 4) Conclusion(s): Following a third COVID-19 vaccine dose, patients established on infliximab treatment have significantly lower neutralising titres against SARS-CoV-2, which were especially low against Omicron variants. Increased breakthrough infection in infliximab recipients was associated with lower neutralising antibody titres against BA.4/5. These data underline the importance of continued COVID-19 vaccination programs, including second-generation bivalent vaccines, especially in patient subgroups where vaccine immunogenicity and efficacy may be reduced.

Debt at a distance: Counter-collection strategies and financial subjectivities of China's working-class defaulters during COVID-19

This paper undertakes an analysis of publicly posted videos sharing debtors' strategies for responding to overzealous credit collection agencies during the earliest stages of the pandemic lockdown. It examines how Chinese debtors and credit collection callers responded to the uncertainties surrounding the handling of personal debts when the debtors' economic activities are heavily restricted. Both parties invoked different imagined collectivities to establish their own moral justifications with regards to debt obligations, state regulations and family values. The paper argues for a recognition of the capacity of debt to collectivize people through loose discursive formations that remoralize debt, recasting the defaulter status as morally acceptable and reshaping their defaulter identities. The imaginative and discursive space built upon debt's collectivizing potential presents a valuable analytical tool for understanding the social dimensions of debt and the dynamic emerging of financial subjectivities in the contemporary era. © 2023 Informa UK Limited, trading as Taylor & Francis Group.

Effectiveness of face mask mandates in 4 suburban US communities during the SARS-CoV2 Omicron surge

Objectives: To evaluate the effectiveness of face mask mandates in four suburban communities in the metropolitan Boston area during the SARS-CoV2 Omicron surge. Background(s): Face mask mandates have been implemented by local, state and national governments to limit the transmission of illness during the SARS-CoV2 pandemic. Method(s): A retrospective review of state reported, PCR positive cases of SARS-CoV2 and vaccination rates in four communities during the Omicron surge from 01/11/21- 01/31/22. Data was analyzed using descriptive statistics. Result(s): Two communities had a face mask mandate in place for all indoor public spaces throughout the study period, and two communities did not. Brookline (population 59,180, fully vaccinated rate per capita 62%) and Newton (population 88,593, vaccination rate 87%) implemented face mask mandates prior to the surge on 08/27/21 and 09/02/21, respectively, that remained in place through 02/18/22. Needham (population 31,248, vaccination rate 93%) and Framingham (population 72,308, vaccination rate 76%) issued mask recommendations but not a mask mandate. SARS-CoV2 percent positive rate per 100,000 population, reported weekly for each community is shown in Figure 1. Prior to Omicron, on 10/14/21 percent positive rates were 1% or less in all four communities. Percent positivity at the peak of Omicron was lower in Newton (13.18%) and Brookline (12.28%) than in Needham (14.92%) and Framingham (22.38%). Brookline had the lowest peak positivity rate and the lowest vaccination rate. Percent positivity also peaked and declined earlier in both communities with mask mandates. Conclusion(s): In this study, suburban communities with mask mandates had a lower SARS-CoV2 peak percent positivity rate and an earlier peak than communities without mask mandates. Face mask requirements in indoor public spaces may reduce transmission of SARS-CoV2 during variant surges, and may be particularly effective in communities with lower vaccination rates. (Figure Presented) .

Farm sector financial ratios: pre-COVID forecasts and pandemic performance for 2020

This study compares 2020 values for farm sector financial ratios before and after the onset of the Coronavirus (COVID-19) pandemic. Forecasts from the February 5, 2020, release of the USDA Economic Research Service's Farm Income and Wealth Statistics data product represent the pre-pandemic (before) forecasts. Those forecast values are compared to the data released on February 4, 2022, which represent the realized values for 2020 and include pandemic impacts on commodity demand and the policy response to the economic shock. Solvency ratios (which are indicators of the sector's ability to repay financial liabilities via the sale of assets) worsened in 2020 relative to pre-pandemic expectations. Efficiency ratios (which evaluate the conversion of assets into production and revenue) and liquidity ratios (which are indicators of the availability of cash to cover debt payments) showed mixed outcomes for the realized results in 2020 relative to the pre-pandemic forecasts. Four profitability ratios were stronger in 2020 relative to pre-pandemic expectations. All solvency, liquidity, and profitability ratios plus 2 out of 5 efficiency ratios for 2020 were weaker than their respective average ratios obtained from 2000 to 2019 data.

A novel, patient-focused approach to home sample collection improves rate of return & sample quality and enables research to continue during the covid-19 pandemic

Background: Successful continuation of research involving blood sample collection during the covid-19 pandemic is particularly challenging due to restrictions on visits to clinic and limited research staff capacity. C-peptide measurement from capillary (finger-prick) samples has been robustly validated. Aim: To increase the rate of return and viability of home finger-prick samples in a prospective multicentre study by combining a more patient-centred approach with improved sampling method. Methods: Original procedure for home sampling involved data collection by telephone followed by independent participant collection of finger-prick samples onto a blood spot card. Following poor rate of return and of successful sample collection, an adapted protocol & novel sampling method were introduced. The improved approach involved the pre-booking of an appointment for both data and sample collection, so that the researcher could support sample collection, and used a blood spot stick (Mitra® VAMS® absorptive device) to enable more user-friendly sampling. We assessed rate of sample return and viability for participants first remote capillary sample collection. Results: 282 participants were followed up using the original method, 173/282 (61%(95% confidence interval 55-67%) samples returned and 112/173 (65%(57-72%) were viable. 115 participants have been followed up using the improved approach, 97 (84%(76-90%) samples returned and 93 (96%(90-99%) were viable for analysis. Summary: A more patient-focused approach with improved method of sample collection was associated with dramatically increased sample rate of return and viability. This novel approach may aid other projects where samples have the stability for home collection.

eP236: TeleKidSeq: Incorporating telehealth into clinical care of children from diverse backgrounds undergoing clinical genome sequencing

Introduction: The global pandemic required healthcare institutions and clinical research programs to adapt quickly to non-traditional care models. TeleKidSeq is a pilot study that emerged from the NYCKidSeq program, an NIH-funded Clinical Sequencing Evidence-Generating (CSER) Consortium site focused on incorporating genomic medicine into the care of diverse New York City children with suspected genetic disorders. Embracing the opportunity to study the use of telehealth in delivering genomic results, TeleKidSeq will examine the impact of innovative remote genetic counseling modalities in medically underserved populations. Studies focusing on the use of telehealth performed before the COVID-19 pandemic have shown that patients prefer in-person visits to virtual visits;however, with the increased familiarity and widespread use of virtual platforms, we anticipate an increase in the preference for telehealth visits. TeleKidSeq aims to fill the gaps in current knowledge on the impact of visual aids in telehealth in diverse urban patient populations. Methods: TeleKidSeq will recruit 496 pediatric participants (aged 0-21 years) with neurologic, immunologic, or cardiac conditions suspected to have an underlying genetic cause who receive care predominantly within two large health systems in the New York metropolitan area. The Mount Sinai Genomics Stakeholder Board, consisting of diverse stakeholders and key community advisors, provided guidance about our study design and materials. Participants will be English- or Spanish-speaking, and based on prior enrollment data from NYCKidSeq study, we expect more than 65% will be from populations underrepresented in medical research. Prior to enrollment, participants will be randomized to receive their genomic results from a genetic counselor via telehealth either with screen sharing (ScrS) or without screen sharing (NScrS). All participants will receive genome sequencing (GS) from a clinically validated laboratory. Additionally, we will use GUÍA, a web-based application designed to enhance the delivery of genomic test results, in both the ScrC and NScrS arms to facilitate delivery of individualized genomic results and clinical information in a personalized, highly visual, and narrative manner. Surveys administered at baseline, after results disclosure, and 6-months post-results disclosure will be used to evaluate study outcomes. The primary outcome of the TeleKidSeq study will be participants’ perceived understanding of their GS results with a comparison between the results disclosed via videoconferencing with ScrS and NScrS arms. Secondary outcomes will include: objective understanding of GS results;understanding of medical follow-up recommendations and the actionability of genome sequencing results;adherence to medical follow-up recommendations made based on genomic results;and satisfaction with and ease of use of the telehealth experience, compared across the two arms. Diagnostic yield, clinical utility and cost of GS will also be assessed. Results: Not applicable. Conclusion: Overall, the TeleKidSeq pilot study will contribute to innovations in communicating genomic test results to diverse populations through telehealth technology. In conjunction with NYCKidSeq, this work will inform best practices for the implementation of genomic medicine in diverse, English- and Spanish-speaking populations.

Antibody decay, T cell immunity and breakthrough infections following SARS-CoV-2 vaccination in infliximab- and vedolizumab-treated patients

Background: Antibody responses following SARS-CoV-2 infection or a single-dose of SARS-CoV-2 vaccine are impaired in patients with inflammatory bowel disease treated with anti-TNF compared to those treated with vedolizumab, a gut-selective anti-integrin α4β7 monoclonal antibody. Here we sought to determine if patients treated with infliximab have attenuated serological and T cell responses and an increased risk of breakthrough COVID-19 infection following primary SARS-CoV-2 vaccination. Methods: Anti-spike (S) receptor binding domain (RBD) antibody concentration in 2306 infliximab-treated patients were compared to a cohort of 1045 vedolizumab-treated patients. Our primary outcome was anti-S RBD antibodies 2 to 10 weeks after a second dose of the BNT162b2 or ChAdOx1 nCoV-19 vaccines. Secondary outcomes were anti-spike T cell responses, durability of vaccine responses and risk of breakthrough infections following two doses of vaccine. Results: Anti-S RBD antibody concentrations were lower in patients treated with infliximab than in those treated with vedolizumab, following a second dose of BNT162b2 (567.3 U/mL [6.1] vs 4601.1 U/ mL [5.3], p <0.0001) and ChAdOx1 nCoV-19 (183.9 U/mL [5.0] vs 789.4 U/mL [3.5], p <0.0001) vaccines (Fig. 1). Vaccination with the BNT162b2 vaccine compared to the ChAdOx1 nCoV-19 was independently associated with a 3.7-fold [95% CI 3.30 - 4.13] higher anti-S RBD antibody concentration (p < 0.0001) (Fig. 2). There were no significant differences in the magnitude of anti-spike T cell responses observed in infliximab- compared with vedolizumabtreated patients after one or two doses of either vaccine. Antibody half-life was shorter in infliximab- than vedolizumabtreated patients following two-doses of BNT162b2 (4.0 weeks [95% CI 3.8 - 4.1] vs 7.2 weeks [95% CI 6.8 - 7.6]) and ChAdOx1 nCoV- 19 (5.3 weeks [95% CI 5.1 - 5.5] vs 9.3 weeks [95% CI 8.5 - 10.2], p value < 0.0001). Breakthrough SARS-CoV-2 infections were more frequent (5.8% (202/3467) vs 3.9% (66/1691), p = 0.0032) and the time to breakthrough shorter in patients treated with infliximab than vedolizumab (p = 0.0023) (Fig. 3). Higher anti-S RBD antibody concentrations following a second dose of SARS-CoV-2 vaccine protected against breakthrough SARS-CoV-2 infection: overall, for every 10-fold rise in anti-S RBD antibody level we observed a 0.8-fold reduction in odds of breakthrough infection ([95% CI 0.70 - 0.99], p = 0.035). Conclusion: Infliximab was associated with attenuated, less durable vaccine induced anti-S RBD antibody responses and a 50% increase in breakthrough SARS-CoV-2 infection. Further follow-up is required to assess whether third primary doses can mitigate the effects of infliximab on anti-S RBD antibody responses.

Online Testing with Blackboard: Lessons Learned (Perspectives from Three Engineering Faculty)

During the past year, faculty managing concerns with COVID-19 have turned to online exams to assist with summative assessment in their courses. As usual, there are benefits to using online exams in Learning Management Systems (LMS) and, of course, there are other aspects of testing in an LMS that could be done much better to suit our individual needs. In this paper, we discuss some of the types of questions that we use in Blackboard Exams and some of the computer tools that we use to create them. We discuss some of the successes as well as some tricks of the trade that we use to address our objectives. Finally, we discuss some additional tools that we use to mitigate cheating. This paper covers subjects such as: 1) Different types of Blackboard questions a. Calculated Formula b. Multiple Choice c. Fill in the Blank d. Fill in Multiple Blanks 2) Software tools to help write questions (e.g.) a. Mathematica b. Excel c. Visio 3) Handling multi-part questions 4) Mitigating cheating using software. © American Society for Engineering Education, 2021

PATIENT-LED REMOTE INTRACAPILLARY PHARMACOKINETIC SAMPLING (FINGERPRICKS): VALIDATION AND ACCEPTABILITY FOR HOME THERAPEUTIC DRUG MONITORING IN PATIENTS WITH IBD IN THE COVID-19 PANDEMIC

Background During the first wave of the coronavirus (COVID-19) pandemic, restrictive public health measures including prolonged shielding, were recommended by the United Kingdom government for many patients with immune-mediated inflammatory disorders treated with immunosuppressive and biologic drugs. Low-volume intracapillary blood sampling can be undertaken by patients at home and returned by post and may ensure access to therapeutic drug monitoring (TDM) for all patients irrespective of shielding status. Methods We undertook a cross-sectional blood sampling methods comparison study to assess the clinical validity and acceptability to patients of low volume intracapillary testing for serum TDM enzyme-linked immunosorbent assays (ELISA) compared to conventional venepuncture. Sample types were compared using linear regression and fit-for-purpose equivalence was defined using total allowable error (TEa) rates derived using interassay coefficient of variations from routine clinical practice. Acceptability was assessed using a purpose-designed questionnaire. Results The median (IQR) volume of serum obtained using intracapillary sampling was 195μL (130 - 210). We showed drug level equivalence (slope [95% CI]: TEa vs observed mean % difference) between intracapillary sampling and conventional venepuncture for adalimumab (1.02 [0.90 - 1.14]: 11.7% vs 2.1%) (Figure 1), infliximab (1.08 [0.98 - 1.18]: 18.3% vs 1.2%), vedolizumab (0.91 [0.85 - 0.96]: 17.6% vs 4.1%), and ustekinumab (0.92 [0.90 - 0.94]: 19.4% vs 3.3%). Anti-drug antibody equivalence was observed for antiadalimumab (0.96 [0.95 - 0.98]: 24.5% vs 2.1%) and anti-infliximab (0.89 [0.81 - 0.97]: 17.3% vs 1.3%) antibody levels. Most patients reported that intracapillary testing was easy, convenient, and that they preferred it to conventional venepuncture (Figure 2). Conclusions Low-volume intracapillary blood sampling was equivalent to conventional venepuncture for the measurement of biologic drug and anti-drug antibodies. Patients preferred intra-capillary testing to conventional venepuncture. Irrespective of future COVID-19 surges, patient-led intracapillary blood sampling is likely to become a key adjunct to telemedicine in patients with immune-mediated inflammatory diseases.(Figure Presented) Adalimumab drug Linear regression and Bland Altman plot Left: Linear regression analysis of venous vs capillary adalimumab drug level results (mg/L), Slope 1.02 [0.90 - 1.14]. Right: Bland Altman plot of mean of venous and capillary adalimumab drug measurement against percentage difference between TEa vs observed mean % difference.(Figure Presented) Figure 2: Questionnaire acceptability response data Patient acceptability questionnaire response results by 5-point Likert scale. (A) Itemised proportional responses, grouped by domain. (B) Cumulative agreement per respondent;+1/+2 points for agree/strongly agree, 0 for neither agree nor disagree, -1/-2 for disagree/strongly disagree. Lowest decile reflecting participants with lowest acceptability scores indicated.