Role of the Inspiratory Muscles on Functional Performance from Critical Care to Hospital Discharge and beyond in Patients with COVID-19.

OBJECTIVE: The role of inspiratory muscle performance in functional performance in patients with COVID-19 is poorly understood. The purpose of this study was to perform a longitudinal examination of inspiratory and functional performance from intensive care unit (ICU) discharge (ICUD) to hospital discharge (HD) and symptoms at HD and 1 month after HD in patients with COVID-19. METHODS: Thirty patients (19 men, 11 women) with COVID-19 were included. Examination of inspiratory muscle performance at ICUD and HD was performed with an electronic manometer which provided the maximal inspiratory pressure (MIP) and several other inspiratory measures. Examination of dyspnea and functional performance was performed at ICUD and HD with the Modified Borg Dyspnea Scale and the 1-minute sit-to-stand test (1MSST), respectively. RESULTS: The mean age was 71 (SD = 11) years, the mean length of ICU stay was 9 (SD = 6) days, and the mean length of hospital stay was 26 (SD = 16) days. Most of the patients were diagnosed with severe COVID-19 (76.7%) and had a mean Charlson Comorbidity Index of 4.4 (SD = 1.9), reflecting high comorbidity. The mean MIP of the entire cohort increased minimally from ICUD to HD (from 36 [SD = 21] to 40 [SD = 20] cm H2O), reflecting predicted values for men and women at ICUD and HD of 46 (25%) to 51 (23%) and 37 (24%) to 37 (20%), respectively. The 1MSTS score increased significantly from ICUD to HD (9.9 [SD = 7.1] versus 17.7 [SD = 11.1]) for the entire cohort but remained far below population-based reference values (2.5th percentile) for the majority of patients at ICUD and HD. At ICUD, MIP was found to be a significant predictor of a favorable change in 1MSTS performance (ß = 0.308; odds ratio = 1.36) at HD. CONCLUSIONS: A significant reduction in inspiratory and functional performance exists in patients with COVID-19 at both ICUD and HD, with a greater MIP at ICUD being a significant predictor of a greater 1MSTS score at HD. IMPACT: This study shows that inspiratory muscle training may be an important adjunct after COVID-19.

Career development and the COVID-19 outbreak: protective functions of career-related teacher support

It is well established that COVID-19 pandemic is associated with arousal of feelings of hopelessness and negativity in adolescents regarding future career development outcomes. However, the current literature has yet to clarify the roles teacher social support play in facilitating students' positive career development during the pandemic. This study investigated the effects of career-related teacher support (CRTS) on ameliorating students' feelings of hopelessness and increasing their career self-efficacy among 402 senior secondary students (Grades 10-12) in Hong Kong, China. Results from mediated moderation analyses showed that academic ability was only weakly related to career self-efficacy. Hopelessness was not a significant moderator concerning the link between academic ability and career self-efficacy when CRTS functioned as the mediator. [ FROM AUTHOR] Copyright of British Journal of Guidance & Counselling is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

COVID-19 reduced scleral buckling training in fellows and shifted young ophthalmologists' preference toward vitrectomy: An Asia-Pacific survey.

BACKGROUND: To assess rhegmatogenous retinal detachment (RRD) surgery trends and training among young ophthalmologists (YOs, vitreoretinal fellows or attendings/consultants with ≤10 years of independent practice) and the impact of the COVID-19 pandemic. METHODS: An anonymous online survey was completed by 117 YOs in the Asia-Pacific regarding their RRD surgery experiences in 2021-2022. RESULTS: To achieve a 90% probability of surgical competency, 91 vitrectomy and 34 scleral buckling (SB) completions during fellowship were needed. In total, 49 (41.9%) YOs had fellowship affected by COVID-19. In the COVID versus pre-COVID era, however, the volume of SB completions per fellowship year decreased significantly (median [IQR] 3.3 [1.5, 9] vs. 13 [6.5, 23]; p < 0.001) and was lower than the required volume to achieve competency. YOs were less confident in conducting SB versus vitrectomy (3.5 ± 1.1 vs. 4.2 ± 0.8, p < 0.001), and they reported a decrease in the proportion of SB (-3.1%, p = 0.047) and an increase in the proportion of vitrectomy (+4.8%, p < 0.001) after the pandemic outbreak. Apart from RRD clinical characteristics, surgical confidence is among the main factors that affect surgical method decisions. During the pandemic, more YOs may have avoided SB due to the need for general anaesthesia, leading to longer surgical time and risk of viral transmission during intubation/extubation. CONCLUSIONS: SB surgical exposure is suboptimal in most fellowship programs in the 11 Asia-Pacific countries/regions we surveyed and further declined during the COVID-19 pandemic. YOs are less confident in performing SB, leading to a trend toward primary vitrectomy since the COVID-19 outbreak.

A temporal examination of inspiratory muscle strength and endurance in hospitalized COVID-19 patients.

BACKGROUND: The two most common symptoms associated with COVID-19 are dyspnea and fatigue. One possible cause of such symptoms may be inspiratory muscle weakness. OBJECTIVES: The purpose of this study was to examine inspiratory muscle performance (IMP) from intensive care unit discharge (ICUD) to hospital discharge (HD) in patients with COVID-19 hypothesizing that IMP would be markedly depressed at both ICUD and HD. METHODS: IMP was examined at ICUD and HD via the PrO2 device (PrO2 Health, Smithfield, RI) which provided the maximal inspiratory pressure (MIP), sustained MIP (SMIP), inspiratory duration (ID), and fatigue index test (FIT). Patient symptoms were assessed at ICUD, HD, and 1-month post-HD. RESULTS: 30 patients (19 men, 11 women) with COVID-19 were included. The mean±SD age, BMI, and length of ICU and hospital stay was 71±11 yrs, 27.9 ± 6.3 kg/m, 9 ± 6 days, and 26±16 days, respectively. The mean±SD MIP, SMIP, ID, and FIT of the entire cohort at ICUD vs HD were 36±21 vs 40±20 cm H2O, 231±157 vs 297±182 PTU, 8.8 ± 4.2 vs 9.5 ± 4.6 s, and 9.0 ± 9.4 vs 13.1 ± 12.3, respectively, with only SMIP and FIT significantly greater at HD (p=.006 and 0.03, respectively). SMIP at HD was significantly related to resting dyspnea at HD (r=-0.40; p=.02). The SMIP and FIT of men were found to increase significantly from ICUD to HD, but no measure of IMP in the women increased significantly from ICUD to HD. At least one COVID-19-related symptom was present 1 month after HD with the most persistent symptoms being fatigue, cough, and dyspnea in 47%, 40%, and 37% of the patients, respectively. CONCLUSIONS: A significant reduction in IMP exists in patients with COVID-19 at both ICUD and HD and no measure of IMP in women was observed to increase significantly from ICUD to HD. Impaired inspiratory muscle endurance rather than strength was associated with greater dyspnea at HD.

The clinical effectiveness and validity of home spirometry in children with cystic fibrosis

Introduction: During the COVID-19 pandemic, home spirometry became essential for continued monitoring of cystic fibrosis patients, however, the clinical effectiveness was unknown. Aim(s): The aims of this study were to assess the success rate of testing patients at home and to compare the home spirometry and lab spirometry results Methods: 147 home spirometry devices (Air Next, NuvoAir, USA) were given out to cystic fibrosis patients (M:F 67:80;mean age 11.8 [4.7 - 17.3]) who had previous experience of spirometry and deemed to be competent to perform spirometry at home. Patients were asked to perform 4 tests in the first month, then 1 test per month unless clinically requested. When Lab spirometry resumed, 28 (M:F 12:16;mean age 13.1 [8.0-17.0]) patients tested on NuvoAir within 5 days (mean 0.7 days (1.0)) of Lab spirometry (Vyntus Spiro, Vyaire Medical, USA). Correlation between spirometry indices were analysed using linear regression. Result(s): 142 patients (96.6%) successfully onboarded onto the NuvoAir platform. Between July 2020 and Jan 2022, 1854 tests were performed, with 1711 (92.3%) tests over-read to be valid. 54 patients (36.7%) performed >=15 tests requested. FEV1 (R2 = 0.93, p = <0.00), FVC (R2 = 0.91, p = <0.00), MMEF (R2 = 0.87, p = <0.00) and PEF (R2 = 0.88, p = <0.00) all showed significant correlation between Lab spirometry and Home spirometry. Conclusion(s): Our results show that home spirometry is well adopted by cystic fibrosis patients and they are able to perform valid loops on this device. Continual encouragement may be required to achieve good trend data. There is also close agreements between this home spirometry device and the gold standard of laboratory spirometry.

A Comprehensive Examination of Inspiratory Muscle Performance from the Intensive Care Unit to Hospital Discharge in Patients with COVID-19

Background The two most common symptoms associated with COVID-19 are dyspnea and fatigue. One possible cause of such symptoms may be inspiratory muscle weakness. Objectives The purpose of this study was to examine inspiratory muscle performance (IMP) from intensive care unit discharge (ICUD) to hospital discharge (HD) in patients with COVID-19 hypothesizing that IMP would be markedly depressed at both ICUD and HD. Methods IMP was examined at ICUD and HD via the PrO2 device (PrO2 Health, Smithfield, RI) which provided the maximal inspiratory pressure (MIP), sustained MIP (SMIP), inspiratory duration (ID), and fatigue index test (FIT). Patient symptoms were assessed at ICUD, HD, and 1-month post-HD. Results 30 patients (19 men, 11 women) with COVID-19 were included. The mean±SD age, BMI, and length of ICU and hospital stay was 71±11 yrs, 27.9±6.3 kg/m, 9±6 days, and 26±16 days, respectively. The mean±SD MIP, SMIP, ID, and FIT of the entire cohort at ICUD vs HD were 36±21 vs 40±20 cm H2O, 231±157 vs 297±182 PTU, 8.8±4.2 vs 9.5±4.6 s, and 9.0±9.4 vs 13.1±12.3, respectively, with only SMIP and FIT significantly greater at HD (p=.006 and .03, respectively). SMIP at HD was significantly related to resting dyspnea at HD (r=-.40;p=.02). The SMIP and FIT of men were found to increase significantly from ICUD to HD, but no measure of IMP in the women increased significantly from ICUD to HD. At least one COVID-19-related symptom was present 1 month after HD with the most persistent symptoms being fatigue, cough, and dyspnea in 47%, 40%, and 37% of the patients, respectively. Conclusions A significant reduction in IMP exists in patients with COVID-19 at both ICUD and HD and no measure of IMP in women was observed to increase significantly from ICUD to HD. Impaired inspiratory muscle endurance rather than strength was associated with greater dyspnea at HD.

A Meta-Analysis of Remote Ischemic Preconditioning in Lung Surgery and Its Potential Role in COVID-19.

Purpose: To determine the effects of remote ischemic preconditioning (RIPC) on pulmonary gas exchange in people undergoing pulmonary surgery and discuss a potential role of RIPC in COVID-19. Method: A search for studies examining the effects of RIPC after pulmonary surgery was performed. RevMan was used for statistical analyses examining measures of A-ado2, Pao2/Fio2, respiratory index (RI), a/A ratio and Paco2 obtained earlier after surgery (i.e., 6-8 hours) and later after surgery (i.e., 18-24 hours). Results: Four trials were included (N = 369 participants). Significant (p < 0.05) overall effects of RIPC were observed early after surgery on A-ado2 and RI (SMD -0.84 and SMD -1.23, respectively), and later after surgery on RI, Pao2/Fio2, and a/A ratio (SMD -0.39, 0.72, and 1.15, respectively) with the A-ado2 approaching significance (p = 0.05; SMD -0.45). Significant improvements in inflammatory markers and oxidative stress after RIPC were also observed. Conclusions: RIPC has the potential to improve pulmonary gas exchange, inflammatory markers, and oxidative stress in people with lung disease undergoing lung surgery and receiving mechanical ventilation. These potential improvements may be beneficial for people with COVID-19, but further investigation is warranted.

Objectif : déterminer les effets du préconditionnement ischémique à distance (PCID) sur les échanges gazeux pulmonaires chez les personnes qui subissent une opération pulmonaire et discuter du rôle potentiel du PCID sur la COVID-19. Méthodologie : les chercheurs ont procédé à une recherche sur les effets du PCID après une opération pulmonaire. Ils ont utilisé le logiciel RevMan pour effectuer les analyses statistiques des mesures du gradient artério-alvéolaire (A-ao2), du rapport entre la pression partielle d'oxygène et la fraction inspirée en oxygène (Pao2/Fio2), de l'indice respiratoire (IR), du gradient alvéolo-artériel (a-A) et de la pression partielle de dioxyde de carbone (Paco2) obtenus de six à huit heures après l'opération, puis de 18 à 24 heures après l'opération. Résultats : les chercheurs ont inclus quatre études (N = 369 participants). Ils ont observé des effets globaux importants (p < 0,05) du PCID peu après l'opération sur l'A-ao2 et l'IR (DMS = −0,84 et DMS = −1,23, respectivement), puis plus tard après l'opération sur l'IR, le Pao2/Fio2 et le gradient a-A (DMS = −0,39, 0,72 et 1,15, respectivement), et l'A-ao2 avoisine une valeur significative (p = 0,05; DMS = −0,45). Ils ont également observé des améliorations notables aux marqueurs inflammatoires et au stress oxydatif après le PCID. Conclusions : le PCID a le potentiel d'améliorer les échanges gazeux pulmonaires, les marqueurs inflammatoires et le stress oxydatif chez les personnes atteintes d'une maladie pulmonaire qui subissent une opération pulmonaire et reçoivent une ventilation mécanique. Ces améliorations potentielles peuvent être bénéfiques aux personnes atteintes de la COVID-19, mais d'autres recherches s'imposent.

How the COVID-19 Pandemic Affected Young People's Mental Health and Wellbeing in the UK: A Qualitative Study

There is emerging evidence of the detrimental impact of the pandemic and associated restrictions on young people's mental health in the UK but to date, these data have been largely quantitative. The aim of the current study was to gain a deeper understanding of young people's experiences in relation to their mental health and wellbeing during the pandemic. Seventeen young people, aged 11 to 16 years, sampled for diverse characteristics, and living in the UK, were interviewed virtually between December 2020 and February 2021. Reflexive thematic analysis was carried out by the research team, which included two young people, and five themes were developed: (1) positives;(2) worries and anxiety;(3) sadness and anger about losses;(4) mental exhaustion;and (5) support from others. Aspects of young people's individual circumstances (e.g., pre-existing mental health difficulties;special educational needs and neurodevelopmental disorders) appeared to play a role in their experiences. Continued measurement of young people's mental health, initiatives to identify young people who have been struggling and the provision of support (including evidence-based and accessible interventions) will be important for protecting young people from future adversities as we emerge from the pandemic.

Wastewater bacteria remediating the pharmaceutical metformin: Genomes, plasmids and products.

Metformin is used globally to treat type II diabetes, has demonstrated anti-ageing and COVID mitigation effects and is a major anthropogenic pollutant to be bioremediated by wastewater treatment plants (WWTPs). Metformin is not adsorbed well by activated carbon and toxic N-chloro derivatives can form in chlorinated water. Most earlier studies on metformin biodegradation have used wastewater consortia and details of the genomes, relevant genes, metabolic products, and potential for horizontal gene transfer are lacking. Here, two metformin-biodegrading bacteria from a WWTP were isolated and their biodegradation characterized. Aminobacter sp. MET metabolized metformin stoichiometrically to guanylurea, an intermediate known to accumulate in some environments including WWTPs. Pseudomonas mendocina MET completely metabolized metformin and utilized all the nitrogen atoms for growth. Pseudomonas mendocina MET also metabolized metformin breakdown products sometimes observed in WWTPs: 1-N-methylbiguanide, biguanide, guanylurea, and guanidine. The genome of each bacterium was obtained. Genes involved in the transport of guanylurea in Aminobacter sp. MET were expressed heterologously and shown to serve as an antiporter to expel the toxic guanidinium compound. A novel guanylurea hydrolase enzyme was identified in Pseudomonas mendocina MET, purified, and characterized. The Aminobacter and Pseudomonas each contained one plasmid of 160 kb and 90 kb, respectively. In total, these studies are significant for the bioremediation of a major pollutant in WWTPs today.

The Clinical Effectiveness and Validity of Home Spirometry in Children with Cystic Fibrosis

Aims During the COVID-19 pandemic, home spirometry became essential for continued monitoring of cystic fibrosis patients, however, the clinical effectiveness was unknown.The aims of this study were to assess the success rate of testing patients at home and to compare the results to the gold standard testing (in lab spirometry). Methods 147 home spirometry devices (Air Next, NuvoAir, USA) were given out to cystic fibrosis patients (M:F 67:80;mean age 11.8 [4.7 - 17.3]) who had previous experience of spirometry and deemed to be competent to perform spirometry at home. Patients were asked to perform 4 tests in the first month, then 1 test per month unless clinically requested. When Lab spirometry resumed, 28 (M:F 12:16;mean age 13.1 [8.0-17.0]) patients tested on NuvoAir within 5 days (mean 0.7 days (1.0)) of Lab spirometry (Vyntus Spiro, Vyaire Medical, USA). Correlation between spirometry indices were analysed using linear regression. Results 142 patients (96.6%) successfully onboarded onto the NuvoAir platform. Between July 2020 and Jan 2022, 1854 tests were performed, with 1711 (92.3%) tests over-read to be valid. 54 patients (36.7%) performed >=15 tests requested. FEV1 (R2 = 0.93, p = <0.00), Ratio (R2 = 0.70, p = <0.00), FVC (R2 = 0.91, p = <0.00), MMEF (R2 = 0.87, p = <0.00) and PEF (R2 = 0.88, p = <0.00) all showed significant correlation between Lab spirometry and Home spirometry. Conclusion Our results show that home spirometry is well adopted by cystic fibrosis patients, however, continual encouragement may be required. We have also shown that valid spirometry loops can be performed by cystic fibrosis patients on this device. There is also close agreement between this home spirometry device and the gold standard of lab spirometry and therefore, results can be deemed valid and reliable.

Complications of Corticosteroid Therapy: A Comprehensive Literature Review.

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices. Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses. Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included "corticosteroids," "avascular necrosis," "gastrointestinal bleeding," and "complications." Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion. Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting. Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.

Structural adjustment programmes and infectious disease mortality.

International financial organisations like the International Monetary Fund (IMF) play a central role in shaping the developmental trajectories of fiscally distressed countries through their conditional lending schemes, known as 'structural adjustment programmes'. These programmes entail wide-ranging domestic policy reforms that influence local health and welfare systems. Using novel panel data from 187 countries between 1990 and 2017 and an instrumental variable technique, we find that IMF programmes lead to over 70 excess deaths from respiratory diseases and tuberculosis per 100,000 population and that IMF-mandated privatisation reforms lead to over 90 excess deaths per 100,000 population. Thus structural adjustment programmes, as currently designed and implemented, are harmful to population health and increase global infectious disease burdens.

THE IMPACT of COVID-19 on ADVERSE BIRTH OUTCOMES in BOTSWANA by HIV STATUS

Background: Botswana has a high prevalence of women living with HIV (WLHIV) and experienced a severe nationwide COVID-19 epidemic in 2021. We evaluated adverse birth outcomes among women routinely tested for COVID-19 by HIV status, during a period when few women had access to COVID-19 vaccination. Methods: The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. We analyzed data from 13 Tsepamo sites that performed routine COVID-19 screening at delivery with rapid antigen or PCR testing between Sept 1, 2020 and Sept 30, 2021 (start dates differed by site). This analysis includes singleton deliveries with known HIV status and a COVID-19 screening test between 14 days prior and 3 days after delivery. Outcomes included maternal death, preterm delivery (PTD), very preterm delivery (VPTD), small for gestational age (SGA), very small for gestational age (VSGA), stillbirth, and neonatal death. Differences in outcomes by COVID-19 and HIV status were assessed using log binomial regression adjusted for maternal age. Results: A total of 17,627 deliveries occurred at the included sites during COVID-19 screening, and 11,149 (63.3%) were screened for COVID-19;among 10,090 (99.7%) with a known HIV status, 530 (5.3%) COVID-19 tests were positive, including 141/2129 (6.6%) among WLHIV and 389/7961 (4.9%) among women without HIV (aRR 1.32, 95% CI 1.09, 1.60). Maternal deaths were reported in 19 (3.8%) women with COVID-19 and 11 (0.12%) women without COVID-19 (aRR 30.5, 95% CI 14.6, 63.7), and did not differ by HIV status. Adverse birth outcomes (any) were more common among infants born to women with COVID-19 (34.3% vs. 26.3%;aRR 1.32, 95% CI 1.16,1.49), including PTD (21.2% vs. 13.3%;aRR 1.60, 95% CI 1.34,1.90) and stillbirth (5.5% vs. 2.8%;aRR 1.89, 95% CI 1.30,2.75), and there was a trend for higher neonatal mortality (2.0% vs. 1.4%, aRR 1.5, 95% CI 0.79, 2.85). Most adverse birth outcomes were highest among infants exposed to both COVID-19 and HIV (Figure 1). Conclusion: Infants born to women with COVID-19 experienced more adverse birth outcomes than other infants, including a 2-fold risk for stillbirth. Those exposed to both COVID-19 and HIV had the highest risk for most adverse outcomes. Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana.

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians.

OBJECTIVE: To identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as "SNFists," with the goal of enriching our understanding of specialization in nursing home care. DESIGN: Qualitative analysis of semistructured interviews. SETTING AND PARTICIPANTS: Virtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes. METHODS: Interviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis. RESULTS: Participants had a mean 19.5 (SD = 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a "good SNFist"; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic. CONCLUSIONS AND IMPLICATIONS: There is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.

People critically ill with COVID-19 exhibit peripheral immune profiles predictive of mortality and reflective of SARS-CoV-2 lung viral burden.

Despite extensive analyses, there remains an urgent need to delineate immune cell states that contribute to mortality in people critically ill with COVID-19. Here, we present high-dimensional profiling of blood and respiratory samples from people with severe COVID-19 to examine the association between cell-linked molecular features and mortality outcomes. Peripheral transcriptional profiles by single-cell RNA sequencing (RNA-seq)-based deconvolution of immune states are associated with COVID-19 mortality. Further, persistently high levels of an interferon signaling module in monocytes over time lead to subsequent concerted upregulation of inflammatory cytokines. SARS-CoV-2-infected myeloid cells in the lower respiratory tract upregulate CXCL10, leading to a higher risk of death. Our analysis suggests a pivotal role for viral-infected myeloid cells and protracted interferon signaling in severe COVID-19.

Harnessing Neuroplasticity to Promote Brain Health in Aging Adults: Protocol for the MOVE-Cog Intervention Study.

BACKGROUND: Extensive evidence supports a link between aerobic exercise and cognitive improvements in aging adults. A major limitation with existing research is the high variability in cognitive response to exercise. Our incomplete understanding of the mechanisms that influence this variability and the low adherence to exercise are critical knowledge gaps and major barriers for the systematic implementation of exercise for promoting cognitive health in aging. OBJECTIVE: We aimed to provide an in-person and remotely delivered intervention study protocol with the main goal of informing the knowledge gap on the mechanistic action of exercise on the brain by characterizing important mechanisms of neuroplasticity, cardiorespiratory fitness response, and genetics proposed to underlie cognitive response to exercise. METHODS: This is an open-label, 2-month, interventional study protocol in neurologically healthy sedentary adults. This study was delivered fully in-person and in remote options. Participants underwent a total of 30 sessions, including the screening session, 3 pretest (baseline) assessments, 24 moderate-to-vigorous aerobic exercise sessions, and 3 posttest assessments. We recruited participants aged 55 years and above, sedentary, and cognitively healthy. Primary outcomes were neuroplasticity, cognitive function, and cardiorespiratory fitness. Secondary outcomes included genetic factors, endothelium function, functional mobility and postural control, exercise questionnaires, depression, and sleep. We also explored study feasibility, exercise adherence, technology adaptability, and compliance of both in-person and remote protocols. RESULTS: The recruitment phase and data collection of this study have concluded. Results are expected to be published by the end of 2021 or in early 2022. CONCLUSIONS: The data generated in these studies will introduce tangible parameters to guide the development of personalized exercise prescription models for maximal cognitive benefit in aging adults. Successful completion of the specific aims will enable researchers to acquire the appropriate expertise to design and conduct studies by testing personalized exercise interventions in person and remotely delivered, likely to be more effective at promoting cognitive health in aging adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03804528; http://clinicaltrials.gov/ct2/show/NCT03804528. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/33589.

Adjunctive inspiratory muscle training for patients with COVID-19 (COVIDIMT): protocol for randomised controlled double-blind trial.

INTRODUCTION: A significant number of patients with COVID-19 may experience dyspnoea, anxiety, depression, pain, fatigue and physical impairment symptoms, raising the need for a multidisciplinary rehabilitation approach, especially for those with advanced age, obesity, comorbidities and organ failure. Traditional pulmonary rehabilitation (PR), including exercise training, psychosocial counselling and education, has been employed to improve pulmonary function, exercise capacity and quality of life in patients with COVID-19. However, the effects of inspiratory muscle training (IMT) in PR programmes remain unclear. This study aimed to determine whether the addition of a supervised IMT in a PR is more effective than PR itself in improving dyspnoea, health-related quality of life and exercise capacity in symptomatic patients with post-COVID-19. METHODS AND ANALYSIS: This parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aimed to assess exercise capacity as the primary outcome. A total of 138 are being recruited at two PR centres in Brazil. Following baseline testing, participants will be randomised using concealed allocation, to receive either (1) standard PR with sham IMT or (2) standard PR added to IMT. Treatment effects or differences between the outcomes (at baseline, after 8 and 16 weeks, and after 6 months) of the study groups will be analysed using an ordinary two-way analysis of variance. ETHICS AND DISSEMINATION: This trial was approved by the Brazilian National Ethics Committee and obtained approval on 7 October 2020 (document number 4324069). The findings will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT04595097.

Moral Distress and Moral Injury in Nephrology During the COVID-19 Pandemic.

Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.