Clinical Epidemiology and Risk Factors for Critical Outcomes Among Vaccinated and Unvaccinated Adults Hospitalized With COVID-19-VISION Network, 10 States, June 2021-March 2023.

BACKGROUND: The epidemiology of coronavirus disease 2019 (COVID-19) continues to develop with emerging variants, expanding population-level immunity, and advances in clinical care. We describe changes in the clinical epidemiology of COVID-19 hospitalizations and risk factors for critical outcomes over time. METHODS: We included adults aged ≥18 years from 10 states hospitalized with COVID-19 June 2021-March 2023. We evaluated changes in demographics, clinical characteristics, and critical outcomes (intensive care unit admission and/or death) and evaluated critical outcomes risk factors (risk ratios [RRs]), stratified by COVID-19 vaccination status. RESULTS: A total of 60 488 COVID-19-associated hospitalizations were included in the analysis. Among those hospitalized, median age increased from 60 to 75 years, proportion vaccinated increased from 18.2% to 70.1%, and critical outcomes declined from 24.8% to 19.4% (all P < .001) between the Delta (June-December, 2021) and post-BA.4/BA.5 (September 2022-March 2023) periods. Hospitalization events with critical outcomes had a higher proportion of ≥4 categories of medical condition categories assessed (32.8%) compared to all hospitalizations (23.0%). Critical outcome risk factors were similar for unvaccinated and vaccinated populations; presence of ≥4 medical condition categories was most strongly associated with risk of critical outcomes regardless of vaccine status (unvaccinated: adjusted RR, 2.27 [95% confidence interval {CI}, 2.14-2.41]; vaccinated: adjusted RR, 1.73 [95% CI, 1.56-1.92]) across periods. CONCLUSIONS: The proportion of adults hospitalized with COVID-19 who experienced critical outcomes decreased with time, and median patient age increased with time. Multimorbidity was most strongly associated with critical outcomes.

Relationships Between Social Vulnerability and Coronavirus Disease 2019 Vaccination Coverage and Vaccine Effectiveness.

BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccination coverage remains lower in communities with higher social vulnerability. Factors such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure risk and access to healthcare are often correlated with social vulnerability and may therefore contribute to a relationship between vulnerability and observed vaccine effectiveness (VE). Understanding whether these factors impact VE could contribute to our understanding of real-world VE. METHODS: We used electronic health record data from 7 health systems to assess vaccination coverage among patients with medically attended COVID-19-like illness. We then used a test-negative design to assess VE for 2- and 3-dose messenger RNA (mRNA) adult (≥18 years) vaccine recipients across Social Vulnerability Index (SVI) quartiles. SVI rankings were determined by geocoding patient addresses to census tracts; rankings were grouped into quartiles for analysis. RESULTS: In July 2021, primary series vaccination coverage was higher in the least vulnerable quartile than in the most vulnerable quartile (56% vs 36%, respectively). In February 2022, booster dose coverage among persons who had completed a primary series was higher in the least vulnerable quartile than in the most vulnerable quartile (43% vs 30%). VE among 2-dose and 3-dose recipients during the Delta and Omicron BA.1 periods of predominance was similar across SVI quartiles. CONCLUSIONS: COVID-19 vaccination coverage varied substantially by SVI. Differences in VE estimates by SVI were minimal across groups after adjusting for baseline patient factors. However, lower vaccination coverage among more socially vulnerable groups means that the burden of illness is still disproportionately borne by the most socially vulnerable populations.

College student sleep quality and mental and physical health are associated with food insecurity in a multi-campus study.

OBJECTIVE: To assess the relationship between food insecurity, sleep quality, and days with mental and physical health issues among college students. DESIGN: An online survey was administered. Food insecurity was assessed using the ten-item Adult Food Security Survey Module. Sleep was measured using the nineteen-item Pittsburgh Sleep Quality Index (PSQI). Mental health and physical health were measured using three items from the Healthy Days Core Module. Multivariate logistic regression was conducted to assess the relationship between food insecurity, sleep quality, and days with poor mental and physical health. SETTING: Twenty-two higher education institutions. PARTICIPANTS: College students (n 17 686) enrolled at one of twenty-two participating universities. RESULTS: Compared with food-secure students, those classified as food insecure (43·4 %) had higher PSQI scores indicating poorer sleep quality (P < 0·0001) and reported more days with poor mental (P < 0·0001) and physical (P < 0·0001) health as well as days when mental and physical health prevented them from completing daily activities (P < 0·0001). Food-insecure students had higher adjusted odds of having poor sleep quality (adjusted OR (AOR): 1·13; 95 % CI 1·12, 1·14), days with poor physical health (AOR: 1·01; 95 % CI 1·01, 1·02), days with poor mental health (AOR: 1·03; 95 % CI 1·02, 1·03) and days when poor mental or physical health prevented them from completing daily activities (AOR: 1·03; 95 % CI 1·02, 1·04). CONCLUSIONS: College students report high food insecurity which is associated with poor mental and physical health, and sleep quality. Multi-level policy changes and campus wellness programmes are needed to prevent food insecurity and improve student health-related outcomes.

Evaluation of Pharmacist Renal Dose Adjustments and Planning for Future Evaluations of Pharmacist Services.

Background: Clinical pharmacy services are known to improve patient outcomes. Pharmacists contribute to patient care in the acute care setting in multiple ways, including providing advice and information to patients and the health care team, performing medication histories to prevent waste and support medication adherence, analyzing the cost-effectiveness of medications, and ensuring patient safety through patient monitoring and medication review. Specific clinical pharmacist services include managing intravenous to oral medication adjustments, renal dose adjustments, and performing pharmacokinetic dosing of medications, among others. Many of these clinical services are performed daily but are not evaluated for clinical quality or compliance with policies. Evaluating these clinical services may provide a multitude of benefits to pharmacy departments, health systems, and patients. Methods: The purpose of this study was to evaluate pharmacist use and percent compliance of a renal dose adjustment policy upon initial order verification and discharge. This was completed through retrospective chart review to determine if dose adjustments were made appropriately and descriptive statistics were used to establish pharmacist compliance. Those orders that were inappropriately adjusted were analyzed for trends that could lead to possible policy improvements or pharmacist education opportunities. The completed evaluation also led to the development of an evaluation system that can be utilized to routinely assess clinical pharmacist services. Conclusions: The results of this study are being used to develop and support future clinical service evaluations, inspire process improvements, and improve patient outcomes and pharmacist accountability.

Risk of COVID-19 Hospitalization and Protection Associated With mRNA Vaccination Among US Adults With Psychiatric Disorders.

BACKGROUND: Although psychiatric disorders have been associated with reduced immune responses to other vaccines, it remains unknown whether they influence COVID-19 vaccine effectiveness (VE). This study evaluated risk of COVID-19 hospitalization and estimated mRNA VE stratified by psychiatric disorder status. METHODS: In a retrospective cohort analysis of the VISION Network in four US states, the rate of laboratory-confirmed COVID-19-associated hospitalization between December 2021 and August 2022 was compared across psychiatric diagnoses and by monovalent mRNA COVID-19 vaccination status using Cox proportional hazards regression. RESULTS: Among 2,436,999 adults, 22.1% had ≥1 psychiatric disorder. The incidence of COVID-19-associated hospitalization was higher among patients with any versus no psychiatric disorder (394 vs. 156 per 100,000 person-years, p < 0.001). Any psychiatric disorder (adjusted hazard ratio [aHR], 1.27; 95% CI, 1.18-1.37) and mood (aHR, 1.25; 95% CI, 1.15-1.36), anxiety (aHR, 1.33, 95% CI, 1.22-1.45), and psychotic (aHR, 1.41; 95% CI, 1.14-1.74) disorders were each significant independent predictors of hospitalization. Among patients with any psychiatric disorder, aHRs for the association between vaccination and hospitalization were 0.35 (95% CI, 0.25-0.49) after a recent second dose, 0.08 (95% CI, 0.06-0.11) after a recent third dose, and 0.33 (95% CI, 0.17-0.66) after a recent fourth dose, compared to unvaccinated patients. Corresponding VE estimates were 65%, 92%, and 67%, respectively, and were similar among patients with no psychiatric disorder (68%, 92%, and 79%). CONCLUSION: Psychiatric disorders were associated with increased risk of COVID-19-associated hospitalization. However, mRNA vaccination provided similar protection regardless of psychiatric disorder status, highlighting its benefit for individuals with psychiatric disorders.

Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: assessing the rural food environment, part 1.

INTRODUCTION: Obesity prevalence in the rural United States is higher than in urban or suburban areas, perhaps as a result of the food environment. Because rural residents live farther from supermarkets than their urban- and suburban-dwelling counterparts, they may be more reliant on smaller corner stores that offer fewer healthful food items. METHODS: As part of a Communities Putting Prevention to Work (CPPW) healthy corner store initiative, we reviewed audit tools in the fall of 2010 to measure the consumer food environment in eastern North Carolina and chose the NEMS-S-Rev (Nutrition Environment Measures Survey-Stores-Revised) to assess 42 food stores. During the spring and summer of 2011, 2 trained graduate assistants audited stores, achieving interrater reliability of at least 80%. NEMS-S-Rev scores of stores in rural versus urban areas were compared. RESULTS: Overall, healthful foods were less available and of lower quality in rural areas than in urban areas. NEMS-S-Rev scores indicated that healthful foods were more likely to be available and had similar pricing and quality in rural corner stores than in urban corner stores. CONCLUSION: Food store audit data provided a baseline to implement and evaluate a CPPW healthy corner store initiative in Pitt County. This work serves as a case study, providing lessons learned for engaging community partners when conducting rural food store audits.

Struggling with the basics: food and housing insecurity among college students across twenty-two colleges and universities.

OBJECTIVES: To quantify the number and type of students failing to secure basic needs. PARTICIPANTS: Students attending 22 postsecondary schools in the United States in Fall 2019. METHODS: The Adult Food Security Module and part of the #RealCollege Survey were used to measure food and housing insecurity, respectively. Logistic and linear regression models were used to assess the relationship between selected factors and basic needs insecurities. RESULTS: Participants (n = 22,153) were classified as 44.1% and 52.3% food insecure and housing insecure, respectively. Homeless students or those who experienced childhood food insecurity were at the greatest odds of college food insecurity. Year in school was the largest contributor to being housing insecure, with PhD or EdD students being 1,157% more likely to experience housing insecurity compared to freshmen. CONCLUSIONS: High prevalence of basic needs insecurities remain. Current campus initiatives may be insufficient, calling for a more holistic approach at the campus, state, and national levels.

Expenditure, Coping, and Academic Behaviors among Food-Insecure College Students at 10 Higher Education Institutes in the Appalachian and Southeastern Regions.

BACKGROUND: A number of studies have measured college student food insecurity prevalence higher than the national average; however, no multicampus regional study among students at 4-y institutions has been undertaken in the Appalachian and Southeast regions of the United States. OBJECTIVES: The aims of this study were to determine the prevalence of food insecurity among college students in the Appalachian and Southeastern regions of the United States, and to determine the association between food-insecurity status and money expenditures, coping strategies, and academic performance among a regional sample of college students. METHODS: This regional, cross-sectional, online survey study included 13,642 college students at 10 public universities. Food-insecurity status was measured through the use of the USDA Adult Food Security Survey. The outcomes were associations between food insecurity and behaviors determined with the use of the money expenditure scale (MES), the coping strategy scale (CSS), and the academic progress scale (APS). A forward-selection logistic regression model was used with all variables significant from individual Pearson chi-square and Wilcoxon analyses. The significance criterion α for all tests was 0.05. RESULTS: The prevalence of food insecurity at the universities ranged from 22.4% to 51.8% with an average prevalence of 30.5% for the full sample. From the forward-selection logistic regression model, MES (OR: 1.47; 95% CI: 1.40, 1.55), CSS (OR: 1.19; 95% CI: 1.18, 1.21), and APS (OR: 0.95; 95% CI: 0.91, 0.99) scores remained significant predictors of food insecurity. Grade point average, academic year, health, race/ethnicity, financial aid, cooking frequency, and health insurance also remained significant predictors of food security status. CONCLUSIONS: Food insecurity prevalence was higher than the national average. Food-insecure college students were more likely to display high money expenditures and exhibit coping behaviors, and to have poor academic performance.

"Moving Toward Healthy": Insights Into Food Choices of Mothers in Residential Recovery.

This study utilized participatory and potentially empowering qualitative research methods of photo-elicitation and face-to-face interviews to investigate food choices of mothers living with their children in a residential substance use disorder recovery program. Face-to-face interviews were conducted with nine women (25-40 years) living in a residential substance use disorder recovery program in the Southeastern United States. Each audio recorded and transcribed interview was coded individually before collectively developing a consensual version of the codebook and identifying themes. The recovering women in this study expressed a new or renewed desire to "eat healthy" and voiced concerns about the nutritional value of foods. Food choices were influenced by their children's nutritional needs and food preferences, their own food preferences and habits, the financial resources available to them, their personal food preparation self-efficacy and skills, and the limitations inherent in residential recovery. Understanding food choices benefits both recovering parents and their children.

Preferred Healthy Food Nudges, Food Store Environments, and Customer Dietary Practices in 2 Low-Income Southern Communities.

OBJECTIVE: To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index. METHODS: Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages. RESULTS: Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02). CONCLUSIONS AND IMPLICATIONS: Future studies should examine associations between elements of the in-store food environment, purchases, and consumption.

Case-based learning facilitates critical thinking in undergraduate nutrition education: students describe the big picture.

BACKGROUND: The vision of dietetics professions is based on interdependent education, credentialing, and practice. Case-based learning is a method of problem-based learning that is designed to heighten higher-order thinking. Case-based learning can assist students to connect education and specialized practice while developing professional skills for entry-level practice in nutrition and dietetics. OBJECTIVE: This study examined student perspectives of their learning after immersion into case-based learning in nutrition courses. DESIGN: The theoretical frameworks of phenomenology and Bloom's Taxonomy of Educational Objectives triangulated the design of this qualitative study. PARTICIPANTS/SETTING: Data were drawn from 426 written responses and three focus group discussions among 85 students from three upper-level undergraduate nutrition courses. MAIN OUTCOME MEASURES: Coding served to deconstruct the essence of respondent meaning given to case-based learning as a learning method. The analysis of the coding was the constructive stage that led to configuration of themes and theoretical practice pathways about student learning. RESULTS: Four leading themes emerged. Story or Scenario represents the ways that students described case-based learning, changes in student thought processes to accommodate case-based learning are illustrated in Method of Learning, higher cognitive learning that was achieved from case-based learning is represented in Problem Solving, and Future Practice details how students explained perceived professional competency gains from case-based learning. CONCLUSIONS: The skills that students acquired are consistent with those identified as essential to professional practice. In addition, the common concept of Big Picture was iterated throughout the themes and demonstrated that case-based learning prepares students for multifaceted problems that they are likely to encounter in professional practice.

'To teach or not to teach?' Factors that motivate and constrain Australian emergency medicine physicians to teach medical students.

OBJECTIVE: Clinical teaching in the ED is crucial to the education of medical students. We attempted to identify and describe Australian emergency physicians who are currently clinical teachers and to elicit the factors that motivate and constrain them to teach. METHODS: An online survey was emailed to all Advanced Trainee and Emergency Physician (Fellow) members of the ACEM. RESULTS: Our response rate was 28%. The 639 survey respondents were broadly representative of the total ACEM membership in level of training, gender and geographic distribution across all Australian states and territories. Although only 30% of survey respondents had a university teaching position, 74% were actively teaching medical students. Ninety per cent of all respondents agreed they would either commence teaching or increase the amount of time they contributed if they had protected teaching time. Other important facilitators were feelings of personal satisfaction and receiving continuing medical education credits. Written comments were received from 162 respondents. Qualitative analysis identified three main themes: personal, systemic and university-related factors. Systemic and university factors were most frequently cited as barriers to teaching, whereas personal factors were motivators. CONCLUSIONS: Although most emergency physicians are willing to teach, systemic and university factors associated with teaching medical students acted against success of this outcome.

Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8.

BACKGROUND: Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. OBJECTIVES: The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. METHODS: In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. RESULTS: The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. CONCLUSIONS: The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.

Associations between food insecurity, supplemental nutrition assistance program (SNAP) benefits, and body mass index among adult females.

Obesity disproportionately affects low-income and minority individuals and has been linked with food insecurity, particularly among women. More research is needed to examine potential mechanisms linking obesity and food insecurity. Therefore, this study's purpose was to examine cross-sectional associations between food insecurity, Supplemental Nutrition Assistance Program (SNAP) benefits per household member, perceived stress, and body mass index (BMI) among female SNAP participants in eastern North Carolina (n=202). Women were recruited from the Pitt County Department of Social Services between October 2009 and April 2010. Household food insecurity was measured using the validated US Department of Agriculture 18-item food security survey module. Perceived stress was measured using the 14-item Cohen's Perceived Stress Scale. SNAP benefits and number of children in the household were self-reported and used to calculate benefits per household member. BMI was calculated from measured height and weight (as kg/m(2)). Multivariate linear regression was used to examine associations between BMI, SNAP benefits, stress, and food insecurity while adjusting for age and physical activity. In adjusted linear regression analyses, perceived stress was positively related to food insecurity (P<0.0001), even when SNAP benefits were included in the model. BMI was positively associated with food insecurity (P=0.04). Mean BMI was significantly greater among women receiving <$150 in SNAP benefits per household member vs those receiving ≥$150 in benefits per household member (35.8 vs 33.1; P=0.04). Results suggest that provision of adequate SNAP benefits per household member might partially ameliorate the negative effects of food insecurity on BMI.

Association between travel times and food procurement practices among female supplemental nutrition assistance program participants in eastern North Carolina.

OBJECTIVE: To examine associations between self-reported vehicular travel behaviors, perceived stress, food procurement practices, and body mass index among female Supplemental Nutrition Assistance Program (SNAP) participants. ANALYSIS: The authors used correlation and regression analyses to examine cross-sectional associations between travel time and distance, perceived stress, food procurement practices (grocery shopping frequency, fast-food consumption, home meal consumption), and body mass index among female SNAP participants aged 20-65 years (n = 215) in eastern North Carolina. RESULTS: There were positive associations (P < .05) between travel patterns and stress (r = 0.18 for average miles traveled), grocery shopping frequency (r = 0.16 for average miles traveled), and fast-food consumption (r = 0.19 for average miles traveled, r = 0.29 for average minutes traveled). CONCLUSIONS AND IMPLICATIONS: SNAP education materials should focus on healthful interactions with the food environment, even when participants must travel long distances.