An exploration of the experiences of respiratory clinical nurse specialists (CNS) and advance nurse practitioners (ANP) in Irish healthcare settings

Background: Nursing practice in Ireland are continually evolving. The introduction of the respiratory CNS/ANP role is one of the most significant changes in recent years. Respiratory CNS/ANP have responsibilities under their scope of practice NMBI (2015) to contribute to the education of their colleagues and patients. The respiratory CNS and ANP brings benefits for patients and consultants, however, raises issues in relation to boundaries affecting identity. Aim(s): Exploring the experience of respiratory CNS/ANP education, knowledge, learning and wellbeing in their clinical health environment. Methodology: This qualitative study is influenced by hermeneutic phenomenology. Ethical approval and permission were obtained, and a gatekeeper forwarded study information to potential participants. Fifteen participants participated in one-to-one semi-structured interviews, via digital media, recorded and transcribed. Result(s): Findings suggest that respiratory CNS/ANP enhance nursing professionalisation which was especially during COVID-19 pandemic and contribute to the empowerment of nursing and nurse education. Respiratory CNS/ANP enhances, compliments nursing practice, enabling a more agentic practitioner, though challenges to this have been identified. Conclusion(s): This study provides an account of the practice and experiences of respiratory CNS/ANP in the Irish health care setting, developing direct knowledge from those experiences. Findings from this research can inform those with direct responsibility for the regulation of respiratory CNS/ANP nursing practice and those responsible for education and research in the nurse context.

Health information use by patients with systemic lupus erythematosus (SLE) pre and during the COVID-19 pandemic.

OBJECTIVE: We conducted an international survey of patients with SLE to assess their access, preference and trust in various health information sources pre-COVID-19 and during the COVID-19 pandemic. METHODS: Patients with SLE were recruited from 18 observational cohorts, and patients self-reporting SLE were recruited through five advocacy organisations. Respondents completed an online survey from June 2020 to December 2021 regarding the sources of health information they accessed in the 12 months preceding (pre-11 March 2020) and during (post-11 March 2020) the pandemic. Multivariable logistic regressions assessed factors associated with accessing news and social media post-11 March 2020, and self-reporting negative impacts from health information accessed through these sources. RESULTS: Surveys were completed by 2111 respondents; 92.8% were female, 76.6% had postsecondary education, mean (SD) age was 48.8 (14.0) years. Lupus specialists and family physicians were the most preferred sources pre-11 March 2020 and post-11 March 2020, yet were accessed less frequently (specialists: 78.5% pre vs 70.2% post, difference -8.3%, 95% CI -10.2% to -6.5%; family physicians: 57.1% pre vs 50.0% post, difference -7.1%, 95% CI -9.2% to -5.0%), while news (53.2% pre vs 62.1% post, difference 8.9%, 95% CI 6.7% to 11.0%) and social media (38.2% pre vs 40.6% post, difference 2.4%, 95% CI 0.7% to 4.2%) were accessed more frequently post-11 March 2020 vs pre-11 March 2020. 17.2% of respondents reported negative impacts from information accessed through news/social media. Those outside Canada, older respondents or with postsecondary education were more likely to access news media. Those in Asia, Latin America or younger respondents were more likely to access social media. Those in Asia, older respondents, males or with postsecondary education in Canada, Asia or the USA were less likely to be negatively impacted. CONCLUSIONS: Physicians, the most preferred and trusted sources, were accessed less frequently, while news and social media, less trusted sources, were accessed more frequently post-11 March 2020 vs pre-11 March 2020. Increasing accessibility to physicians, in person and virtually, may help reduce the consequences of accessing misinformation/disinformation.

Confinement, Care, and Commodification in Mati Diop’s In My Room

In her article, “Confinement, Care, and Commodification in Mati Diop’s In My Room,” Brittany Murray discusses a short film released in 2020 by the French and Senegalese director, Mati Diop. Shot in the artist’s studio in a Parisian banlieue during mandatory Covid-19 confinement, the film tackles the issues of grief, isolation, and care. The article shows how the film represents these issues, particularly urgent during the pandemic and yet belonging to longstanding concerns about care work and reproductive labor. To mediate between present crisis and a larger historical framework, the article demonstrates how the film’s formal attributes make a claim to artistic autonomy. Finally, the article shows how the film might point to opportunities for collective action meant to construct alternatives to the ongoing crises of capitalism. © Purdue University.

Design of the National Adaptive Trial for PTSD-related Insomnia (NAP Study), VA Cooperative Study Program (CSP) #2016.

There are currently no validated pharmacotherapies for posttraumatic stress disorder (PTSD)-related insomnia. The purpose of the National Adaptive Trial for PTSD-Related Insomnia (NAP Study) is to efficiently compare to placebo the effects of three insomnia medications with different mechanisms of action that are already prescribed widely to veterans diagnosed with PTSD within U.S. Department of Veterans Affairs (VA) Medical Centers. This study plans to enroll 1224 patients from 34 VA Medical Centers into a 12- week prospective, randomized placebo-controlled clinical trial comparing trazodone, eszopiclone, and gabapentin. The primary outcome measure is insomnia, assessed with the Insomnia Severity Index. A novel aspect of this study is its adaptive design. At the recruitment midpoint, an interim analysis will be conducted to inform a decision to close recruitment to any "futile" arms (i.e. arms where further recruitment is very unlikely to yield a significant result) while maintaining the overall study recruitment target. This step could result in the enrichment of the remaining study arms, enhancing statistical power for the remaining comparisons to placebo. This study will also explore clinical, actigraphic, and biochemical predictors of treatment response that may guide future biomarker development. Lastly, due to the COVID-19 pandemic, this study will allow the consenting process and follow-up visits to be conducted via video or phone contact if in-person meetings are not possible. Overall, this study aims to identify at least one effective pharmacotherapy for PTSD-related insomnia, and, perhaps, to generate definitive negative data to reduce the use of ineffective insomnia medications. NATIONAL CLINICAL TRIAL (NCT) IDENTIFIED NUMBER: NCT03668041.

Reimbursement for clinical services provided by ambulatory care pharmacists via telehealth

Introduction: Data specific to pharmacists' value in patient-provided clinical services in New York are limited due to their scope of practice restrictions. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there has been an expansion of telehealth and allowance for billable services for pharmacists. Objectives: The objective of this study was to complete a retrospective review to assess reimbursement of clinical services provided by pharmacists via telehealth during the pandemic in a primary care setting. Methods: A report was generated which identified patients 18 years and older, who were provided services by pharmacists within a primary care group via telehealth during March to July 2020 in New York. It identified patients with an appointment type code of “PharmD Telemed 30” or “PharmD TM Follow UP 15,” including Medicare Annual Wellness Visits or AWVs (G0438-G0439) with procedural codes, and incident-to CPT codes (99211-99214). Information received included medical record number, name, date of birth, carrier plan name, billed procedure code and description, carrier payment amount, and patient responsible amount. Results: A total of 485 patients were provided services during the timeframe. There were 223 encounters billed for the 99 211 CPT code, 156 of which received payment from insurers with an average of $20.14. For initial and subsequent AWVs there were a total of 48 and 150 encounters, respectively, billed by the pharmacists. Forty-one of the encounters billed as a G0438 received payment from insurers with an average of $175.75. One hundred thirty-three of the encounters billed as a G0439 received payment from insurers with an average payment of $114.09. Conclusion: The results of this study provided insight into whether specific services or insurances should be targeted for payment of services. Expansion of these services could show improvement in patient care and can assist in gathering outcomes to better support pharmacists gaining provider status on the state and national level.

Decline In New Starts Of Psychotropic Medications During The COVID-19 Pandemic.

COVID-19 interrupted delivery of mental health care in the US. During the initial course of the COVID-19 pandemic new starts of antidepressants declined by 7.5 percent, anxiolytics by 5.6 percent, and antipsychotics by 2.6 percent compared with expected levels. Our findings suggest that there is large unmet need for mental health treatment in the US due to COVID-19.

144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts

Introduction COVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults. Methods Observational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over;unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020;COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322);(ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020;self-report or report-by-proxy data;reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough. Results Hospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough. Conclusions This study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.

Pronation response as a predictor of COVID-19-related acute respiratory distress syndrome mortality

INTRODUCTION: Severe acute respiratory failure is a common complication of COVID-19, with refractory hypoxemia being a hallmark finding in severe illness and a common cause of mortality. With limited therapeutic strategies, management centers on good supportive care. Prone positioning has been shown to improve oxygenation and survival in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) but the impact of prone positioning in COVID-19 with severe hypoxemia is unknown. This study aims to examine the response to proning as a predictor of COVID-19 related mortality. METHODS: This is a single-center, retrospective analysis of critically ill patients with COVID-19 confirmed by PCR. Patients were included if they were invasively ventilated, and if supportive care included prone positioning for management of refractory hypoxemia. Data points collected include demographics, ventilator settings, rates of mortality and progression to ECMO, ventilator-days, and time between symptom onset and intubation, hospital and ICU admission. Endpoints included response in oxygenation (PaO2:FiO2) and mortality. RESULTS: Forty-nine patients were included in the analysis. The average age was 56.9, and 61% of the patients were male. Patients had an average of 19 ventilator-days (2-52), 21 ICU-days (4-54), 26 hospital-days (8-65), an ECMO rate of 27%, and a mortality rate of 55%. Of the 22 survivors, there was an average increase in PaO2:FiO2 by 108, 93.1, and 93 for each of the first three pronations respectively. For the 27 nonsurvivors, there was an average increase in PaO2:FiO2 by 76.1, 84.3, and 50.9 for the first three pronations. The difference in improvement in PaO2:FiO2 was not statistically significant between survivors and non-survivors. There was no inflection point that could be determined that provided a high sensitivity and specificity to predict mortality or need for ECMO based on response to pronation at any of the time points. CONCLUSIONS: Proning improves PaO2:FiO2 in patients with severe hypoxemia related to COVID-19. Survivors in our study had a numerically greater response to proning, but this finding was not statistically significant. The clinical significance remains unclear. Larger studies assessing the efficacy of proning in critically ill patients with COVID-19 are needed.

Characterization of cytokine expression in critically ill patients with COVID-19

INTRODUCTION: Early commentary on SARS-CoV-2 infection proposed a mechanism of cytokine release syndrome (CRS) to explain severe acute respiratory failure associated with COVID-19. Management strategies have included targeted immunomodulation with biologic agents. The role of IL-6 and other cytokines in the pathogenesis of COVID-19 is not well defined. Evidence for use of immunomodulators has been mixed and these agents may expose patients to harm. This study aims to characterize the expression of cytokines and their association with inflammatory biomarkers and outcomes in critically ill patients with COVID-19. METHODS: This was a single-center, retrospective analysis of critically ill patients with COVID-19 confirmed by PCR. Patients were included if they had a partial or full cytokine panel drawn while admitted. Descriptive statistics were used to assess demographics, outcomes, and relationships between cytokine levels and inflammatory markers. The Mann- Whitney U Test was used to compare IL-6 levels between survivors and nonsurvivors. RESULTS: Eighty-nine patients were included with 68 full cytokine panels and 108 IL-6 levels. Patients had a mean (range) of 10 ventilator-days (0-47), 15 ICU-days (1-60), 20 hospital-days (3-69) and a mortality rate of 31%. Cytokine levels were assessed a median of 10 days from symptom onset and 1 day from ICU admission. Levels of IL-1B, IL-2, IL-4, IL-5, IL-8, IL-12, IL-13, IL-17, IFN-G, and TNF-A were undetectable in at least 80% of patients, and expression did not correlate with other inflammatory biomarkers (CRP, ferritin), severity of illness (SOFA), or outcome. IL-2R levels were numerically elevated in most patients (n=68;median 1227, range: 76-30670). IL-6 levels were mildly elevated (n=108;median: 31, range: 2-882, SD: 150), and levels were statistically significantly higher in nonsurvivors (p = 0.002). CONCLUSIONS: Assessment of cytokine levels in critically ill patients with COVID-19 does not support a hypothesis of CRS. While IL-6 levels were numerically higher in nonsurvivors, the clinical significance of this finding is unknown. The role of IL-2R in the pathogenesis of COVID-19 remains unclear. Larger studies exploring the role of inflammatory mediators in pathogenesis and targeted immunomudulators in management of COVID-19 are warranted.

Remote or Removed: Predicting Successful Engagement with Online Learning during COVID-19

Using data from a spring 2020 survey of nearly 10,000 parents of elementary school parents in one large southeastern public school district, the authors investigate predictors of elementary school student engagement during the initial period of pandemic remote learning. The authors hypothesize that household material and technological resources, school programming and instructional strategies, and family social capital contribute to student engagement in remote learning. The analyses indicate that even after controlling for rich measures of family socioeconomic resources, students with access to high-speed Internet and Internet-enabled devices have higher levels of engagement. Exposure to more diverse socioemotional and academic learning opportunities further predicts higher levels of engagement. In addition, students whose families remained socially connected to other students’ families were more likely to engage online. © The Author(s) 2021.

Optimal symptom combinations to aid COVID-19 case identification: Analysis from a community-based, prospective, observational cohort.

OBJECTIVES: Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health. METHODS: UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity. FINDINGS: UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC. INTERPRETATION: We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.

Diagnostic value of cutaneous manifestation of SARS-CoV-2 infection.

BACKGROUND: One of the challenging aspects of SARS-CoV-2 infection is its diverse multisystemic disease presentation. OBJECTIVES: To evaluate the diagnostic value of cutaneous manifestations of SARS-CoV-2 infection and investigate their duration and timing in relation to other COVID-19 symptoms. METHODS: We used data from 336 847 UK users of the COVID Symptom Study app to assess the diagnostic value of body rash or an acral rash in SARS-CoV-2 infection, and data from an independent online survey of 11 544 respondents to investigate skin-specific symptoms and collect their photographs. RESULTS: Using data from the app, we show significant association between skin rashes and a positive swab test result (odds ratio 1·67, 95% confidence interval 1·42-1·97). Strikingly, among the respondents of the independent online survey, we found that 17% of SARS-CoV-2-positive cases reported skin rashes as the first presentation, and 21% as the only clinical sign of COVID-19. Together with the British Association of Dermatologists, we have compiled a catalogue of images of the most common skin manifestations of COVID-19 from 400 individuals (https://covidskinsigns.com), which we have made publicly available to assist clinicians in recognition of this early clinical feature of COVID-19. CONCLUSIONS: Skin rashes cluster with other COVID-19 symptoms, are predictive of a positive swab test, and occur in a significant number of cases, either alone or before other classical symptoms. Recognizing rashes is important in identifying new and earlier cases of COVID-19.

Optimal symptom combinations to aid COVID-19 case identification: analysis from a community-based, prospective, observational cohort.

OBJECTIVES: Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health. METHODS: UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity. FINDINGS: UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC. INTERPRETATION: We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.