Safety and Feasibility of Third-Party Cytotoxic T Lymphocytes for High-Risk Patients with Covid-19.

Cytotoxic T lymphocytes (CTLs) destroy virally infected cells and are critical for the elimination of viral infections such as those caused by the SARS-CoV-2 virus. Delayed and dysfunctional adaptive immune responses to SARS-CoV-2 are associated with poor outcomes. Treatment with allogeneic SARS-CoV-2-specific CTLs may enhance cellular immunity in high-risk patients and provide a safe, direct mechanism of treatment. Thirty high-risk ambulatory patients with COVID-19 were enrolled on a phase I trial to assess the safety of 3rd party, SARS-CoV-2-specific CTLs. Twelve Interventional patients, 6 of whom were immunocompromised, matched the human leukocyte antigen (HLA)-A*02:01 restriction of the CTLs and received a single infusion of one of four escalating doses of a product containing 68.5% SARS-CoV-2-specific CD8+ CTLs/total cells. Symptom improvement and resolution in these patients was compared to an Observational group of eighteen patients lacking HLA-A*02:01 who could receive standard of care. No dose-limiting toxicities were observed at any dosing level. Nasal swab PCR data showed ≥ 88% and >99% viral elimination from baseline in all patients at 4- and 14-days post-infusion. The CTLs did not interfere with the development of endogenous anti-SARS-CoV-2 humoral or cellular responses. T-cell receptor beta (TCR) analysis comparing SARS-CoV-2-specific T-cell responses derived from the CTL donor versus recipients showed persistence of donor-derived CTLs through the end of the 6-month follow-up period. Interventional patients consistently reported symptomatic improvement 2-3 days after infusion, whereas improvement was more variable in Observational patients. This study shows that SARS-CoV-2-specific CTLs are a potentially feasible cellular therapy for COVID-19 illness. (Clinicaltrials.gov #NCT04765449).

Full practice authority and burnout among primary care nurse practitioners.

BACKGROUND: Full practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout. PURPOSE: Estimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout. METHODS: In this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs. DISCUSSION: Seventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant. CONCLUSION: NPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.

Intimate Partner Violence Survivorship, Posttraumatic Stress Disorder and Disaster: Implications for Future Disasters.

This study investigated posttraumatic stress disorder (PTSD) prevalence among a sample of intimate partner violence (IPV) survivors (n = 77) who filed for restraining orders in rural Louisiana during the COVID-19 pandemic. IPV survivors were individually interviewed to assess their self-reported levels of perceived stress, resilience, potential PTSD, COVID-19-related experiences, and sociodemographic characteristics. Data were analyzed to differentiate group membership between two groups; non-PTSD and probable PTSD. Results suggest the probable PTSD group had lower levels of resilience and higher levels of perceived stress compared to the non-PTSD group. Findings suggest the importance of providing services during disaster to reduce PTSD for IPV survivors.

Patient Enrollment Growth and Burnout in Primary Care at the Veterans Health Administration.

BACKGROUND: Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. OBJECTIVE: Estimate associations between patient enrollment and burnout. DESIGN: In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA's annual All Employee Survey provided burnout estimates. PARTICIPANTS: A total of 82,421 responses to the 2014-2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. MAIN MEASURES: Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. KEY RESULTS: Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). CONCLUSIONS: Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.

Changes in electronic notification volume and primary care provider burnout.

OBJECTIVES: Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout. STUDY DESIGN: In this observational study, we tested the association between the percent change in daily inbox notification volumes and PCP burnout after an initiative to reduce low-value notifications at the Veterans Health Administration (VHA). METHODS: The VHA initiative resulted in increases and decreases in notification volumes for PCPs. For each facility, the proportion of PCPs reporting burnout was estimated using VHA All Employee Survey responses before and after the initiative in 2016 and 2018, respectively. Survey responses were aggregated for 6459 PCPs (physicians, nurse practitioners, and physician assistants) at 138 VHA facilities. Fixed effects regression models estimated the association of small and large increases and small and large decreases in notifications on burnout. RESULTS: Daily inbox notifications per PCP decreased by a mean (SD) of 5.9% (30.1%) across study facilities, from a mean (SD) of 128 (52) notifications to 114 (44) notifications after the initiative. Fifty-one percent of facilities experienced reductions in notifications, 30% experienced no change, and 20% experienced increased notifications. PCP burnout was not significantly associated with any level of increase or decrease in notifications. CONCLUSIONS: Changes in notification volumes alone did not predict PCP burnout. Future research to reduce burnout might still address EHR notification volumes, but as part of a broader set of strategies that consider the other stressors that PCPs experience.

Impacts of the COVID-19 pandemic on rural survivors of intimate partner violence.

OBJECTIVE: Our objective was to understand experiences of intimate partner violence (IPV) by survivors living through the COVID-19 pandemic in a rural area. METHOD: Structured interviews were conducted with a purposive sample of IPV survivors, 93% of whom identified as women, living in a rural parish (county) in Louisiana (n = 41). Interviews included COVID-19-related stressors (e.g., rent stress due to the pandemic) and posttraumatic stress disorder (PTSD; Primary Care PTSD Screen for DSM-5) and resilience (Connor-Davidson Resilience Scale 10) validated scales. Data were analyzed using independent t tests to determine differences across race with respect to PTSD and resilience and logistic regression to predict group membership in the probable PTSD group. RESULTS: Results indicate 72.5% and 56.2% of rural IPV survivors interviewed reported experiencing rent/mortgage stress and nutritional stress, respectively, due to the pandemic. No statistically significant differences by race for probable PTSD or resilience were found. Rent or mortgage stress due to COVID-19 was a significant predictor of probable PTSD in the regression model. CONCLUSIONS: Findings suggest the possibility that IPV concerns may exacerbate pandemic-related concerns, which in turn exacerbates health functioning. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Overdose and substance-related mortality after release from prison in Washington State: 2014-2019.

BACKGROUND: Persons released from prison are at an increased risk of mortality compared to the non-incarcerated population, particularly from drug- and opioid-related overdose. Contributors to overdose mortality vary with changing patterns of substance use and updating overdose and mortality statistics may help focus resources for persons released from prison. METHODS: In this retrospective cohort study, records for 33,811 people released from Washington State Department of Corrections prisons between 2014 and 2018 were linked to Washington State death records from 2014 to 2019. We calculated post-release mortality rates by cause of death, including overdose and substance-related mortality. Hazard ratios for risk factors for all-cause, non-overdose, and overdose mortality were estimated using Cox proportional hazards regression. RESULTS: 862 deaths were identified among persons released from prison. The all-cause mortality rate was 747 per 100,000 person-years (95 % CI: 699-800), and drug overdose was the leading cause of death (216 per 100,000 person-years; 95 % CI: 190-244). Psychostimulant-related mortality (152 per 100,000 person-years; 95 % CI: 131-177) and opioid-related mortality (138 per 100,000 person-years; 95 % CI: 118-161) were the most prevalent among substance-related causes of death, with the greatest mortality risk occurring within two weeks after release. Older age at most recent release, previous incarceration, and drug-related convictions were significant risk factors for all-cause and overdose mortality within six years after release. CONCLUSIONS: Psychostimulants were the greatest contributors to substance-related mortality for persons released from Washington State prisons. Greater efforts to prevent psychostimulant- and opioid-related overdose are needed.

Emergency Medical Service Utilization and Response Following COVID-19 Emergency and Stay-at-Home Policies: An Interrupted Time-Series Analysis.

Objective Examine changing emergency medical services (EMS) utilization and response patterns associated with coronavirus disease 2019 (COVID-19) emergency declaration and stay-at-home orders during the first year of the COVID-19 pandemic. Methods We conducted an uncontrolled interrupted time series analysis of EMS calls (January 1, 2019 - March 1, 2021) in Marin County, California analyzing call volume (All calls, n=46,055); patient refusal of EMS care or transport and patient care resolved on scene (Calls with opportunity for transport; n=37,401); and call severity (Transported calls; n=27,887). Results Pre-COVID-19 (1/1/2019-3/2/2020), EMS transported patients were predominately female (50.6%), 80+ years old (31.6%), and Marin County residents (68.0%). During COVID-19 (3/3/2020-3/1/2021), EMS transported patients were predominately male (52.7%), 35-64 years old (29.8%), and Marin County residents (70.4%). After the first stay-at-home order on 3/17/2020, call volume immediately decreased by 48% (adjusted incidence rate ratio [aIRR]=0.52; 95% CI=0.35,0.79) for children (0-15 years) and 34% for adults 80+ years (aIRR=0.66;95% CI=0.46,0.95). The odds of a transported call being prioritized as severe doubled (adjusted odds ratio [aOR]=2.26; 95% CI=1.11,4.59). Though transport refusals increased by 69% for children after the first order (aOR, 1.69 [95% CI, 1.13-2.52]), immediately following the second order on 12/8/2020, transport refusals decreased by 30% for children but increased 38-40% for adults 35-79 years (aOR=1.40 [95% CI=1.04-1.89] for 35-64 years; 1.38 [95% CI=1.02-1.87] for 65-79 years). Calls resolved on scene by EMS increased after the first order among all ages and after the second order for adults 16-79 years.  Conclusions Call volume reduced for children and older adults after the first COVID-19 stay-at-home order. Changes in call severity, patient care refusals, and on-scene care provided by EMS indicated a changing role for EMS during the outbreak.

The role of nonstandard and precarious jobs in the well-being of disabled workers during workforce reintegration.

BACKGROUND: Nonstandard employment arrangements are becoming increasingly common and could provide needed flexibility for workers living with disabilities. However, these arrangements may indicate precarious employment, that is, employment characterized by instability, powerlessness, and limited worker rights and benefits. Little is known about the role of nonstandard and precarious jobs in the well-being of disabled persons during workforce reintegration after permanent impairment from work-related injuries or illnesses. METHODS: We used linked survey and administrative data for a sample of 442 Washington State workers who recently returned to work and received a workers' compensation permanent partial disability award after permanent impairment from a work-related injury. Multivariable logistic regression models were used to examine associations between nonstandard employment and outcomes related to worker well-being and sustained employment. We also examined associations between a multidimensional measure of precarious employment and these outcomes. Secondarily, qualitative content analysis methods were used to code worker suggestions on how workplaces could support sustained return to work (RTW). RESULTS: Workers in: (1) nonstandard jobs (compared with full-time, permanent jobs), and (2) precarious jobs (compared with less precarious jobs) had higher adjusted odds of low expectations for sustained RTW. Additionally, workers in precarious jobs had higher odds of reporting fair or poor health and unmet need for disability accommodation. Workers in nonstandard and precarious jobs frequently reported wanting safer and adequately staffed workplaces to ensure safety and maintain sustained employment. CONCLUSIONS: Ensuring safe, secure employment for disabled workers could play an important role in their well-being and sustained RTW.

Considering Work Arrangement as an "Exposure" in Occupational Health Research and Practice.

Most occupational health research is conducted with the so-called "standard employment relationship" in mind, which entails ongoing, full-time employment for a single employer. Yet mounting evidence suggests the way work is organized is increasingly deviating from this standard model, and that work arrangements themselves-the terms and conditions of employment such as contract type and the extent of directive control over tasks-are important determinants of worker health and safety. However, a lack of clear conceptual definitions or taxonomic system defining the wide variety of economic work arrangements in the contemporary workplace hampers rigorous investigation of their relationship to health. The various forms of "non-standard" employment arrangements-also called non-traditional, alternative, flexible, fissured, precarious, contingent, temporary, atypical, or gig work-may have overlapping attributes, yet ambiguity regarding the character of these arrangements obscures mechanisms that lead to increased health and safety risks. Here, we attempt to clarify work arrangements as a workplace exposure, deserving of specific attention within occupational health and safety research, practice, and policy. We argue that, at minimum, three key features of work arrangements need to be considered: (1) whether an arrangement is permanent or temporary; (2) whether a worker is a contractor or an employee; and (3) whether an arrangement involves more than one firm. We further propose mechanisms linking work arrangements to increased work-related health risks to better inform strategies aimed at protecting the growing non-standard workforce.

Free-Floating Bikeshare and Helmet Use in Seattle, WA.

Wearing a helmet when bicycling prevents traumatic brain injury in the event of a crash. Most cyclists nationwide use helmets when riding. However, the growth of free-floating bike sharing systems, which offer short-term access to bicycles but not helmets, may erode helmet-wearing norms among cyclists. We counted cyclists over several hours at four locations in Seattle, WA. We categorized each rider according to whether he or she was wearing a helmet and to whether or not he or she was riding a bike share bike. Whereas 91% of riders of private bikes wore helmets, only 20% of bike share riders wore helmets. Moreover, in locations where a greater proportion of riders were on bikes hare bikes, fewer riders of private bicycles wore helmets (r = - 0.96, p = 0.04). The impact of bike sharing programs on helmet wearing norms among private bike riders warrants further exploration.