Development, and evaluation of a handheld digital inspiratory airflow resistance monitor, to aid remote respiratory consultations in primary care, post the COVID19 pandemic

Respiratory medicinal therapies are most frequently delivered using inhalers. There are two types (MDI and DPI) which each have different characteristics and requirements. Even between brands of the same type, variations exist. This study developed a prototype handheld, digital device that can measure the inhalation airflow rate against resistance, alongside a value for the peak inspiratory airflow and breath-hold time. Allowing the assessment of inspiratory capacity, in a remote, post-COVID-19 environment. Currently, the Clement-Clarke InCheckTM device measures inspiratory effort. This device has an analogue scale and measures only peak inspiratory airflow. Therefore, MPXV7007 differential pressure sensor was used, as it can create a pressure differential that can then be related to airflow. The device was linked via blue tooth to a smartphone. Proof of concept was evaluated using a sample of healthy male volunteers (n=4). Ethics approval was obtained (ERGO/FEPS/68640). Repetitive comparative testing was carried out, on the prototype device, against each resistance level, and repeated on the InCheckTM device (usual care). The mean of these readings was compared to illustrate the performance of the prototype device against the InCheck TM device. The performance of the prototype is in agreement with the InCheckTM device, albeit with a relatively consistent bias of around -31 L/min. The table in (Figure1) shows on average an overall -31 L/min difference in the means. The measurements are comparable, however, a larger population is required including people with lung disease, to apply in clinical practice.

The future of work, workplaces and smart buildings

This paper presents a discussion on how smart buildings and technologies currently and will continue to contribute to the future of work and workplaces. In the aftermath of the COVID-19 pandemic, a hybrid way of working has emerged and physical office spaces are becoming more a space for collaboration, innovation and interactions, which can be facilitated by the use of smart technologies. An analysis of the 15 highest-scoring smart buildings through the Smart Building Certification process highlights key trends in the smartest buildings as they contribute to the future of work and a hybrid way of working: increased flexibility, emphasis on user experience including indoor environmental quality and safety, and an overall drive towards sustainability. The shift towards smarter buildings also offers an opportunity to study the impacts of smart technologies on key performance aspects of the buildings and the building occupants. © 2022 ACM.

Length of Pre-Ecmo Mechanical Ventilation Is Not Associated with Mortality in Patients with Covid-19

INTRODUCTION: Previous studies suggest that delayed initiation of extracorporeal membrane oxygenation (ECMO) is associated with higher patient mortality. Hence, we hypothesized that prolonged invasive mechanical ventilation (IMV) prior to ECMO was associated with higher mortality in patients with COVID-19. METHOD(S): The COVID-19 Critical Care Consortium, a prospective international multicenter registry, was queried for all patients with COVID-19 infection who received IMV and ECMO. Patients who were intubated prior to transfer to a study site were excluded. The primary variable was number of days on IMV prior to ECMO initiation and study endpoint was death or discharge from the study site. Cox proportional hazards model for the time between ECMO initiation and death was built using covariates including age, gender, selected comorbidities, and time intervals from ICU admission to IMV and IMV to ECMO initiation. RESULT(S): Between 1/1/2020 and 6/6/2022, A total of 593 patients from 107 study sites and 25 countries were included in the analysis. In this cohort, the median age was 50 (Interquartile range [IQR]: 40-58) years. Obesity and hypertension were prevalent among 220 (38.4%) and 223 (38.8%) of the patients, respectively. Twenty-four (4.2%) patients had chronic pulmonary disease. Prior to ECMO initiation, patients spent a median of 3.68 (IQR: 1.36-8.07) days in the ICU and a median of 2.49 (IQR: 0.88-5.65) days on IMV. Overall mortality was 47.2% with 3.9% patients' status not finalized or unknown. According to the final survival model, the number of days on IMV prior to ECMO initiation was not associated with mortality. The hazard ratios for 0, 3, 7, and 14 days of pre-ECMO IMV were 0.94 (95% confidence interval [CI]: 0.83 to 1.07), 1.02 (95% CI: 0.97 to 1.08), 1.09 (95% CI: 0.92 to 1.3) and 1.09 (95% CI: 0.83 to 1.42), respectively. Other noticeable contributory factors in the model included age and gender. CONCLUSION(S): Among patients with COVID-19 who received ECMO, the length of pre-ECMO IMV was not associated with hospital mortality. Further studies evaluating the ventilator settings before and after ECMO initiation are needed.

Hemorrhagic, coagulopathic, and thrombotic (HECTOR) complications among critically-ill patients with COVID-19: An International COVID-19 critical care consortium study

Background: Hemorrhage, coagulopathy and thrombosis (HECTOR) are reported complications of coronavirus disease 2019 (COVID-19) however, more information is needed on the prevalence of these complications and their associated outcomes in intensive care unit (ICU) settings. Aim(s): To determine the prevalence and outcomes of HECTOR complications in ICU patients with COVID-19. Method(s): Observational cohort study spanning 229 ICUs across 32 countries. Patients >=16 years admitted for severe COVID-19 from 1st January 2020, through 31st December 2021 were included. Patient characteristics and clinical data were collected. Survival analysis estimated the instantaneous impact of HECTOR complications on ICU-mortality and discharge. Result(s): HECTOR complications occurred in 1,735 (14%) of 11,972 study-eligible patients. Acute thrombosis occurred in 1,249 (10%) patients, including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial infarction, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic stroke. Hemorrhagic complications were reported in 582 (4.9%) patients, including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, and 77 (13%) with pulmonary hemorrhage. Disseminated intravascular coagulation occurred in 11 (0.09%) patients. Univariate analysis identified diabetes, hypertension, cardiac and kidney disease and ECMO as statistically-significant risk factors for HECTOR complications. Patients with versus without HECTOR complications suffered higher ICU-mortality at 28 days (25%vs.13%, p < 0.001), 90 days (32%vs.15%, p < 0.0001) and overall (44%vs.36%, p < 0.001). Among ICU survivors, the ICU stay was longer (median days 19vs.12, p < 0.001). ICU mortality was similar between patients with and without HECTOR complications (HR = 1.01, 95%CI 0.92-1.12, p = 0.783) where an increased hazard of ICU mortality with hemorrhage (HR = 1.26, 1.09-1.45, p = 0.002) was balanced by a reduced hazard of thrombosis (HR = 0.88, 0.79-0.99, p = 0.03). Kaplan-Meier curves are presented in the Figure. Conclusion(s): HECTOR events are frequent complications of severe COVID-19 in ICU patients. Hemorrhagic, but not thrombotic complications are associated with increased ICU-mortality.

Reykjanes Mantle Convection and Climate: Crustal Objectives

The five primary sites proposed for International Ocean Discovery Program (IODP) Expedition 395, which was postponed because of the COVID-19 pandemic, were cored during IODP Expedition 395C. The Expedition 395C operations, shipboard measurements, and sampling were adjusted to account for the absence of a sailing science party. The Expedition 395/395C objectives are (1) to investigate temporal variations in ocean crust generation at the Reykjanes Ridge and test hypotheses for the influence of Iceland mantle plume fluctuations on these processes, (2) to analyze sedimentation rates at the Björn and Gardar contourite drifts, as proxies for Cenozoic variations of North Atlantic deepwater circulation, and for uplift and subsidence of the Greenland-Scotland Ridge gateway related to plume activity, and (3) to analyze the alteration of oceanic crust and its interaction with seawater and sediments. During Expedition 395C, basalt cores were collected at four sites: U1554, U1555, U1562, and U1563. Sediment cores were also collected from these sites as well as from Site U1564, and casing was installed to 602 m at Site U1554. The amount of recovered cores, their preliminary descriptions, and the analyses of shipboard samples show that the results of Expedition 395C will fulfill a significant part of the Expedition 395 objectives. Basalts were collected from two V-shaped ridge and trough pairs, which will allow the investigation of the variability in mantle source and temperature causing this ridge/trough pattern. Basalt cores span an expected age range of 2.8–13.9 Ma, which will allow us to investigate the hydrothermal weathering processes. Sediments from the Björn drift were cored to basement, along with the uppermost 600 m of sediments from the Gardar drift. The data provided by Expedition 395C are a major advancement in achieving the work of Expedition 395. © 2022 Authors. All rights reserved.

Renin-angiotensin-aldosterone system inhibition is associated with reduced in-hospital mortality in critically ill covid-19 patients with pre-existing hypertension

Background: The virus responsible for COVID-19 enters human cells by binding angiotensinconverting enzyme 2. The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs), remains uncertain. Aim: To examine the role of ACEi / ARB exposure on outcomes in COVID-19 patients with preexisting hypertension (HTN) admitted to intensive care units (ICU). Methods: The COVID-19 Critical Care Consortium is a prospective, observational cohort study of patients requiring ICU admission for active COVID-19 spanning 354 participating sites in 54 countries. Patients >18 years old with pre-existing HTN requiring antihypertensive therapy were analysed. Length of stay and in-hospital mortality to 90 days post ICU admission were analysed as time-to-eventoutcomes by multistate survival analysis, and the influence of ACEi / ARB use on the hazards of death and discharge by multi-state Cox proportional hazard modelling and sensitivity analysis. Results: From December 1, 2019 through December 30, 2020, 663 eligible patients were registered. Of these, 480 patients had received ACEi and / or ARB therapy (median age 65 years, 67% male) in the 2 weeks before ICU admission, while 183 had not (66 years, 61% male). Average lengths of ICU and general ward stays were longer in the ACEi / ARB than non-ACEi / ARB group (20.8 days and 6.5 days vs. 15.5 and 6.0 days, respectively). ACEi / ARB use was associated with a decreased hazard of death (HR, 0.69, 95% CI, 0.54 -0.88) that persisted after adjusting for propensity scores (0.67, 0.53 -0.86). Cumulative probabilities (unadjusted for baseline characteristics) for death and discharge post ICU admission are depicted in the figure for ACEi/ARB (red) and non-ACEi / ARB (blue) patients. Conclusions: In 663 critically ill COVID-19 patients with pre-existing HTN, RAAS inhibition pre-ICU admission was linked to reduced in-hospital mortality.

A Short Report Examining the Introduction of Routine Use of Patient-Reported Outcome Measures in a Mixed Oncology Population.

AIMS: People living with treatable but not curable cancer often experience a range of symptoms related to their cancer and its treatment. During the COVID-19 pandemic, face-to-face consultations were reduced and so remote monitoring of these needs was necessary. University Hospitals Sussex implemented the routine use of electronic remote patient-reported outcome measures (PROMs) in a mixed oncology population, focusing on those with treatable but not curable cancers. MATERIALS AND METHODS: Over a 9-month period, patients were invited to register with My Clinical Outcomes (MCO) - a secure online platform for the collection of electronic PROMs. They were prompted by e-mail to complete assessments (EORTC QLQ-C30, EQ-5D-3L and EQ-5D VAS) routinely every 2 weeks. The team monitored patient scores and changes in these prompted clinical interventions. RESULTS: In total, 324 patients completed at least one assessment. The median number of assessments completed by each patient was eight. The most represented tumour groups were secondary breast (28%), prostate (25%) and other (32%). Median scores for the assessments did not deteriorate in a clinically or numerically significant way for patients living with non-curable conditions for the majority of patients monitored. CONCLUSION: Routine collection of electronic remote PROMs is an effective and useful strategy to provide real-time clinical feedback to teams. With integration into existing systems, online platforms (such as MCO) could provide efficient and patient-centred information for those providing care for people with cancer.

Chloroquine/ hydroxychloroquine prevention of coronavirus disease (COVID-19) in the healthcare setting;protocol for a placebo-controlled prophylaxis study (COPCOV)

There is no proven preventative therapy or vaccine against COVID-19. Theinfection has spread rapidly and there has already been a substantial adverse impact on the global economy. Healthcare workers have been affected disproportionately in the continuing pandemic. Significant infection rates in this critical group have resulted in a breakdown of health services in some countries. Chloroquine, and the closely related hydroxychloroquine, are safe and well tolerated medications which can be given for years without adverse effects. Chloroquine and hydroxychloroquine have significant antiviral activity against SARS-CoV-2, and despite the lack of benefit of hydroxychloroquine treatment in patients hospitalised with severe COVID-19, these drugs could still work in prevention. The emerging infection paradigm of an early viral peak, and late inflammation where there is benefit from corticosteroids. If these direct actiing antivirals are to work, they have the best chance given either early in infection infection occurs. We describe the study protocol for multi-centre, multi-country randomised, double blind, placebo controlled trial to answer the question can chloroquine/ hydroxychloroquine prevent COVID-19. 40,000 participants working in healthcare facilities or involved in the management of COVID-19 will be randomised 1:1 to receive chloroquine/ hydroxychloroquine or matched placebo as daily prophylaxis for three months. The primary objective is the prevention of symptomatic, virological or serologically proven coronavirus disease (COVID-19). The study could detect a 23% reduction from an incidence of 3% in the placebo group for either drug with 80% power. Secondary objectives are to determine ifchloroquine/hydroxychloroquine prophylaxis attenuates severity, prevents asymptomaticCOVID-19 and symptomatic acute respiratory infections of another aetiology (non-SARS-CoV-2). © 2020. Schilling WH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The WHO guideline on drugs to prevent COVID-19: small numbers- big conclusions

The World Health Organization living guideline on drugs to prevent COVID-19 has recently advised that ongoing trials evaluating hydroxychloroquine in chemoprophylaxis should stop. The WHO guideline cites "high certainty" evidence from randomised controlled trials (RCTs) that hydroxychloroquine prophylaxis does not reduce mortality and does not reduce hospital admission, and "moderate certainty" evidence of poor tolerability because of a significantly increased rate of adverse events leading to drug discontinuation. Yet there is no such evidence. In the three pre-exposure chemoprophylaxis RCTs evaluated in the guideline there were no deaths and only two COVID-19-related hospital admissions, and there was a mistake in the analysis of the number of discontinuations (after correction there is no longer a statistically significant difference between those taking the drug and the controls). Guidelines on the prevention and treatment of COVID-19 should be based on sufficient verified evidence, understanding of the disease process, sound statistical analysis and interpretation, and an appreciation of global needs.

An appraisal of respiratory system compliance in mechanically ventilated COVID-19 patients

Rationale Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous smallcase series or studies conducted at a national level.Methods We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe the impact of CRS on the ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide.Results We enrolled 318 COVID-19 patients enrolled into the study from January 14th through September 31th, 2020 in 19 countries and stratified into two CRS groups. CRS was calculated as: tidal volume/[airway plateau pressure-positive endexpiratory pressure (PEEP)] and available within 48h from commencement of MV in 318 patients. Patients were mean±SD of 58.0±12.2, predominantly from Europe (54%) and males (68%). Median CRS (IQR) was 34.1 mL/cmH2O (26.5-45.5) and PaO2/FiO2 was 119 mmHg (87.1-164) and was not correlated with CRS. Female sex presented lower CRS than in males (95% CI:-13.8 to-8.5 P<0.001) and higher body mass index (34.7±10.9 vs 29.1±6.0, p<0.001). Median (IQR) PEEP was 12 cmH2O (10-15), throughout the range of CRS, while median (IQR) driving pressure was 12.3 (10-15) cmH2O and significantly decreased as CRS improved (p<0.001). No differences were found in comorbidities and clinical management between CRS strata. In addition, 28-day ICU mortality and hospital mortality did not differ between CRSgroups.Conclusions This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV-predominantly males or overweight females, in their late 50s-admitted to ICU during the first international outbreaks. Phenotypes associated with different CRS upon commencement of MV could not be identified.

Neuromuscular blocking agents in critically-ill COVID-19 patients requiring mechanical ventilation

RATIONALE. Neuromuscular blocking agents (NMBA) are used in patients with moderate to severe acute respiratory distress syndrome. NMBA have also been used in COVID-19 patients who required mechanical ventilation (MV), but their benefit-to-risk ratio remains uncertain.METHODS. We investigated the effects associated with the use of NMBA in COVID-19 patients who required MV from January 1, 2020 to October 31, 2020 in 153 hospitals across 6 continents, comprising the COVID-19 Critical Care Consortium. Cox proportional hazards analysis was conducted to study the impact of NMBA on 28-day intensive care unit (ICU) mortality. Hospital/ICU lengths of stay were appraised. We performed a propensity score (PS) matching analysis to control confounding factors.RESULTS. 1227 patients were eligible for analysis, among those 598 (48.7%) received NMBA for 2 days or longer, with a median time from ICU admission to commencement of NMBA therapy of 0 day (IQR 0-1 days). The median duration of NMBA therapy was 2 days (N=789, IQR 1-5). In comparison with standard of care, treatment with NMBA was more frequent in obese (31% vs. 39%, P = 0.03) and diabetic patients (2% vs. 8%, P <0.01) and less frequent in patients with hypertension (52% vs. 46%, P =0.04) or cardiac diseases (21% vs. 14%, P =0.003). Upon commencement of MV, patients who underwent NMBA therapy vs those who did not presented a PaO2/FiO2 of 136.1±69.2 vs. 162.7 ±125.8 (p<0.01), required more often ECMO (10% vs 5.2%, p <0.01) and prone position (25.1% vs 6.2%, p <0.01). Unadjusted 28-day all-cause mortality was similar (58.2% vs. 62.4%, P =0.134) between patients without or with NMBA therapy, respectively, but length of MV (3 days [2-5] vs. 6 [3-12] P <0.01) and ICU stay (8 days [4-14] vs. 13 [7-19] P <0.01) were prolonged. After PS matching, NMBA therapy was strongly associated with 28-day ICU mortality (adjusted HR 3.18, 95% CI 2.65-3.81, P <0.01). CONCLUSION. Use of NMBA in COVID-19 patients requiring MV is associated with increased 28-day mortality, delayed discontinuation of MV and prolonged ICU stay.

Factors associated with mortality in patients with COVID-19 requiring mechanical ventilation: An international cohort study from 139 intensive care unit across 6 continents

Rationale: Patients with COVID-19 commonly develop severe hypoxemic respiratory failure and require invasive mechanical ventilation (MV). The disease burden and predictors of mortality in this population remain uncertain. Methods: Prospective observational cohort study from 139 intensive care units of the international COVID-19 Critical Care Consortium. Patients enrolled from January 14th through November 31st 2020 were included in the analysis. Patient's characteristics and clinical data were assessed. Multivariable Cox proportional hazards analysis was conducted to identify indipendent predictors of mortality within 28 days from commencement of MV. Results: 1578 patients on MV were included into the analysis. Mean±SD age was 59 years±13 and patients were predominantly males (66%). 542 Patients (34.4%) died within 28 days from commencement of MV. Nonsurvivors were slightly older (mean age±SD 62±13 vs. 59±13) and presented more frequently hypertension, chronic cardiac disease and diabetes. Median (IQR) PaO2/FiO2 upon commencement of MV was 96 (68-135) and 111 (81-173) in patients who did not survive vs. survivors, respectively (p=0.04). ECMO (13% vs 25%, p<0.01), inhaled nitric oxide (11% vs 15%, p=0.02) and recruitment manoeauvres (26% vs 31%, p<0.01) were used less frequently in patients who did not survive. Independent risk factors associated with 28-day mortality included age older than 70 years (hazard ratio [HR], 2.83;95% CI, 1.32-6.07), higher creatinine levels upon ICU admission (HR, 1.20;95% CI, 1.03-1.40), and lower pH within 24h from commencement of MV (HR, 0.12;95% CI, 0.02-0.62), while a shorter period (day) from early symptoms to hospitalisation reduced mortality risks (HR, 0.96;95% CI, 0.93-0.99). Conclusions: Our findings from a large international cohort of critically-ill COVID-19 patients on mechanical ventilation emphasises that elderly patients, not promptly admitted to the hospital, and who present higher creatinine levels and acidosis are at higher risk of mortality.

Characteristics and outcomes of patients with COVID-19 admitted to intensive care units-a report from the global COVID-19 critical care consortium

Objective: SARS-CoV-2 has been reported in almost all countries around the world, and a significant proportion of critically ill patients with COVID-19 require care in the intensive care unit (ICU). There have been few observational cohorts including patients in ICU across different countries. We present summary data from a global critical care consortium. Methods: The COVID-19 Critical Care Consortium/ ECMOCARD (COVID-19 CCC/ECMOCARD) is an ongoing international multicenter observational study including more than 377 hospitals in 53 countries. Clinical and treatment characteristics are collected for patients with COVID-19 requiring ICU admission. Results: Data from 2,670 patients with COVID-19 admitted between January 28 and December 19, 2020 were summarized - 182 from Africa, 516 from Asia, 72 from Oceania, 710 from Europe, 343 from Latin America, and 847 from North America. The median (IQR) age was 59 (49 to 68) years, and 909 (34%) were female. 1,283 (49%) patients had hypertension and 830 (32%) had diabetes mellitus. The time from symptom onset to hospital admission was 7 (3 to 10) days, and 1,360 (51%) patients were admitted to ICU on the same day as hospital admission. Upon ICU admission, the heart rate was 95 (80 to 110) beats/min, respiratory rate was 26 (20 to 33) breaths/ min, and oxygen saturation was 93 (89 to 96) %. Details of arterial blood gases and ICU interventions are tabulated. Amongst survivors, ICU length of stay (LOS) was 13 (7 to 25) days, and hospital LOS was 24 (14 to 39) days. As of 31 December 2020, 1,358 (51%) patients were discharged from ICU, and 1,219 (46%) patients survived to hospital discharge. Among 963 (36%) patients who died in hospital, 837 (87%) died within 28 days of ICU admission. Conclusions: The COVID-19 CCC/ECMO offers a unique global perspective of characteristics and outcomes of patients with COVID-19 requiring admission to the ICU.

Farming in the time of pandemic: Small farms demonstrate flexibility, innovation, and hope

The COVID-19 pandemic affected small farmers in the 2020 growing season as they navigated how to maintain their businesses while meeting health and safety concerns. Through interviews with Ellis Creek Farm and Riverbend Ranch, two small farms in Thurston County, Washington, I explore the impacts of the pandemic, the need for flexibility, and the unique challenges and adaptations these farms employed early in the pandemic to stay afloat. These stories are valuable community assets because hearing directly from farmers about their experiences, challenges, and plans is a way to gain insight and learn. In the face of crises such as a pandemic or climate change, a changed food system that includes small farms is necessary for community resiliency.

Evaluation of an introductory pharmacy practice experience to reinforce student learning and increase student confidence immediately prior to advanced pharmacy practice experiences Amid a COVID-19 pandemic

Introduction: Preparing pharmacy students with practice skills necessary for entry into Advanced Pharmacy Practice Experiences (APPEs) is essential. Responding to an internal survey indicating 85% of thirdyear students did not feel prepared for APPEs, an Introductory Pharmacy Practice Experience (IPPE IV) was designed to provide 16-hours of clinical case-based on-site or virtual experiences with clinical faculty immediately prior to APPEs. The IPPE IV occurred April-May 2020 during the COVID-19 pandemic. Research Question or Hypothesis: Will the IPPE IV increase thirdyear pharmacy students' confidence in APPE preparedness? Study Design: Pre-test/post-test. Methods: Students were administered a pre-post survey in Qualtrics around the IPPE IV. Surveys consisted of items assessing confidence and perceived ability in the Pharmacists' Patient Care Process, patient case presentations, professionalism, communication and electronic medical record (EMR) use. A Wilcoxon signed-rank test was used to examine differences pre- and post-IPPE IV. Results: A total of 122 students completed the surveys. Post IPPE IV, students were significantly more confident in their ability to: collect information to identify patient's health-related problems (P = .013), analyze information to identify medication-related problems (P < .001), analyze information to prioritize patient's health-related needs (P < .001), create an evidence-based patient care plan (P < .001), create a cost-effective patient care plan (P < .001), create a patient care plan in collaboration with the patient, caregiver(s), and/or other health professionals (P = .007), and follow-up/monitor a patient care plan (P = .015). Students were significantly more confident in their ability to work up a patient (P = .006) and in presenting patient cases (P = .005). Additionally, students were significantly more confident in demonstrating self-awareness (P = .041), effectively communicating with patients and/or caregivers (P = .016) and health care providers (P = .010) and using an EMR to detect medication-related problems (P = .010). Conclusion: An IPPE IV immediately prior to APPEs had a positive impact on students' confidence in areas important for APPE success. Future research should examine how these improvements in confidence manifest in actual APPE performance.