Interrelationships among College Students' Perceptions of Smart Classroom Environments, Perceived Usefulness of Mobile Technology, Achievement Emotions, and Cognitive Engagement.

Cognitive engagement is a crucial factor that shapes successful learning outcomes, but our understanding of the factors that influence such engagement in the smart classroom context remains limited. This study aims to narrow this research gap by exploring the relationships among college students' perceptions of the smart learning environment, perceived usefulness of mobile technology, achievement emotions, and cognitive engagement. A total of 1293 college students completed an online questionnaire survey, and 1076 valid responses were received. Structural equation modeling was used to analyze the interrelationships among these factors. The results revealed that students' perceptions of the smart classroom environment and perceived usefulness of mobile technology as well as two achievement emotions (pride and anxiety) significantly impact cognitive engagement. Both pride and anxiety act as mediators in the relationships among perceptions of smart classroom environments, the perceived usefulness of mobile technology, and cognitive engagement, in which context the mediating effect of pride is stronger than that of anxiety. These findings have practical implications for instructors, who should focus on implementing strategies that promote positive achievement emotions when students use mobile technology in smart classrooms. Additionally, these findings can inform the design and construction of smart classroom environments. Moreover, our study has limitations due to reliance on online data collection and self-reported data, which may introduce biases and measurement errors. Future research should incorporate multimodal data and advanced technologies for a comprehensive assessment to better understand students' engagement in smart learning environments, while also considering individual factors and the educational context to enhance the effectiveness of mobile technology in supporting students' emotions and achievement.

Corrigendum: Tracheal intubation in patients with Pierre Robin sequence: development, application, and clinical value based on a 3-dimensional printed simulator.

[This corrects the article DOI: 10.3389/fphys.2023.1292523.].

Global research and scientific publications on PND between 1969 and 2022: A bibliometric analysis.

Objectives: We hope to offer a comprehensive understanding of the advancements and patterns in research on PND. Methods: We performed a thorough search on the Web of Science Core Collection to locate relevant studies published from 1969 to 2022 and utilized four distinct tools, namely VOSviewer (J Data Inf Sci, 2017, 2, 1; J Am Soc Inf Sci, 1973, 24, 265; Amer Doc, 1963, 14, 10 and Scientometrics, 2010, 82, 581), CiteSpace (Scientometrics, 2010, 84, 523), Scimago Graphica, and R-bibliometrix which allowed us to examine various aspects. Results: We included a total of 6787 articles and reviews for analysis which described PND research, the sources, and the subfields; highlighted the significant developments in this field; identified three main directions in PND.Conclusion: This study highlights the rapid growth of research on PND in recent years and provided an overview of previous studies in the field of PND, thereby establishing the overall landscape of PND research and identifying potential avenues for future investigations. Methods: We performed a thorough search on the Web of Science Core Collection to locate relevant studies published from 1969 to 2022. To perform bibliometric analysis and network visualization, we utilized four distinct tools, namely VOSviewer (J Data Inf Sci, 2017, 2, 1; J Am Soc Inf Sci, 1973, 24, 265; Amer Doc, 1963, 14, 10 and Scientometrics, 2010, 82, 581), CiteSpace (Scientometrics, 2010, 84, 523), Scimago Graphica, and R-bibliometrix. These tools allowed us to examine various aspects, including the yearly publication output, the contribution of different countries or regions, the involvement of active journals, co-citation analysis, publication status, keywords, and terms, as well as scientific categories. We hope to offer a comprehensive understanding of the advancements and patterns in research on PND. The insights gained from this study can assist researchers and clinicians in enhancing the management and implementation of their work in this field. Results: In this study, we included a total of 6787 articles and reviews for analysis. First, publication trends and contribution by country analysis described PND research. Second, a historical analysis described PND research, the sources, and the subfields. Third, an analysis of keywords highlighted the significant developments in this field. Fourth, an analysis of research themes identified three main directions in PND. Conclusion: In summary, the research volume exhibits exponential growth over time. Furthermore, the majority of contributions originate from Western countries and China. The interdisciplinary nature of the field is evident, with its roots in biology and medicine and further branching into psychology and social sciences. POCD, delirium-predominant associated clinical management were major research themes about PND.

Expert consensus on difficult airway assessment.

Background: Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety. Methods: Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts. Results: This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway. Conclusions: This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

To compare the influence of blind insertion and up-down optimized glottic exposure manoeuvre on oropharyngeal leak pressure using SaCoVLM™ video laryngeal mask among patients undergoing general anesthesia.

To compare the potential influences of blind insertion and up-down optimized glottic exposure manoeuvre on the oropharyngeal leak pressure (OPLP) in using SaCoVLM™ video laryngeal mask (VLM) among patients undergoing general anesthesia. A randomized self-control study controlled was conducted to investigate the effect of two insertion techniques on OPLP. A total of 60 patients (male or female, 18-78 years, BMI 18.0-30.0 kg m-2 and ASA I-II) receiving selective surgery under general anesthesia were randomly recruited. After induction of anesthesia, the SaCoVLM™ was inserted by blind insertion manoeuvre. The glottic exposure grading(V1) of the SaCoVLM™ visual laryngeal mask and the OPLP(P1) were recorded. And the glottic exposure grading(V2) and OPLP(P2) of SaCoVLM™ were recorded again when the glottic exposure grading was optimal. The glottis exposure grading and OPLP were compared before and after different insertion manoeuver. The glottic exposure grading (V2) obtained by using up-down optimized glottic exposure manoeuvre was better than that obtained by using blind insertion manoeuvre (V1)(P < 0.001). The OPLP was significantly lower in the blind insertion manoeuvre (P1) than in the up-down optimized glottic exposure manoeuvre (P2) (32.4 ± 5.0 cmH2O vs. 36.3 ± 5.2 cmH2O, P < 0.001). In using SaCoVLM™, higher OPLP and better glottic exposure grading were achieved through up-down optimized glottic exposure manoeuvre, protecting the airway while real-time monitoring of conditions around the glottis, which significantly improves airway safety. Our results suggests that up-down optimized glottic exposure manoeuver may be a useful technique for SaCoVLM™ insertion.Trial registration: ChiCTR, ChiCTR2000028802. Registered 4 January 2020, http://www.chictr.org.cn/ChiCTR2000028802.

Tracheal intubation in patients with Pierre Robin sequence: development, application, and clinical value based on a 3-dimensional printed simulator.

Background: The main clinical manifestations of patients with Pierre Robin sequence (PRS) include micrognathia, the glossoptosis and dyspnoea. The difficulty of tracheal intubation (TI) in such patients is increased. Objective: The purpose of the study was to evaluate the reliability and efficacy of the PRS simulator. Methods: A PRS simulator was developed by using 3-dimensional (3D) printing technology under computer-aided design. A total of 12 anaesthesiologists each trained 5 times for TI on the PRS Training Simulator-1 and recorded the simulation time. After the training, they were randomly divided into three groups with a total of 12 nontrained anaesthesiologists, and the simulation was completed on PRS Simulator-2, 3 and 4. The simulation time was recorded, and the performance was evaluated by three chief anaesthesiologists. Then, all 24 anaesthesiologists completed the questionnaire. Results: A PRS simulator developed by 3D printing was used to simulate the important aspects of TI. The average number of years worked was 6.3 ± 3.1 years, and 66.7% were female. The time for the 12 anaesthesiologists to complete the training gradually decreased (p < 0.01). Compared with the trained anaesthesiologists, the simulation time of TI in the nontrained anaesthesiologists was much longer (all p < 0.01). In addition, the simulation performance of the trained anaesthesiologists was relatively better (all p < 0.01). Conclusion: The reliability and efficacy of the PRS simulator is herein preliminarily validated, and it has potential to become a teaching and training tool for anaesthesiologists.

Comparison of the supraglottic airway device BlockBusterTM and laryngeal mask airway Supreme in anaesthetised, paralyzed adult patients: a multicenter randomized controlled trial.

BACKGROUND: This multicenter prospective, randomized controlled clinical trial compared the clinical performance of supraglottic airway device (SAD) BlockBusterTM and laryngeal mask airway (LMA) Supreme for airway maintenance in anesthetized, paralyzed adult patients. METHODS: A total of 651 adult patients scheduled for elective surgery in 13 hospitals were randomly allocated into BlockBuster group (n = 351) or Supreme group (n = 300). The primary outcome was oropharyngeal leak pressure (OLP). Duration and ease of insertion, fiberscopic view of positioning, airway manipulations, and complications were also assessed. RESULTS: The OLP was significantly higher in BlockBuster group compared with Supreme group (29.9 ± 4.2 cmH2O vs 27.4 ± 4.3 cmH2O, p < 0.001). Success rate of insertion at the first attempt (90.2% vs 85.1%, p = 0.027), rate of optimal fiberscopic view (p = 0.002) and satisfactory positioning of SAD (p < 0.001) were significantly increased in BlockBuster group. CONCLUSIONS: Both SAD BlockBusterTM and LMA Supreme are safe, effective, and easy-to-use devices for airway maintenance in anesthetized, paralyzed adult patients, but the SAD BlockBusterTM is superior to LMA Supreme in terms of OLP, success rate at the first attempt, and fiber-optic view of positioning. TRIAL REGISTRATION: The trial is registered at www.chictr.org.cn (ChiCTR-ONC-16009105).

Comparison of SaCoVLM™ video laryngeal mask-guided intubation and i-gel combined with flexible bronchoscopy-guided intubation in airway management during general anesthesia: a non-inferiority study.

BACKGROUND: When a difficult airway is unanticipatedly encountered and the initial laryngoscopic intubation fails, a supraglottic airway device (SAD) may be placed to aid ventilation and oxygenation, and act as a conduit for intubation. SaCoVLM™, as new SAD, can offer a direct vision to guide intubation. However, no study has evaluated the performance of SaCoVLM™ video laryngeal mask (VLM) intubation and i-gel combined with flexible bronchoscopy (FB)-guided intubation in airway management during general anesthesia. METHODS: A total of 120 adult patients were randomly allocated into the SaCoVLM™ group (Group S) and i-gel group (Group I). After induction of general anesthesia, guided tracheal intubation under direct vision of the SaCoVLM™ was conducted in Group S, while Group I received FB-guided tracheal intubation using the i-gel. The success rate of SAD placement, first-pass success rate of guided tracheal tube placement, and total success rate in both groups were recorded. The time for SAD placement, time for guided tracheal intubation, total intubation time (time for SAD placement and intubation), glottic exposure grading and postoperative intubation complications (i.e., dysphagia, hoarseness, pharyngalgia, etc.) of both groups were also compared. RESULTS: The first-time success rate of SAD placement was 98% in two groups. The first-pass success rate of guided endotracheal intubation was 92% in Group S and 93% in Group I (P = 0.74 > 0.05). The total intubation time was 30.8(± 9.7) s and 57.4(± 16.6) s (95% CI = -31.5 to -21.7) in Group S and Group I, respectively (P < 0.01). The total complication rate was 8% in Group S and 22% in Group I (P < 0.05). The laryngeal inlet could be observed in the S group through the visual system of SaCoVLM™. No dysphagia or hoarseness was reported. CONCLUSION: SaCoVLM™ can reveal the position of laryngeal inlet, thus providing direct vision for tracheal intubation. SaCoVLM™ -guided intubation is faster, and does not rely on FB, compared to i-gel combined with FB-guided intubation. Besides, SaCoVLM™ has a lower post-intubation complication rate. TRIAL REGISTRATION: Chinese Clinical Trials Registry (ChiCTR2100043443); Date of registration: 18/02/2021.

Preliminary evaluation of SaCoVLM™ video laryngeal mask airway in airway management for general anesthesia.

BACKGROUND: To preliminary evaluate the application of SaCoVLM™ video laryngeal mask airway in airway management of general anesthesia. METHODS: We recruited 100 adult patients (ages 18-78 years, male 19, female 81, weight 48-90 kg) with normal predicted airway (Mallampati I ~ II, unrestricted mouth opening, normal head and neck mobility) and ASA I-II who required general anaesthesia. The SaCoVLM™ was inserted after anesthesia induction and connected with the anesthesia machine for ventilation. Our primary outcome was glottic visualization grades. Secondary outcomes included seal pressure, success rate of insertion, intraoperative findings (gastric reflux and contraposition), gastric drainage and 24-h complications after operation. RESULTS: The laryngeal inlet was exposed in all the patients and shown on the video after SaCoVLM™ insertion. The status of glottic visualization was classified: grade 1 in 55 cases, grade 2 in 23 cases, grade 3 in 14 cases and grade 4 in 8 cases. The first-time success rate of SaCoVLM™ insertion was 95% (95% CI = 0.887 to 0.984), and the total success rate was 96% (95% CI = 0.901 to 0.989). The sealing pressure of SaCoVLM™ was 34.1 ± 6.2 cmH2O and the gastric drainage were smooth. Only a small number of patients developed mild complications after SaCoVLM™ was removed (such as blood stains on SaCoVLM™ and sore throat). CONCLUSIONS: The SaCoVLM™ can visualize partial or whole laryngeal inlets during the surgery, with a high success rate, a high sealing pressure and smooth gastroesophageal drainage. SaCoVLM™ could be a promise new effective supraglottic device to airway management during general anesthesia. TRIAL REGISTRATION: ChiCTR, ChiCTR2000028802 .Registered 4 January 2020.

K-12 students' online learning motivation in China: An integrated model based on community of inquiry and technology acceptance theory.

Learning motivation is crucial to online learning success, especially for K-12 students. Although previous research has proved that there are many factors influencing online learning motivation, few studies have systematically investigated this phenomenon from the integrated perspectives of community of inquiry and technology acceptance, two theoretical frameworks that are commonly used to explain experiences of and attitude towards online learning. This study investigates the effects of K-12 students' perceived presence and technology acceptance on their online learning motivation. A total of 13,610 valid questionnaires were collected from K-12 students from Wuhan and adjacent areas in central China participated in the survey. The findings reveal that: (1) perceived usefulness, self-efficacy, social presence, and perceived ease of use have a larger positive effect on online learning motivation, while cognitive presence has a small positive effect on online learning motivation; (2) teaching presence positively influences online learning motivation through social or cognitive presence; (3) factors, such as school location, previous online learning experience, family social-economic status, and prior academic achievements, may influence technology acceptance. The implications for designing, developing, and managing K-12 online education are discussed.

Electroacupuncture Pretreatment Mitigates Myocardial Ischemia/Reperfusion Injury via XBP1/GRP78/Akt Pathway.

Myocardial ischemia/reperfusion injury is a common clinical problem and can result in severe cardiac dysfunction. Previous studies have demonstrated the protection of electroacupuncture against myocardial ischemia/reperfusion injury. However, the role of X-box binding protein I (XBP1) signaling pathway in the protection of electroacupuncture was still elusive. Thus, we designed this study and demonstrated that electroacupuncture significantly improved cardiac function during myocardial ischemia/reperfusion injury and reduced cardiac infarct size. Electroacupuncture treatment further inhibited cardiac injury manifested by the decrease of the activities of serum lactate dehydrogenase and creatine kinase-MB. The results also revealed that electroacupuncture elevated the expressions of XBP1, glucose-regulated protein 78 (GRP78), Akt, and Bcl-2 and decreased the Bax and cleaved Caspase 3 expressions. By using the inhibitor of XBP1 in vitro, the results revealed that suppression of XBP1 expression could markedly increase the activities of lactate dehydrogenase and creatine kinase-MB and cell apoptosis, thus exacerbating stimulated ischemia/reperfusion-induced H9c2 cell injury. Compared with stimulated ischemia/reperfusion group, inhibition of XBP1 inhibited the downstream GRP78 and Akt expressions during stimulated ischemia/reperfusion injury. Collectively, our data demonstrated that electroacupuncture treatment activated XBP1/GRP78/Akt signaling to protect hearts from myocardial ischemia/reperfusion injury. These findings revealed the underlying mechanisms of electroacupuncture protection against myocardial ischemia/reperfusion injury and may provide novel therapeutic targets for the clinical treatment of myocardial ischemia/reperfusion injury.

Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.

BACKGROUND: Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural-general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. METHODS: Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. RESULTS: Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural-general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural-general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001). CONCLUSIONS: Older patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.

Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial.

BACKGROUND: Experimental and observational research suggests that combined epidural-general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural-general anesthesia improves long-term survival in elderly patients. METHODS: This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival. RESULTS: Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural-general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural-general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural-general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural-general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815. CONCLUSIONS: In elderly patients having major thoracic and abdominal surgery, combined epidural-general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference.

Factors affecting the risk of SARS-CoV-2 transmission to anesthesiologists performing endotracheal intubation in patients with SARS-CoV-2.

BACKGROUND: In this study, we estimated the predictive factors of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in anesthesiologists performing endotracheal intubation in patients with confirmed SARS-CoV-2. METHOD: We analyzed data from a survey conducted by the Chinese Society of Anesthesiology Task Force on Airway Management on endotracheal intubation in 98 patients with SARS-CoV-2 confirmed through nucleic acid testing and chest computed tomography. The multivariate logistic model with stepwise selection was used for selecting the predictive factors significantly associated with SARS-CoV-2 infection in the corresponding anesthesiologists. RESULTS: SARS-CoV-2 prevalence in the corresponding anesthesiologists was 20.41% after intubation in patients with SARS-CoV-2. Univariate analysis indicated that intubation for elective treatment, intubation in an operating room or isolation ward, and routine rapid induction with continuous positive-pressure ventilation (PPV) for intubation were associated with a lower SARS-CoV-2 risk in the anesthesiologists. Multivariate analysis revealed that intubation for elective treatment was associated with a significantly decreased SARS-CoV-2 risk (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI]: 0.14-0.68, P < 0.0001), and coughing by patients during endotracheal intubation was associated with a significantly increased SARS-CoV-2 risk (aOR = 1.70, 95% CI: 1.39-2.97, P = 0.0404) in the anesthesiologists. CONCLUSION: Endotracheal intubation for elective treatments, intubation in an operating room or isolation ward, and routine rapid induction with continuous PPV for patients with confirmed SARS-CoV-2 are associated with a lower risk of SARS-CoV-2 transmission in practicing anesthesiologists, and coughing by patients during intubation increases the risk.

Acquired infection after intubating patients with COVID-19: Datasets.

Thirty-six anesthesia departments in 36 hospitals in four provinces of China where an outbreak of COVID-19 occurred were surveyed. We found that there were ten anesthesiologists (5 male and 5 female) who contracted the infection after performing intubation, as well as 4 nurses (1 male and 3 female) who contracted the infection after assisting with the intubation. This is a retrospective investigation and no intervention was applied. The numbers are presented as mean ± Standard Deviation (SD). We used Graphpad Prism (version 8.2.1 Windows version, GraphPad Software, San Diego). Fisher's exact test at a two-sided significance level of 0.05 was used to identify potential risk factor (s) for intubation providers. A P value less than 0.05 is considered statistically significant. A total of 211 anesthesiologists from four provinces were involved in the intubation of 664 patients with confirmed or potential COVID-19. Of these 644 patients, 640 cases were eventually confirmed with a diagnosis of COVID-19. Among the 211 anesthesiologists who performed intubation, 10 of them had a confirmed diagnosis of COVID-19 afterwards. Coughing is a risk factor for provider infection (P = 0.0001). The number of intubation attempts (within three attempts) did not increase the risk of the infection. All of the affected anesthesiologists had symptoms 2-12 days after the intubation encounter (average 6 ±â€¯3 days). All had radiological image evidence of bilateral pneumonia and all reported relatively mild symptoms. The affected doctors were out of clinical service for 20-60 days (average 46 ±â€¯12 days). Seven of the doctors have been discharged from the hospital, but three of them remain hospitalized. Four nurses who assisted with intubations contracted COVID-19. One of these nurses was in critical condition but was eventually discharged with a loss of 50 days of clinical service. The remaining three nurses have had mild symptoms so far, but one is still hospitalized.