Phenomenology, quality of life, and predictors of reversibility in patients with drug-induced movement disorders: a prospective study.

BACKGROUND: Drug-induced movement disorders (DIMDs) form an important subgroup of secondary movement disorders, which despite conferring a significant iatrogenic burden, tend to be under-recognized and inappropriately managed. OBJECTIVE: We aimed to look into phenomenology, predictors of reversibility, and its impact on the quality of life of DIMD patients. METHODS: We conducted the study in the Department of Neurology at a tertiary-care centre in India. The institutional ethics-committee approved the study. We assessed 55-consecutive DIMD patients at presentation to our movement disorder clinic. Subsequently, they followed up to evaluate improvement in severity-scales (UPDRS, UDRS, BARS, AIMS) and quality of life (EuroQol-5D-5L). Wilcoxan-signed-rank test compared the scales at presentation and follow-up. Binary-logistic-regrerssion revealed the independent predictors of reversibility. RESULTS: Fourteen patients (25.45%) had acute-subacute DIMD and 41 (74.55%) had tardive DIMD. Tardive-DIMD occurred more commonly in the elderly (age 50.73±16.92 years, p<0.001). Drug-induced-Parkinsonism (DIP) was the most common MD, followed by tardivedyskinesia. Risperidone and levosulpiride were the commonest culprit drugs. Patients in both the groups showed a statistically significant response to drug-dose reduction /withdrawal based on follow-up assessment on clinical-rating-scales and quality of life scores (EQ-5D-5L). DIMD was reversible in 71.42% of acute-subacute DIMD and 24.40% of patients with chronic DIMD (p=0.001). Binary-logistic-regression analysis showed acute-subacute DIMDs and DIP as independent predictors of reversibility. CONCLUSION: DIP is the commonest and often reversible drug-induced movement disorder. Levosulpiride is notorious for causing DIMD in the elderly, requiring strict pharmacovigilance.

Valproic Acid Inhibits Human Retinal Pigment Epithelial (hRPE) Cell Proliferation Via a P38 MAPK Signaling Mechanism.

Valproic acid (VPA) has been reported to inhibit cancer cell growth and has therapeutic use in retinal diseases. However, the mechanism of this action remains unclear. In order to explore this mechanism, primary human retinal pigment epithelial (hRPE) cell cultures were established. Cell viability was assessed by the trypan blue exclusion method (T), and the cell proliferation was measured by 3H-thymidine incorporation (3H-thy). P38 synthesis was quantitated by using 14C-methionine-labeled P38 (14C-P38) by using P38-specific antibody. SB203580 (SB), a selective inhibitor of p38 MAPK, was also used to test the specificity of P38 stimulation. Antinuclear staining (NS) studies were performed by DAPI. Statistical significance was established by student's t-test. We observed that VPA (1 mM) inhibited 10% fetal bovine serum (FBS)-stimulated cell proliferation (1.75 ± 0.37 vs. 3.25 ± 0.68 cells per 1 µl ± SEM, p < 0.05, n = 4). VPA also stimulated 14C-P38 synthesis in a dose-dependent manner. SB (30 µM) inhibited VPA (4 mM)-stimulated 14C-P38 synthesis (197.74 ± 41.17 vs. 425.89 ± 59.17, CPM ± SEM, p < 0.05, n = 4) and increased hRPE cell proliferation (1.79 ± 0.45 vs. 4.93 ± 1.12 cells per 1 µl ± SEM, p < 0.05, n = 4); NS demonstrated VPA-induced cell damage. We conclude that VPA inhibits hRPE cell growth via P38 MAP mechanism and may be of therapeutic value in treating or preventing proliferative eye diseases.

Effect of Aging on the Composition of Fecal Microbiota in Donors for FMT and Its Impact on Clinical Outcomes.

BACKGROUND: Fecal microbiota transplantation (FMT) is emerging as an effective therapy for the treatment of recurrent Clostridium difficile infection (RCDI). Selecting an appropriate donor is vital to the success of FMT. However, the relationship between age of donors and the efficacy of FMT has not been examined to date. The aim of this study was to examine the effect of age of healthy donors on their fecal microbiota and assess the impact of these changes on the clinical efficacy of FMT. MATERIALS AND METHODS: This IRB-approved prospective study enrolled donors who were deemed healthy for FMT after careful detailed screening for infectious diseases per institutional protocol. The study was conducted between January 2011 and October 2014. Fecal samples were processed and analyzed using 16S rRNA gene amplicon sequencing. Differences in relative abundance and diversity of the donor fecal microbiota were analyzed in donors above and below 60 years of age. Effect of fecal microbiota from donors of different age groups on the efficacy of FMT was also evaluated. RESULTS: Twenty-eight healthy human subjects from ages 20-82 years were enrolled as donors for FMT. All patients receiving FMT from their respective donors had resolution of RCDI symptoms and had a negative C. difficile toxin test 4-12 weeks after FMT. Genomic analysis showed that the relative abundance of phylum Actinobacteria and family Bifidobacteriaceae was reduced in the donors ≥60 years of age (p < 0.05). However, Bacteroidetes-to-Fermicutes ratio did not demonstrate a significant change between the two groups. Furthermore, microbial diversity did not change significantly with advancing age. CONCLUSION: These observations suggest that aging in healthy donors is associated with compositional alterations in the fecal microbiome without change in the overall microbial diversity. These changes do not seem to affect the clinical efficacy of FMT in RCDI patients over 12 months.

Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in the Elderly: Long-Term Outcomes and Microbiota Changes.

BACKGROUND AND AIMS: Fecal microbiota transplantation (FMT) has become the cornerstone in management of recurrent Clostridium difficile infection (RCDI) in adults. However, data on efficacy, safety, long-term outcomes, and microbiota alterations are limited in elderly patients (>65 years). METHODS: Twenty-nine consecutive elderly patients with RCDI underwent FMT with combined jejunal and colonic method and monitored for long-term outcomes. Fecal samples from five elderly RCDI patients (G65) were subjected to genomic analysis before and after FMT, and microbiota changes were compared with matched RCDI patients below 65 years (L65). RESULTS: FMT resulted in marked improvement in all clinical parameters, including abdominal pain, bloating, and diarrhea in all elderly RCDI patients. Fecal C. difficile toxin was positive in all 29 patients and turned negative in all 27 patients, who agreed to undergo this test after FMT. Statistically significant improvement in leukocytosis was noted (p < 0.05). Only adverse events reported were transient mild fever (2/29) and bloating (3/29). Long-term follow-up over 25.4 ± 12.8 months did not reveal any additional adverse events or RCDI recurrence. Genomic analysis suggested that overall microbiota diversity increased post-FMT in elderly RCDI patients. However, this response was less robust than the younger group. While Firmicutes did not change markedly, Proteobacteria decreased significantly in post-FMT samples in elderly RCDI patients. CONCLUSIONS: These observations suggest that FMT in elderly patients with RCDI appears to be highly efficacious with no recurrence of infection over long-term follow-up. Alterations in microbiota in this group of patients are characterized by less robust increase in microbial diversity and marked reduction in phylum Proteobacteria.

Influence of Early Total Enteral Feeding in Preterm Infants with Respiratory Distress Syndrome.

INTRODUCTION: Providing adequate nutrition in the management of preterm infants has been challenging. The objective of this secondary analysis of data from the randomized trial comparing "less invasive surfactant therapy (LISA) with InSurE method of surfactant administration" is to demonstrate the feasibility of early total enteral feeding (ETEF) in hemodynamically stable preterm neonates on respiratory support and to examine the factors associated with failure of ETEF. METHODS: Secondary analysis of a randomized controlled trial comparing "LISA versus InSurE among preterm infants between 26 and 34 weeks of gestation" enrolled 150 infants with 117 being hemodynamically stable. ETEF without any parenteral supplementation was started on day 1 of life using the mother's own milk (MoM) or donor human milk (<32 weeks of GA) and MoM or preterm formula (33-34 weeks of GA). The data were analyzed to assess the proportion of babies developing feed intolerance and/or necrotizing enterocolitis (NEC) and factors associated with failure of ETEF. All Infants were assessed for the day of attainment of full enteral feeding defined as receiving and tolerating 150 mL/kg of enteral feeds per day. RESULTS: Out of these 117 babies, 102 tolerated ETEF, and 15 had one or more episodes of FI requiring total parenteral nutrition, but none developed NEC till discharge or death. On the assessment of possible factors associated with ETEF failure, there were no differences in baseline characteristics but statistically significantly increased incidence of culture-positive sepsis as well as the requirement of antibiotic therapy for possible sepsis (early as well as late-onset sepsis) in babies with failure of ETEF. The babies who tolerated ETEF achieved full enteral feeding (150 mL/kg/day) significantly earlier (5.48 ± 1.1 days) compared to those with ETEF failure (7 ± 3.4 days) (p 0.001). The time to regain birth weight was earlier in the ETEF group without significant differences in growth parameters. There was also a reduction in the duration of hospital stay in babies who tolerated ETEF, but both these results were not statistically significant. CONCLUSION: ETEF is feasible in preterm neonates with respiratory distress syndrome who are on respiratory support. It resulted in earlier attainment of full enteral feeds and decreased the incidence of sepsis with reduced antibiotic usage.

Perrault syndrome: The Way Forward After Genetic Counselling?

A female, term neonate, born via vaginal delivery to a G5P1D1A3 hypothyroid mother with a history of an elder sibling being homozygous for HSD17B4 mutation, diagnosed while working up his progressive neurological disorder and succumbing to the same. The family screening revealed that both parents were heterozygous carriers of the same mutation in the gene HSD17B4 After genetic counselling, amniocentesis revealed the fetus to be having homozygosity for the same mutation. In view of precious pregnancy, normal antenatal scans and investigations, the pregnancy was continued, and baby was born with a birth weight of 2.65 kg and had a smooth perinatal transition. Parents were counselled regarding the course of the illness, possible complications and the need for regular follow-up. Ultrasound of the abdomen, pelvis and head was normal in the neonatal period. She was vaccinated as per the national schedule and gaining weight normally.

Congenital pyloric atresia associated with epidermolysis bullosa junctionalis: a novel lethal variant.

A term male baby was born vaginally to a primi mother. An antenatal ultrasound revealed polyhydramnios and a distended stomach in the baby. At birth, the baby had well-defined areas of peeling skin on the face and blisters on the forearm region. The abdominal X-ray revealed a single gastric bubble, which is consistent with pyloric atresia and needs surgery. Pyloroplasty was initially performed, but it was unsuccessful. Therefore, a feeding jejunostomy and gastrostomy were performed. However, the baby developed sepsis and septic shock and died at about 2 months of age. Skin biopsy revealed cleavage above the lamina densa, and genetic analysis indicated heterozygosity in ITGB4 exons 10 and 16, which are associated with epidermolysis bullosa junctionalis and pyloric atresia.

Single-atom catalysts supported on a hybrid structure of boron nitride/graphene for efficient nitrogen fixation via synergistic interfacial interactions.

Hexagonal boron nitride (BN) shows significant chemical stability and promising thermal nitrogen reduction reaction (NRR) activity but suffers from low conductivity in electrolysis with a wide band gap. To overcome this problem, two-dimensional (2D) BN and graphene (G) are designed as a heterostructure, namely BN/G. According to density functional theory (DFT), the higher conductivity of G narrows the band gap of BN by inducing some electronic states near the Fermi energy level (Ef). Once transition metals (TMs) are anchored in the BN/G structure as single atom catalysts (SACs), the NRR activity improves as the inert BN basal layer activates with moderate *NH2 binding energy and further the band gap is reduced to zero. V (vanadium) and W (tungsten) SACs exhibit the best performance with limiting potentials of -0.22 and -0.41 V, respectively. This study helps in understanding the improvement of the NRR activity of BN, providing physical insights into the adsorbate-TM interaction.

Agri-waste derived electroactive carbon-iron oxide nanocomposite for oxygen reduction reaction: an experimental and theoretical study.

Herein, we have utilized agri-waste and amalgamating low Fe3+, to develop an economic iron oxide-carbon hybrid-based electrocatalyst for oxygen reduction reaction (ORR) with water as a main product following close to 4e- transfer process. The electrocatalytic activity is justified by electrochemical active surface area, synergetic effect, and density functional theory calculations.

A Hybrid Form of Telemedicine and Quality Improvement: A Unique Way to Extend Intensive Care Services to Neonates.

OBJECTIVES: To evaluate the impact of hybrid support (tele-mentoring and conventional support) on adverse outcome among neonates admitted to 10 special newborn care units (SNCUs) in Chhattisgarh. METHODS: This before-and-after study was conducted at 10 SNCUs in Chhattisgarh in 2022. Conventional support was given earlier and later, that was supplemented with tele-rounds which were carried out using Skype technology. The principal investigator (PI) visited each unit for one day per month to kickstart quality improvement (QI) projects and provide guidance. Patient outcome data were collected on clinical sepsis proportion, IV fluid usage, antibiotic usage, length of stay, referral and mortality. RESULTS: A total of 2807 babies across 10 units were assessed. This was retrospectively correlated with 5169 babies in these units in the year before the intervention was started. The percentage of clinical neonatal sepsis cases decreased from 53.4% to 29.4% (P < 0.05). IV fluid usage dropped from 40% to 22.2% (P < 0.05). The initiation and continuation of kangaroo mother care (KMC) increased from 55.5% to 93.8% (P < 0.05). The average length of stay decreased from 5.5 ± 0.97 d to 4 ± 0.2 d (P < 0.05). Oxygen utilization decreased from 39.3% to 33.6% (P < 0.05). The proportion of antibiotic usage decreased from 50.2% to 39.7% (P < 0.05). The mortality rate decreased from 8.18% to 6.99% (P < 0.05). Referral rate decreased from 13.12% to 11.93% (P < 0.05). CONCLUSIONS: The implementation of a QI package through hybrid support, which includes tele-mentoring, supportive supervision visits, and local QI project advocacy, proves to be an effective approach in enhancing newborn intensive care.

Prospective Study to Evaluate Efficacy of Single Versus Double Drains in Breast Cancer Patients Undergoing Surgery.

Seroma formation is a common sequel following modified radical mastectomy (MRM), which hinders healing, may prolong hospital stay, and cause a delay in adjuvant treatment. Closed suction drains have been used to prevent formation of seroma; however, the use of a single drain in the axilla along with draining the mastectomy flaps and axilla separately remains a topic of debate. This prospective randomized dual-arm study was conducted in the Department of Endocrine Surgery. All female patients with carcinoma breast diagnosed on core tissue biopsy, undergoing modified radical mastectomy, upfront or post neoadjuvant systemic therapy were included. Patients were randomized into two groups. In the first group, a single drain was placed in the axilla whereas in the second group, a drain each was placed below the mastectomy flaps and the axilla. Patients' particulars and the weight of the mass excised along with the operative details were documented. The volume of the drain was recorded daily. The flap drain was removed on postoperative day 5 and the axillary drain was removed when the drain volume was less than 30 mL/24 h for 2 consecutive days. The period of drain placement, volume of drainage, volume of seroma (if formed), and other complications (if any) were recorded. Patients in the single drain group had a significantly earlier drain removal time as compared to those with double drains (p = 0.01). The number of patients in whom seroma formation had occurred was more in the double drain group, but the difference was not significant. The average volume of aspirated seroma fluid was insignificantly more in the single drain group. The only other complication noticed was flap necrosis-in 5% patients of the double drain group. Total volume of drainage (p < 0.0001) and type of drain (p = 0.0208) were associated with higher rates of seroma formation, whereas BMI (p = 0.0516), weight of excised breast mass (p = 0.407), and age (p = 0.6379) were not associated with the rate of seroma formation. Outcomes in terms of drain volume or seroma formation were statistically indifferent between the two groups. Still, use of only a single axillary drain should be promoted, keeping in mind the earlier drain removal period, better patient compliance, and reduced hospital stay.

A wideband hybrid combiner design for ITER ion cyclotron radio frequency source.

The high-power radio frequency source for ion cyclotron heating and current drive of ITER tokamak consists of two identical 1.5 MW amplifier chains. These two chains will be combined using a wideband hybrid combiner with adequate coupling flatness, phase balance, return loss, and isolation response to generate 2.5 MW radio frequency (RF) power in the frequency range of 36 to 60 MHz. As part of the in-house development program at ITER-India, a wideband hybrid combiner with coupling flatness and return loss/isolation better than 0.4 and -25 dB, respectively, has been simulated. A detailed analysis for matched load performance of the hybrid combiner for the output power level of 3 MW as well as mismatched load performance for load power of 2.5 MW with voltage standing wave ratio 2.0 and 3.0 MW with voltage standing wave ratio 1.5 has been performed. Based on the simulation, a prototype model was in-house fabricated, and the simulated results have been validated experimentally in splitter and combiner mode. To evaluate performance as a combiner, two solid-state power amplifiers were combined through the prototype combiner for input power levels up to 2.5 kW on matched and mismatched load conditions. In the power splitter experiment, the RF power level up to 1.5 MW from a single amplifier chain was split through the prototype combiner to be dumped in the high power loads in the frequency range of 36 to 60 MHz.

Less invasive surfactant administration via infant feeding tube versus InSurE method in preterm infants: a randomized control trial.

There is growing evidence that less invasive surfactant administration (LISA) is a better alternative to the standard Intubate-surfactant-extubate (InSurE) procedure in spontaneously breathing preterm infants with RDS. The infant feeding tube is easily available and cost-effective in comparison to special catheters used for surfactant administration in various studies on LISA and cost-effective health care is the need of the hour for countries like ours which are Low and middle-income countries(LMICs).The present study was planned to compare the total duration of respiratory support in preterm babies between 26 to 34 weeks of gestation with RDS requiring surfactant therapy administered by LISA technique using an infant feeding tube or InSurE method. In this unblinded randomised controlled trial, 150 infants were allocated to LISA (n = 74) or InSurE group (n = 76). An 8F feeding tube was used for surfactant delivery in the LISA group. The primary outcome was the total duration of respiratory support required and secondary outcomes included the proportion of babies developing BPD, IVH, PDA, NEC, ROP, air leaks, CPAP failure, and those requiring a repeat dose of surfactant along with the duration of hospitalization, time to regain birth weight and Death. The baseline variables including birth weight and gestation age were similar in the two groups. Nearly 27% of the mothers did not receive any dose of antenatal steroids (ANS) while around 37% of the mothers received complete course of ANS. A high proportion of babies (57%) were delivered by cesarean section. Intrapharyngeal reflux was significantly more in babies who received surfactant with the LISA method in comparison to InSurE technique (32% v/s 3%, p < 0.001). There was no statistically significant difference in the primary outcome of the total duration of respiratory support in both groups with a median duration of 120 h, 95% CI (69-235), and p = 0.618. The need for invasive mechanical ventilation was significantly lower in the LISA group (p = 0.017) with RR (95% CI) 0.498 (0.259-0.958). The rate of CPAP failure was significantly lower in the LISA group (p = 0.005) with RR (95% CI) 0.55 (0.34-0.89). In this study, the total duration of hospital stay was reduced in the LISA group (19 days) compared to InSurE group (26 days), although the same was not statistically significant. LISA with an 8F feeding tube is feasible and an effective strategy for surfactant administration which resulted in a significant reduction in CPAP failure and the need for invasive mechanical ventilation.Trial registration: www.ctri.nic.in id CTRI/2020/05/025360. Trial was registered at CTRI on 26/05/2020. First case of trial was enrolled on 28/05/2020.

Fast atomic structure optimization with on-the-fly sparse Gaussian process potentials.

We apply on-the-fly machine learning potentials (MLPs) using the sparse Gaussian process regression (SGPR) algorithm for fast optimization of atomic structures. Great acceleration is achieved even in the context of a single local optimization. Although for finding the exact local minimum, due to limited accuracy of MLPs, switching to another algorithm may be needed. For random gold clusters, the forces are reduced to ∼0.1 eV Å-1within less than ten first-principles (FP) calculations. Because of highly transferable MLPs, this algorithm is specially suitable for global optimization methods such as random or evolutionary structure searching or basin hopping. This is demonstrated by sequential optimization of random gold clusters for which, after only a few optimizations, FP calculations were rarely needed.

Sclerotic lumbar chordoma: A case report.

Chordoma is a rare tumor, often occurring in the cervical spine and sacrococcygeal spine with a lytic appearance, but rarely in the thoracolumbar spine. Chordomas can occasionally be sclerotic and are included in the differential diagnosis for an ivory vertebra. We present a case of a sclerotic chordoma in an upper lumbar vertebral body with corresponding multimodality imaging. This case demonstrates that chordoma should be a concern for an older adult with a sclerotic vertebral lesion, particularly if it is a solitary lesion. Knowledge of the variable location and appearance of chordomas is critical so it is not mistaken for a metastasis.

Assessing the clinical utility of volumetric HRCT in pediatric enlarged vestibular aqueduct related hearing loss.

OBJECTIVES: |The aim of this study was to evaluate the use of volumetric HRCT measurements in the diagnosis of enlarged vestibular aqueduct syndrome (EVAS) and describe the association of this novel radiographic approach with clinical hearing outcomes. We hypothesized that volumetric measurements may have stronger correlation to hearing loss given the anatomic variability of the vestibular aqueduct in linear measurements. METHODS: A retrospective study design was used, including 51 patients that fit the inclusion criteria for the study for a total of 81 ears. 3D volumes were calculated using the MIM Software platform (MIM Software Inc.) from semiautomatic segmentation of the VA across individual slices on CT scan. Air and bone conduction data was collected from medical records with the air-bone gap being calculated from these data. Univariate and multivariate analyses were conducted to determine if volumetric VA size correlated with hearing loss outcomes. RESULTS: Out of the study population, 30 subjects (58.8%) demonstrated bilateral EVA. Average VA size estimated by volumetric CT methodology was 0.035 mm3; sd = 0.025 mm3. Volumetric measurements significantly correlated to both midpoint length and operculum size. Multivariate analysis adjusting for age, race, and gender demonstrated significant correlation between volumetric VA size and both low and high frequencies for PTA Air (p = 0.009; 0.010) and PTA Bone (p = 0.027; 0.002), respectively. Of note, the coefficient values for volumetric data were higher than linear measurements showing a potentially stronger correlation, albeit with high variability. Volumetric size was not significantly correlated to air-bone gap at either low or high frequency (p = 0.335; 0.062). CONCLUSION: Our results indicate that volumetric CT measurements of the VA may be a valid and viable new method for assessing EVAS patients. In our study, volumetric VA measurements demonstrated a strong correlation across both air and bone conduction at both frequency ranges measured, with potentially greater correlative strength than linear measurements.

Mask Detection and Social Distance Identification Using Internet of Things and Faster R-CNN Algorithm.

The drones can be used to detect a group of people who are unmasked and do not maintain social distance. In this paper, a deep learning-enabled drone is designed for mask detection and social distance monitoring. A drone is one of the unmanned systems that can be automated. This system mainly focuses on Industrial Internet of Things (IIoT) monitoring using Raspberry Pi 4. This drone automation system sends alerts to the people via speaker for maintaining the social distance. This system captures images and detects unmasked persons using faster regions with convolutional neural network (faster R-CNN) model. When the system detects unmasked persons, it sends their details to respective authorities and the nearest police station. The built model covers the majority of face detection using different benchmark datasets. OpenCV camera utilizes 24/7 service reports on a daily basis using Raspberry Pi 4 and a faster R-CNN algorithm.

Unveiling the Role of Charge Transfer in Enhanced Electrochemical Nitrogen Fixation at Single-Atom Catalysts on BX Sheets (X = As, P, Sb).

To tune single-atom catalysts (SACs) for effective nitrogen reduction reaction (NRR), we investigate various transition metals implanted on boron-arsenide (BAs), boron-phosphide (BP), and boron-antimony (BSb) using density functional theory (DFT). Interestingly, W-BAs shows high catalytic activity and excellent selectivity with an insignificant barrier of only 0.05 eV along the distal pathway and a surmountable kinetic barrier of 0.34 eV. The W-BSb and Mo-BSb exhibit high performances with limiting potentials of -0.19 and -0.34 V. The Bader-charge descriptor reveals that the charge transfers from substrate to *NNH in the first protonation step and from *NH3 to substrate in the last protonation step, circumventing a big hurdle in NRR by achieving negative free energy change of *NH2 to *NH3. Furthermore, machine learning (ML) descriptors are introduced to reduce computational cost. Our rational design meets the three critical prerequisites of chemisorbing N2 molecules, stabilizing *NNH, and destabilizing *NH2 adsorbates for high-efficiency NRR.

Urban Classification, Not COVID-19 Community Rates, Was Associated With Modes of Learning in US K-12 Schools?

OBJECTIVES: To identify factors associated with the decision to provide in-person, hybrid, and remote learning in kindergarten through 12th grade school districts during the 2020-2021 school year. METHODS: We performed a retrospective study evaluating school district mode of learning and community coronavirus 2019 (COVID-19) incidence and percentage positivity rates at 3 time points during the pandemic: (1) September 15, 2020 (the beginning of the school year, before Centers for Disease Control and Prevention guidance); (2) November 15, 2020 (midsemester after the release of Centers for Disease Control and Prevention guidance and an increase of COVID-19 cases); and (3) January 15, 2021 (start of the second semester and peak COVID-19 rates). Five states were included in the analysis: Michigan, Missouri, North Carolina, Ohio, and Wisconsin. The primary outcome was mode of learning in elementary, middle, and high schools during 3 time points. The measures included community COVID-19 incidence and percentage positivity rates, school and student demographics, and county size classification of school location. RESULTS: No relationship between mode of learning and community COVID-19 rates was observed. County urban classification of school location was associated with mode of learning with school districts in nonmetropolitan and small metropolitan counties more likely to be in-person. CONCLUSIONS: Community COVID-19 rates did not appear to influence the decision of when to provide in-person learning. Further understanding of factors driving the decisions to bring children back into the classroom are needed. Standardizing policies on how schools apply national guidance to local decision-making may decrease disparities in emergent crises.