A Simulation of the Effect of Interview Caps on the National Resident Matching Program Match in Otolaryngology.

Concerns regarding interview hoarding in the Match process have led to calls for a cap on the number of interviews an applicant can accept. However, no study has examined the effects of interview caps on applicants or a specialty. The authors created a simulation otolaryngology Match to analyze the effects of interview caps. The simulation included 120 residency programs, 360 positions, and 570 applicants (each assigned a competitiveness weighted value). Programs created interview lists (subject to 4 different interview cap conditions: no, 16, 12, and 8 cap) using weighted random selection and the competitiveness weighted values. Programs then selected 3 interviewees to fill their positions via weighted random selection using the competitiveness weighted values. Data analysis explored the effects of interview caps on individual applicants' probability of matching, the probability of matching with a certain number of interviews, and the average matched applicant competitiveness rank using one-way analysis of variance. The introduction of interview caps caused interviews to be distributed more equally among applicants. The 12-interview cap caused the applicants in the 100th competitiveness percentile to see their probability of matching fall from 99.3% to 67.2% ( P < .001). Applicants with ≥ 12 interviews had a probability of matching of 94.4% when there was no cap, compared to 76.9% with a 12-interview cap ( P < .001). The average competitiveness rank of matched applicants fell from 191 with no cap to 245 with a 12-interview cap ( P < .001). Interview caps in the otolaryngology Match may create major distortions in the probability of matching, leading to much lower chances of matching for more competitive applicants, lower probabilities of matching with certain numbers of interviews, and a decreased average competitiveness of matched applicants.

National Trends in Mental Health-Related Emergency Department Visits Among Youth, 2011-2020.

Importance: There has been increasing concern about the burden of mental health problems among youth, especially since the COVID-19 pandemic. Trends in mental health-related emergency department (ED) visits are an important indicator of unmet outpatient mental health needs. Objective: To estimate annual trends in mental health-related ED visits among US children, adolescents, and young adults between 2011 and 2020. Design, Setting, and Participants: Data from 2011 to 2020 in the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national probability sample survey of EDs, was used to examine mental health-related visits for youths aged 6 to 24 years (unweighted = 49 515). Main Outcomes and Measures: Mental health-related ED visits included visits associated with psychiatric or substance use disorders and were identified by International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) and ICD-10-CM (2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. We estimated the annual proportion of mental health-related pediatric ED visits from 2011 to 2020. Subgroup analyses were performed by demographics and broad psychiatric diagnoses. Multivariable-adjusted logistic regression analyses estimated factors independently associated with mental health-related ED visits controlling for period effects. Results: From 2011 to 2020, the weighted number of pediatric mental health-related visits increased from 4.8 million (7.7% of all pediatric ED visits) to 7.5 million (13.1% of all ED visits) with an average annual percent change of 8.0% (95% CI, 6.1%-10.1%; P < .001). Significant linearly increasing trends were seen among children, adolescents, and young adults, with the greatest increase among adolescents and across sex and race and ethnicity. While all types of mental health-related visits significantly increased, suicide-related visits demonstrated the greatest increase from 0.9% to 4.2% of all pediatric ED visits (average annual percent change, 23.1% [95% CI, 19.0%-27.5%]; P < .001). Conclusions and Relevance: Over the last 10 years, the proportion of pediatric ED visits for mental health reasons has approximately doubled, including a 5-fold increase in suicide-related visits. These findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people, especially for children experiencing suicidal symptoms.

COVID-19 Vaccine Acceptance and Uptake in Bangkok, Thailand: Cross-sectional Online Survey.

BACKGROUND: The third most severe COVID-19 wave in the middle of 2021 coincided with the dual challenges of limited vaccine supply and lagging acceptance in Bangkok, Thailand. Understanding of persistent vaccine hesitancy during the "608" campaign to vaccinate those aged over 60 years and 8 medical risk groups was needed. On-the-ground surveys place further demands on resources and are scale limited. We leveraged the University of Maryland COVID-19 Trends and Impact Survey (UMD-CTIS), a digital health survey conducted among daily Facebook user samples, to fill this need and inform regional vaccine rollout policy. OBJECTIVE: The aims of this study were to characterize COVID-19 vaccine hesitancy, frequent reasons for hesitancy, mitigating risk behaviors, and the most trusted sources of COVID-19 information through which to combat vaccine hesitancy in Bangkok, Thailand during the 608 vaccine campaign. METHODS: We analyzed 34,423 Bangkok UMD-CTIS responses between June and October 2021, coinciding with the third COVID-19 wave. Sampling consistency and representativeness of the UMD-CTIS respondents were evaluated by comparing distributions of demographics, 608 priority groups, and vaccine uptake over time with source population data. Estimates of vaccine hesitancy in Bangkok and 608 priority groups were tracked over time. Frequently cited hesitancy reasons and trusted information sources were identified according to the 608 group and degree of hesitancy. Kendall tau was used to test statistical associations between vaccine acceptance and vaccine hesitancy. RESULTS: The Bangkok UMD-CTIS respondents had similar demographics over weekly samples and compared to the Bangkok source population. Respondents self-reported fewer pre-existing health conditions compared to census data overall but had a similar prevalence of the important COVID-19 risk factor diabetes. UMD-CTIS vaccine uptake rose in parallel with national vaccination statistics, while vaccine hesitancy and degree of hesitancy declined (-7% hesitant per week). Concerns about vaccination side effects (2334/3883, 60.1%) and wanting to wait and see (2410/3883, 62.1%) were selected most frequently, while "not liking vaccines" (281/3883, 7.2%) and "religious objections" (52/3883, 1.3%) were selected least frequently. Greater vaccine acceptance was associated positively with wanting to "wait and see" and negatively with "don't believe I need (the vaccine)" (Kendall tau 0.21 and -0.22, respectively; adjusted P<.001). Scientists and health experts were most frequently cited as trusted COVID-19 information sources (13,600/14,033, 96.9%), even among vaccine hesitant respondents. CONCLUSIONS: Our findings provide policy and health experts with evidence that vaccine hesitancy was declining over the study timeframe. Hesitancy and trust analyses among the unvaccinated support Bangkok policy measures to address vaccine safety and efficacy concerns through health experts rather than government or religious officials. Large-scale surveys enabled by existing widespread digital networks offer an insightful minimal-infrastructure resource for informing region-specific health policy needs.

Using pulse oximeters in care homes for residents with COVID-19 and other conditions: A rapid mixed-methods evaluation

Background: There are over 15,000 care homes in England, with a total of approximately 450,000 beds. Most residents are older adults, some with dementia, and other residents are people of any age with physical or learning disabilities. Using pulse oximetry in care homes can help the monitoring and care of residents with COVID-19 and other conditions. Objectives: To explore the views of care home staff, and the NHS staff they interact with, with regard to using pulse oximetry with residents, as well as the NHS support provided for using pulse oximetry. Design: We carried out a rapid mixed-methods evaluation of care homes in England, comprising (1) scoping interviews with NHS leaders, care association directors and care home managers, engaging with relevant literature and co-designing the evaluation with a User Involvement Group;(2) an online survey of care homes;(3) interviews with care home managers and staff, and with NHS staff who support care homes, at six purposively selected sites;and (4) synthesis, reporting and dissemination. The study team undertook online meetings and a workshop to thematically synthesise findings, guided by a theoretical framework. Results: We obtained 232 survey responses from 15,362 care homes. Although this was a low (1.5%) response rate, it was expected given exceptional pressures on care home managers and staff at the time of the survey. We conducted 31 interviews at six case study sites. Pulse oximeters were used in many responding care homes before the pandemic and use of pulse oximeters widened during the pandemic. Pulse oximeters are reported by care home managers and staff to provide reassurance to residents and their families, as well as to staff. Using pulse oximeters was usually not challenging for staff and did not add to staff workload or stress levels. Additional support provided through the NHS COVID Oximetry @home programme was welcomed at the care homes receiving it;however, over half of survey respondents were unaware of the programme. In some cases, support from the NHS, including training, was sought but was not always available. Limitations: The survey response rate was low (1.5%) and so findings must be treated with caution. Fewer than the intended number of interviews were completed because of participant unavailability. Throughout the COVID-19 pandemic, care homes may have been asked to complete numerous other surveys etc., which may have contributed to these limitations. Owing to anonymity, the research team was unable to determine the range of survey respondents across location, financial budget or quality of care. Conclusions: Using pulse oximeters in care homes is considered by managers and staff to have been beneficial to care home residents. Ongoing training opportunities for care home staff in use of pulse oximeters would be beneficial. Escalation processes to and responses from NHS services could be more consistent, alongside promoting the NHS COVID Oximetry @home programme to care homes. Future research: Further research should include the experiences of care home residents and their families, as well as finding out more from an NHS perspective about interactions with care home staff. Research to investigate the cost-effectiveness of pulse oximetry in care homes, and of the NHS COVID Oximetry @home programme of support, would be desirable. © 2022 Sidhu et al.

Public health genomics capacity assessment: readiness for large-scale pathogen genomic surveillance in Canada's public health laboratories.

BACKGROUND: Along with rapid diagnostic testing, contact tracing, and public health measures, an effective pandemic response incorporates genomics-based surveillance. Large-scale SARS-CoV-2 genome sequencing is a crucial component of the global response to COVID-19. Characterizing the state of genomics readiness among Canada's public health laboratories was necessary to inform strategic planning and deployment of capacity-building resources in the early stages of the pandemic. METHODS: We used a qualitative study design and focus group discussions, encompassing both technical and leadership perspectives, to perform an in-depth evaluation of the state of pathogen genomics readiness in Canada. RESULTS: We found substantial diversity in the state of readiness for SARS-CoV-2 genomic surveillance across Canada. Despite this variability, we identified common barriers and needs in the areas of specimen access, data flow and sharing, computing infrastructure, and access to highly qualified bioinformatics personnel. CONCLUSIONS: These findings enable the strategic prioritization and deployment of resources to increase Canada's ability to perform effective public health genomic surveillance for COVID-19 and prepare for future emerging infectious diseases. They also provide a unique qualitative research model for use in capacity building.

Planning and Reporting Effective Web-Based RAND/UCLA Appropriateness Method Panels: Literature Review and Preliminary Recommendations.

BACKGROUND: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels. OBJECTIVE: The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices. METHODS: The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement. RESULTS: Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process). CONCLUSIONS: Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic.

Performance of the Sofia SARS-CoV-2 Rapid Antigen Test in Symptomatic and Asymptomatic Pediatric Patients.

The sensitivity and specificity of SARS-CoV-2 antigen tests have not been widely assessed in children. We evaluated children presenting to outpatient care with Quidel Sofia SARS-CoV-2 antigen test (Sofia-Ag-RDT) compared against Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV reverse transcriptase-polymerase chain reaction test from November 2020 to April 2021. Sofia-Ag-RDT had the highest sensitivity in symptomatic (82%; 95% confidence interval, 68%-91%) children.

Inaccuracies in electronic health records smoking data and a potential approach to address resulting underestimation in determining lung cancer screening eligibility.

OBJECTIVE: The US Preventive Services Task Force (USPSTF) requires the estimation of lifetime pack-years to determine lung cancer screening eligibility. Leading electronic health record (EHR) vendors calculate pack-years using only the most recently recorded smoking data. The objective was to characterize EHR smoking data issues and to propose an approach to addressing these issues using longitudinal smoking data. MATERIALS AND METHODS: In this cross-sectional study, we evaluated 16 874 current or former smokers who met USPSTF age criteria for screening (50-80 years old), had no prior lung cancer diagnosis, and were seen in 2020 at an academic health system using the Epic® EHR. We described and quantified issues in the smoking data. We then estimated how many additional potentially eligible patients could be identified using longitudinal data. The approach was verified through manual review of records from 100 subjects. RESULTS: Over 80% of evaluated records had inaccuracies, including missing packs-per-day or years-smoked (42.7%), outdated data (25.1%), missing years-quit (17.4%), and a recent change in packs-per-day resulting in inaccurate lifetime pack-years estimation (16.9%). Addressing these issues by using longitudinal data enabled the identification of 49.4% more patients potentially eligible for lung cancer screening (P < .001). DISCUSSION: Missing, outdated, and inaccurate smoking data in the EHR are important barriers to effective lung cancer screening. Data collection and analysis strategies that reflect changes in smoking habits over time could improve the identification of patients eligible for screening. CONCLUSION: The use of longitudinal EHR smoking data could improve lung cancer screening.

Use of At-Home COVID-19 Tests - United States, August 23, 2021-March 12, 2022.

COVID-19 testing provides information regarding exposure and transmission risks, guides preventative measures (e.g., if and when to start and end isolation and quarantine), identifies opportunities for appropriate treatments, and helps assess disease prevalence (1). At-home rapid COVID-19 antigen tests (at-home tests) are a convenient and accessible alternative to laboratory-based diagnostic nucleic acid amplification tests (NAATs) for SARS-CoV-2, the virus that causes COVID-19 (2-4). With the emergence of the SARS-CoV-2 B.1.617.2 (Delta) and B.1.1.529 (Omicron) variants in 2021, demand for at-home tests increased† (5). At-home tests are commonly used for school- or employer-mandated testing and for confirmation of SARS-CoV-2 infection in a COVID-19-like illness or following exposure (6). Mandated COVID-19 reporting requirements omit at-home tests, and there are no standard processes for test takers or manufacturers to share results with appropriate health officials (2). Therefore, with increased COVID-19 at-home test use, laboratory-based reporting systems might increasingly underreport the actual incidence of infection. Data from a cross-sectional, nonprobability-based online survey (August 23, 2021-March 12, 2022) of U.S. adults aged ≥18 years were used to estimate self-reported at-home test use over time, and by demographic characteristics, geography, symptoms/syndromes, and reasons for testing. From the Delta-predominant period (August 23-December 11, 2021) to the Omicron-predominant period (December 19, 2021-March 12, 2022)§ (7), at-home test use among respondents with self-reported COVID-19-like illness¶ more than tripled from 5.7% to 20.1%. The two most commonly reported reasons for testing among persons who used an at-home test were COVID-19 exposure (39.4%) and COVID-19-like symptoms (28.9%). At-home test use differed by race (e.g., self-identified as White [5.9%] versus self-identified as Black [2.8%]), age (adults aged 30-39 years [6.4%] versus adults aged ≥75 years [3.6%]), household income (>$150,000 [9.5%] versus $50,000-$74,999 [4.7%]), education (postgraduate degree [8.4%] versus high school or less [3.5%]), and geography (New England division [9.6%] versus West South Central division [3.7%]). COVID-19 testing, including at-home tests, along with prevention measures, such as quarantine and isolation when warranted, wearing a well-fitted mask when recommended after a positive test or known exposure, and staying up to date with vaccination,** can help reduce the spread of COVID-19. Further, providing reliable and low-cost or free at-home test kits to underserved populations with otherwise limited access to COVID-19 testing could assist with continued prevention efforts.

Global monitoring of the impact of the COVID-19 pandemic through online surveys sampled from the Facebook user base.

Simultaneously tracking the global impact of COVID-19 is challenging because of regional variation in resources and reporting. Leveraging self-reported survey outcomes via an existing international social media network has the potential to provide standardized data streams to support monitoring and decision-making worldwide, in real time, and with limited local resources. The University of Maryland Global COVID-19 Trends and Impact Survey (UMD-CTIS), in partnership with Facebook, has invited daily cross-sectional samples from the social media platform's active users to participate in the survey since its launch on April 23, 2020. We analyzed UMD-CTIS survey data through December 20, 2020, from 31,142,582 responses representing 114 countries/territories weighted for nonresponse and adjusted to basic demographics. We show consistent respondent demographics over time for many countries/territories. Machine Learning models trained on national and pooled global data verified known symptom indicators. COVID-like illness (CLI) signals were correlated with government benchmark data. Importantly, the best benchmarked UMD-CTIS signal uses a single survey item whereby respondents report on CLI in their local community. In regions with strained health infrastructure but active social media users, we show it is possible to define COVID-19 impact trajectories using a remote platform independent of local government resources. This syndromic surveillance public health tool is the largest global health survey to date and, with brief participant engagement, can provide meaningful, timely insights into the global COVID-19 pandemic at a local scale.

Syndromic Surveillance-Based Estimates of Vaccine Efficacy Against COVID-Like Illness from Emerging Omicron and COVID-19 Variants (preprint)

New infections from the omicron variant of SARS-CoV-2 have been increasing dramatically in South Africa since first identification in November 2021. Despite increasing uptake of COVID-19 vaccine, there are concerns vaccine protection against omicron may be reduced compared to other variants. We sought to characterize a surrogate measure of vaccine efficacy in Gauteng, South Africa by leveraging real-time syndromic surveillance data. The University of Maryland Global COVID Trends and Impact Survey (UMD-CTIS) is an online, cross-sectional survey conducted among users sampled from the Facebook active user base. We derived three COVID-like illness (CLI) definitions (stringent, classic, and broad) using combinations of self-reported symptoms (present or not in the prior 24 hours) that broadly tracked with reported COVID-19 cases during June 18, 2021 - December 14, 2021 (inclusive of the delta wave and up-trend of the omicron wave). We used syndromic-surveillance-based CLI prevalence measures among the vaccinated (PV) and unvaccinated (PU) respondents to estimate V ECLIP = 1 - (PV /PU), a proxy for vaccine efficacy, during the delta (June 18-July 18, N= 9,387 surveys) and omicron (December 4-14, N= 2,389 surveys) wave periods. We assume no waning immunity, CLI prevalence approximates incident infection with each variant, and vaccinated and unvaccinated survey respondents in the two variant wave periods are exchangeable. The vaccine appears to have consistently lower V ECLIP against omicron, compared to delta, regardless of the CLI definition used. Stringent CLI (i.e. anosmia plus fever, cough and/or myalgias) yielded a delta V ECLIP = 0.85 [0.54, 0.95] higher than omicron V ECLIP = 0.62 [0.46, 0.72]. Classic CLI (cough plus anosmia, fever, and/or myalgias) gave lower estimates (delta V ECLIP = 0.76 [0.54, 0.87], omicron V ECLIP = 0.51 [0.42, 0.59]), but omicron was still lower than delta. We acknowledge the potential for measurement, confounding, and selection bias, as well as limitations for generalizability for these self-reported, syndromic surveillance-based V ECLIP measures. Thus V ECLIP as estimates of true, population-level vaccine efficacy should therefore be taken with caution. Nevertheless, these preliminary findings demonstrating declining V ECLIP raise concern for a true decline in vaccine efficacy versus waning immunity as a potential contributor to the omicron variant taking hold in Gauteng and elsewhere.

Preferred method of two week post operative follow up after pelvic reconstructive surgery. (phone callversus clinic visit): A randomized clinical trial

Objective: There is no current standardization of when and how postoperative follow up visits are completed after pelvic reconstructive surgery. Telemedicine visits are favorable amongst patients and have been associated with increased patient satisfaction, less waiting time, and reduced travel costs. The COVID-19 pandemic highlighted the importance of telemedicine visits. Prior to the pandemic, we designed a Randomized Control Trial with primary aim to investigate if patient satisfaction with telephone visit was non-inferior to clinic visits post operatively at two weeks. Secondary aims were to investigate if the telehealth postoperative visit is a safe alternative to clinic visits. Methods: This was an IRB approved randomized controlled trial investigating patient satisfaction with the use of telephone visits for two week post surgery follow up. Inclusion criteria included women undergoing pelvic reconstructive surgery. Eligiblewomen were randomized to either a two-week postoperative telephone visit or two-week postoperative clinic visit. Primary outcome was satisfaction with two week postoperative visit as defined by answering 'strongly agree' on Likert scale. Sample sizes of 71 women in each group was needed in order to achieve an 80% power to detect a non-inferiority margin difference of 12% between groups. The clinic visits were completed by physicians and the telephone visits were completed by the clinic nurses with a scripted guideline for all patients including need for triage to clinic visits. Patients completed a non-validated patient satisfaction questionnaire and patient global impression of improvement at their six-week post op visit. Statistical analysis was performed using P-value for independent samples ttest/ Wilcoxon-Mann-Whitney for continuous variables or chi-square/Fisher's exact test for categorical variables to determine statistical significance. Results: A total of 67 patients were recruited between July 2018 to March 2020, 21 patients declined to participate. There were 36 patients in the clinic arm and 31 patients in the telephone arm. Due to the Covid-19 pandemic, most clinic postoperative visits were converted to telehealth visits and elective surgeries were cancelled. The study was halted in March 2020 and did not reach its prior power calculation of 71 per group. There was no difference seen in patient satisfaction with postoperative visits between the two groups. The results of the non-validated questionnaire showed that patients who had telephone visits were likely to be satisfied with telephone visits and would prefer telephone visits in the future when compared to those who had clinic visits. Conversely, patients who had clinic visits were likely to be satisfied with in person visits and were more likely to prefer those in the future. (P < 0.001, Table 2) For validated questionnaires such as PGI-I there was no difference between groups. For secondary outcomes there was no difference in emergency visits, hospital readmissions, or postoperative complications between the two groups. Clinic visits lasted longer than telephone visits (15 mins vs 6 mins, Table 3). Conclusions: Two week postoperative telephone visits were well received by patients, resulted in shorter visit length, had high patient satisfaction and PGI scores, and are a safe alternative to clinic visits with no difference in adverse outcomes. Given the recent pandemic, it is important that we continue to design future studies to evaluate telemedicine in patient care for FPMRS.

Dual Substance Use of Electronic Cigarettes and Alcohol.

Electronic cigarettes (ECs) are a modern nicotine delivery system that rapidly grew in widespread use, particularly in younger populations. Given the long history of the comorbidity of alcohol and nicotine use, the rising prevalence of ECs raises the question as to their role in the consumption of alcohol. Of the numerous models of ECs available, JUUL is the most popular. This narrative review aims to determine current trends in literature regarding the relationship between EC and alcohol dual use, as well as hypothesize potential pathogenic tissue damage and summarize areas for future study, including second-hand vapor exposure and calling for standardization among studies. In summary, EC users are more likely to participate in hazardous drinking and are at higher risk for alcohol use disorder (AUD). We surmise the pathogenic damage of dual use may exhibit an additive effect, particularly in pathogen clearance from the lungs, increased inflammation and decreased immune response, physical damage to epithelial cells, and exacerbation of chronic obstructive pulmonary disease (COPD)-like illnesses. A better understanding of pathogenic damages is critical to understand the risks placed on dual users when exposed to respiratory pathogens, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis.

Given perceived similarities between coronavirus disease 2019 pneumonia and the acute respiratory distress syndrome, we explored whether awake self-proning improved outcomes in coronavirus disease 2019-infected patients treated in a rural medical center with limited resources during a significant local coronavirus disease 2019 outbreak. DESIGN: Retrospective analysis of prospectively collected clinical data. SETTING: Single-center rural community-based medical center in Grand Island, NE. PATIENTS: One hundred five nonintubated, coronavirus disease-infected patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After patients were educated on the benefits of awake self-proning, compliance was voluntary. The primary outcome was need for intubation during the hospital stay; secondary outcomes included serial peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios, in-hospital mortality, and discharge disposition. Of 105 nonintubated, coronavirus disease-infected patients, 40 tolerated awake self-proning. Patients who were able to prone were younger and had lower disease severity. The risk of intubation was lower in proned patients after adjusting for disease severity using Sequential Organ Failure Assessment scores (adjusted hazard ratio, 0.30; 95% CI, 0.09-0.96; p = 0.043) or Acute Physiology and Chronic Health Evaluation II scores (adjusted hazard ratio, 0.30; 95% CI, 0.10-0.91; p = 0.034). No prone patient died compared with 24.6% of patients who were not prone (p < 0.001; number needed to treat = 5; 95% CI, 3-8). The probability of being discharged alive and peripheral capillary oxygen saturation measured by pulse oximetry to the Fio2 ratios were statistically similar for both groups. CONCLUSIONS: Awake self-proning was associated with lower mortality and intubation rates in coronavirus disease 2019-infected patients. Prone positioning appears to be a safe and inexpensive strategy to improve outcomes and spare limited resources. Prospective efforts are needed to better delineate the effect of awake proning on oxygenation and to improve patients' ability to tolerate this intervention.