Virtual First Uses Virtual Emergency Medicine Clinicians as a Health System Entry Point: A Cross-Sectional Survey Study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic accelerated utilization and acceptance of telemedicine. Simultaneously, Emergency Departments (ED) have experienced significantly increased ED boarding. With this acceptance of telemedicine and the weighty increase in patient boarding we proposed an innovative Virtual First (VF) program to leverage Emergency Medicine Clinicians' (EMCs) ability to triage patients. VF seeks to reduce unnecessary ED visits by connecting patients with EMCs prior to seeking in-person care rather than utilizing traditional ED referral systems. OBJECTIVE: The goal of this study is to investigate how patients' access to EMCs from home via the establishment of VF changed how patients seek care for acute care needs. METHODS: VF is a synchronous virtual video visit stationed at a tertiary care academic hospital. VF was staffed by EMCs and enabled full management of patient complaints, or if necessary, referral to a primary care physician (PCP), urgent care center (UCC), or ED. Patients self-selected this service as an alternative to seeking in-person care at PCP, UCC or ED. A post-visit convenience sample survey was collected through phone text message or email to VF users. This is a cross- sectional survey study. Primary outcome measure is based on responses to the question, "How would you have sought care if a VF visit was not available to you?" Secondary outcome measures describe valued aspects and criticisms from their visit. Results were analyzed using descriptive statistics. RESULTS: There were 3097 patients seen via VF from July 2021 through May 2022. 176 of 3097 (5.7%) completed the survey. 87 of 176 (49.4%) would have sought care at UCCs if VF had not been available. Twenty-eight (15.9%), twenty-six (14.8%), and one (0.6%) would have sought care at PCPs, EDs, or other locations, respectively. Interestingly, 34 of 176 (19.3%) of patients would not have sought care. The most valued aspects of VF were receiving care in the comfort of home (137 of 176; 77.8%), availability of appointments (105 of 176; 59.6%), not waiting in a lobby (100 of 176; 56.8%), and decreased infectious exposure (89 of 176; 50.6%). For suggested improvements to VF, 58 of 176 (33.0%) patients free-texted "Nothing", 47 (26.7%) suggested connectivity improvements, 23 (13.1%) wanted the ability to have lab work or imaging ordered, 14 (8.0%) had to seek medical care after the VF visit , and desired having a doctor perform a physical exam (5.7%). CONCLUSIONS: VF has potential to restructure how patients seek medical care by connecting EMCs with patients prior to ED arrival. Without the option of VF, 64.2% of patients would have sought care at an acute care facility. VF's innovative employment of EMCs allows for acute care needs to be treated virtually if feasible. If not, EMCs understand the local resources to better direct patients to the appropriate site. This has potential to substantially decrease patient costs because patients are given the appropriate destination for in-person care, reducing the likelihood of the need for transfer and multiple ED visits.

tRNA abundance, modification and fragmentation in nasopharyngeal swabs as biomarkers for COVID-19 severity.

Emerging and re-emerging respiratory viruses can spread rapidly and cause pandemics as demonstrated by the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The early human immune responses to respiratory viruses are in the nasal cavity and nasopharyngeal regions. Defining biomarkers of disease trajectory at the time of a positive diagnostic test would be an important tool to facilitate decisions such as initiation of antiviral treatment. We hypothesize that nasopharyngeal tRNA profiles could be used to predict Coronavirus Disease 19 (COVID-19) severity. We carried out multiplex small RNA sequencing (MSR-seq) on residual nasopharyngeal swabs to measure simultaneously full-length tRNA abundance, tRNA modifications, and tRNA fragmentation for the human tRNA response to SARS-CoV-2 infection. We identified distinct tRNA signatures associated with mild symptoms versus severe COVID-19 manifestations requiring hospitalization. These results highlight the utility of host tRNA properties as biomarkers for the clinical outcome of SARS-CoV-2.

Profiling Selective Packaging of Host RNA and Viral RNA Modification in SARS-CoV-2 Viral Preparations.

Viruses package host RNAs in their virions which are associated with a range of functions in the viral life cycle. Previous transcriptomic profiling of host RNA packaging mostly focused on retroviruses. Which host RNAs are packaged in other viruses at the transcriptome level has not been thoroughly examined. Here we perform proof-of-concept studies using both small RNA and large RNA sequencing of six different SARS-CoV-2 viral isolates grown on VeroE6 cells to profile host RNAs present in cell free viral preparations and to explore SARS-CoV-2 genomic RNA modifications. We find selective enrichment of specific host transfer RNAs (tRNAs), tRNA fragments and signal recognition particle (SRP) RNA in SARS-CoV-2 viral preparations. Different viral preparations contain the same set of host RNAs, suggesting a common mechanism of packaging. We estimate that a single SARS-CoV-2 particle likely contains up to one SRP RNA and four tRNA molecules. We identify tRNA modification differences between the tRNAs present in viral preparations and those in the uninfected VeroE6 host cells. Furthermore, we find uncharacterized candidate modifications in the SARS-CoV-2 genomic RNA. Our results reveal an under-studied aspect of viral-host interactions that may be explored for viral therapeutics.