COVID-19 Incidence and Mortality Among Unvaccinated and Vaccinated Persons Aged ≥12 Years by Receipt of Bivalent Booster Doses and Time Since Vaccination - 24 U.S. Jurisdictions, October 3, 2021-December 24, 2022.

On September 1, 2022, CDC recommended an updated (bivalent) COVID-19 vaccine booster to help restore waning protection conferred by previous vaccination and broaden protection against emerging variants for persons aged ≥12 years (subsequently extended to persons aged ≥6 months).* To assess the impact of original (monovalent) COVID-19 vaccines and bivalent boosters, case and mortality rate ratios (RRs) were estimated comparing unvaccinated and vaccinated persons aged ≥12 years by overall receipt of and by time since booster vaccination (monovalent or bivalent) during Delta variant and Omicron sublineage (BA.1, BA.2, early BA.4/BA.5, and late BA.4/BA.5) predominance.† During the late BA.4/BA.5 period, unvaccinated persons had higher COVID-19 mortality and infection rates than persons receiving bivalent doses (mortality RR = 14.1 and infection RR = 2.8) and to a lesser extent persons vaccinated with only monovalent doses (mortality RR = 5.4 and infection RR = 2.5). Among older adults, mortality rates among unvaccinated persons were significantly higher than among those who had received a bivalent booster (65-79 years; RR = 23.7 and ≥80 years; 10.3) or a monovalent booster (65-79 years; 8.3 and ≥80 years; 4.2). In a second analysis stratified by time since booster vaccination, there was a progressive decline from the Delta period (RR = 50.7) to the early BA.4/BA.5 period (7.4) in relative COVID-19 mortality rates among unvaccinated persons compared with persons receiving who had received a monovalent booster within 2 weeks-2 months. During the early BA.4/BA.5 period, declines in relative mortality rates were observed at 6-8 (RR = 4.6), 9-11 (4.5), and ≥12 (2.5) months after receiving a monovalent booster. In contrast, bivalent boosters received during the preceding 2 weeks-2 months improved protection against death (RR = 15.2) during the late BA.4/BA.5 period. In both analyses, when compared with unvaccinated persons, persons who had received bivalent boosters were provided additional protection against death over monovalent doses or monovalent boosters. Restored protection was highest in older adults. All persons should stay up to date with COVID-19 vaccination, including receipt of a bivalent booster by eligible persons, to reduce the risk for severe COVID-19.

A mobile app for delirium screening.

OBJECTIVE: The objective of this study is to describe the algorithm and technical implementation of a mobile app that uses adaptive testing to assess an efficient mobile app for the diagnosis of delirium. MATERIALS AND METHODS: The app was used as part of a NIH-funded project to assess the feasibility, effectiveness, administration time, and costs of the 2-step delirium identification protocol when performed by physicians and nurses, and certified nursing assistants (CNA). The cohort included 535 hospitalized patients aged 79.7 (SD = 6.6) years enrolled at 2 different sites. Each patient was assessed on 2 consecutive days by the research associate who performed the reference delirium assessment. Thereafter, physicians, nurses, and CNAs performed adaptive delirium assessments using the app. Qualitative data to assess the experience of administering the 2-step protocol, and the app usability were also collected and analyzed from 50 physicians, 189 nurses, and 83 CNAs. We used extensible hypertext markup language (XHTML) and JavaScript to develop the app for the iOS-based iPad. The App was linked to Research Electronic Data Capture (REDCap), a relational database system, via a REDCap application programming interface (API) that sent and received data from/to the app. The data from REDCap were sent to the Statistical Analysis System for statistical analysis. RESULTS: The app graphical interface was successfully implemented by XHTML and JavaScript. The API facilitated the instant updating and retrieval of delirium status data between REDCap and the app. Clinicians performed 881 delirium assessments using the app for 535 patients. The transmission of data between the app and the REDCap system showed no errors. Qualitative data indicated that the users were enthusiastic about using the app with no negative comments, 82% positive comments, and 18% suggestions of improvement. Delirium administration time for the 2-step protocol showed similar total time between nurses and physicians (103.9 vs 106.5 seconds). Weekly enrollment reports of the app data were generated for study tracking purposes, and the data are being used for statistical analyses for publications. DISCUSSION: The app developed using iOS could be easily converted to other operating systems such as Android and could be linked to other relational databases beside REDCap, such as electronic health records to facilitate better data retrieval and updating of patient's delirium status. CONCLUSION: Our app operationalizes an adaptive 2-step delirium screening protocol. Its algorithm and cross-plat formed code of XHTML and JavaScript can be easily exported to other operating systems and hardware platforms, thus enabling wider use of the efficient delirium screening protocol that we have developed. The app is currently implemented as a research tool, but with adaptation could be implemented in the clinical setting to facilitate widespread delirium screening in hospitalized older adults.

Rural-Urban Differences in Hospitalizations for Opioid Use-Associated Infective Endocarditis in the United States, 2003-2016.

BACKGROUND: The incidence of infective endocarditis, a serious heart infection that can result from injection drug use, has increased in step with the opioid epidemic. Harm reduction services aimed at decreasing infectious complications of injection drug use are limited in rural areas; however, it is unknown whether the burden of opioid use-associated infective endocarditis varies between rural and urban populations. METHODS: We used 2003-2016 National (Nationwide) Inpatient Sample data and joinpoint regression to compare trends in hospitalization for opioid use-associated infective endocarditis between rural and urban populations. RESULTS: Rates of US hospitalizations for opioid use-associated infective endocarditis increased from 0.28 to 3.86 per 100 000 rural residents, as compared with 1.26 to 3.49 for urban residents (overall difference in annual percent change P < .01). We observed 2 distinct trend periods, with a period of little change between 2003 and 2009/2010 (annual percent change, 0.0% rural vs -0.08% urban) followed by a large increase in hospitalization rates between 2009/2010 and 2016 (annual percent change, 0.35% rural vs 0.36% urban). Over the study period, opioid use-associated infective endocarditis hospitalizations shifted toward younger age groups for both rural and urban residents, and rural resident hospitalizations increasingly occurred at urban teaching hospitals. For both groups, Medicaid was the most common payer. CONCLUSIONS: The increase in US hospitalizations for opioid use-associated infective endocarditis over the past decade supports the importance of public health efforts to reduce injection-related infections in both urban and rural areas. Future studies should examine factors affecting the higher increase in rate of these hospitalizations in rural areas.

Teaching Residents How to Talk About Death and Dying: A Mixed-Methods Analysis of Barriers and Randomized Educational Intervention.

OBJECTIVES: We present a pilot study exploring the effects of a brief, 30-minute educational intervention targeting resident communication surrounding dying in the intensive care unit (ICU). We sought to determine whether simulation or didactic educational interventions improved resident-reported comfort, preparation, and skill acquisition. We also sought to identify resident barriers to using the word "dying." METHODS: In this mixed-methods prospective study, second- and third-year medical residents were randomized to participate in a simulation-based communication training or a didactic session. Residents completed a pre-post survey after the sessions evaluating the sessions and reflecting on their use of the word "dying" in family meetings. RESULTS: Forty-five residents participated in the study. Residents reported increases in comfort (Mean [M]-pre = 3.3 [standard deviation: 0.6], M-post = 3.7 [0.7]; P < .01, Cohen d = 0.75) and preparation (M-pre = 3.4 [0.7], M-post = 3.9 [0.6]; P < .01, d = 1.07) using the word "dying" after both the simulation and didactic versions. Residents randomized to the simulation reported they were more likely to have learned new skills as compared to residents in the didactic (M-simulation = 2.2 [0.4], M-didactic = 1.9 [0.3]; P = .015, d = 0.80). They estimated that they used the word "dying" in 50% of their end-of-life (EOL) conversations and identified uncertain prognosis as the main barrier to explicitly stating the word "dying." CONCLUSION: A 30-minute educational intervention improves internal medicine residents' self-reported comfort and preparation in talking about death and dying in the ICU. Residents in simulation-based training were more likely to report they learned new skills as compared to the didactic session. Residents report multiple barriers to using the word "dying" EOL conversations.