Impact of the Pandemic was Minor Compared to Systemic Decrease in Fidelity of Assertive Community Treatment Services- A Provincial Study in Ontario, Canada.

Assertive Community Treatment (ACT) model is the gold standard in community psychiatry serving people with severe mental illness. With its outreach-based design, the pandemic has profoundly affected the operations and functioning of ACT. The Dartmouth ACT Scale (DACTS) provides a standardized comprehensive and quantitative way to evaluate ACT quality. Results could inform nature of impact and identify areas for improvement. Current online survey used DACTS during the pandemic in April-May 2021. Clinical and administrative leadership of the 80 ACT teams in Ontario, Canada cross-sectionally rated ACT quality one-year pre-Covid (2018-2019) and one-year post the start of Covid (2020-2021). The overall pre-Covid Ontario ACT DACTS fidelity was 3.65. The pandemic led to decreases in all domains of DACTS (Human Resources: -4.92%, p < 0.001, 95% CI [0.08-0.27]; Organizational Boundary: -1.03%, p < 0.013,95%CI [0.01-0.07]; and Nature of Services: -6.18%, p < 0.001, 95%CI [0.16-0.26]). These changes were accounted by expected lower face-to-face encounters, time spent with clients, reduction in psychosocial services, less interactions with hospitals and diminished workforces. The magnitude of change was modest (-3.84%, p < 0.001, 95%CI [0.09-0.19]). However, the Ontario ACT pre-Covid DACTS was substantially lower (-13.5%) when compared to that from a similar survey 15 years ago (4.22), suggestive of insidious systemic level loss of fidelity. Quantitative fidelity evaluation helped to ascertain specific pandemic impact. Changes were significant and specific, but overall relatively modest when compared to the larger system level drop over the last decade. There is both evidence for model adaptability and resilience during Covid disruption, and concerns over larger downward drift in ACT fidelity and quality.

Bleeding Control Protections Within US Good Samaritan Laws.

INTRODUCTION: In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. METHODS: This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. RESULTS: Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. CONCLUSION: Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes.

OBJECTIVES: Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS: This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS: Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS: In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Implementation of a prehospital whole blood program: Lessons learned.

Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer et al, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team.  This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.

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.

Efficacy and Safety of Prehospital Diltiazem.

OBJECTIVE: This study assesses the likelihood of clinical improvement and adverse events from EMS-administered diltiazem. Current prehospital protocols direct paramedics to administer diltiazem, a calcium channel blocker, to decrease the heart rate (HR) of symptomatic, hemodynamically stable patients with rapid atrial fibrillation. However, diltiazem can also cause systemic hypotension and bradycardia, which can precipitate end-organ injury. . METHODS: To assess whether the rate control benefit of prehospital diltiazem outweighs the risk of adverse events, we conducted a retrospective chart review of all adult patients who received diltiazem from Maryland Advanced Life Support EMS clinicians between January 1, 2019, and March 31, 2022. Collected data included patient demographics, vital signs, diltiazem dose, transport times, administered medications, and procedures. The main outcomes were clinical improvement (HR <100 beats per minute or ≥20% decrease from the maximum HR) and adverse events (bradycardia or hypotension). Multivariable logistic regression was used for statistical analysis. RESULTS: During the study period, 2396 patients received prehospital diltiazem and 94% of these patients (n = 2254) were included in the study. Overall, 1414 (63.8%) patients improved clinically, 604 (27.3%) patients achieved rate control as defined by a HR of <100 beats per minute, and 78 patients (3.5%) experienced an adverse event. Patients over the age of 50 were less likely to clinically improve with diltiazem administration. Adverse events were more likely in patients with systolic blood pressures (SBP) less than 140 mmHg, patients with maximum HR of less than 120 beats per minute, and patients who received nitroglycerin. CONCLUSIONS: Prehospital diltiazem is effective and safe for most patients. Adverse events are more likely in patients with baseline SBP less than 140 mmHg, HR less than 120 beats per minute, and concurrent nitroglycerin administration. Future opportunities for research include examining the relationship between adverse events and underlying etiology as well as investigating downstream outcomes.

The Association of Mental Health and Substance Use With Retention in HIV Care Among Black Women in Washington, District of Columbia.

BACKGROUND: Black women with HIV are impacted by mental health and substance use disorders alongside barriers to care. The impact of these disorders on retention in care, a crucial step of the HIV care continuum, has not been well-studied. We examined the association between these disorders and retention in care over a 2-year period. METHODS: Data from January 1, 2011, to June 30, 2019, were obtained from the DC Cohort, an observational HIV study in Washington, District of Columbia. We examined the associations between mental health (i.e., mood-related or trauma-related) or substance use disorders, separately, on not being retained in HIV care over a 2-year interval post-enrollment among non-Hispanic Black women with HIV. Multivariate logistic regression with adjusted odds ratios (aORs) for sociodemographic and clinical variables was used to quantify the association of 1) having a confirmed mental health or substance use disorder and 2) not being retained in care. RESULTS: Among the 2,181 women in this analysis, 690 (31.64%) were not retained in care. The prevalence of a mood-related disorder (39.84%) was higher compared with a substance use (16.19%) or trauma-related disorder (7.75%). Age per a 10-year increase (aOR 0.87; confidence interval [CI] 0.80, 0.94) and a mood-related disorder diagnosis (aOR 0.72; CI: 0.59, 0.88) were inversely associated with not being retained in care. CONCLUSION: Mood-related disorders were prevalent among Black women with HIV in Washington, District of Columbia, but were not associated with worse retention in care. Future studies should examine key facilitators for Black women with HIV and coexisting mood-related disorders and how they impact retention in care.

SARS-CoV-2 Antiviral Prescribing Gaps Among Non-Hospitalized High-Risk Adults.

Within a multi-state clinical cohort, SARS-CoV-2 antiviral prescribing patterns were evaluated from April 2022-June 2023 among non-hospitalized SARS-CoV-2-infected patients with risk factors for severe COVID-19. Among 3,247 adults, only 31.9% were prescribed an antiviral agent (87.6% nirmatrelvir/ritonavir, 11.9% molnupiravir, 0.5% remdesivir), highlighting the need to identify and address treatment barriers.

Evaluation of New Hypertension Guidelines on the Prevalence and Control of Hypertension in a Clinical HIV Cohort: A Community-Based Study.

The prevalence and control of hypertension (HTN) among people with HIV (PWH) have not been widely studied since the release of newer 2017 ACC/AHA guidelines ("new guidelines"). To address this research gap, we evaluated and compared the prevalence and control of HTN using both 2003 JNC 7 ("old guidelines") and new guidelines. We identified 3,206 PWH with HTN from the DC Cohort study in Washington, DC, between January 2018 and June 2019. We defined HTN using International Classification of Diseases (ICD)-9/-10 diagnosis codes for HTN or ≥2 blood pressure (BP) measurements obtained at least 1 month apart (>139/89 mm Hg per old or >129/79 mm Hg per new guidelines). We defined HTN control based on recent BP (≤129/≤79 mm Hg per new guidelines). We identified socio-demographics, cardiovascular risk factors, and co-morbidities associated with HTN control using multivariable logistic regression [adjusted odds ratio (aOR); 95% confidence interval (CI)]. The prevalence of HTN was 50.9% per old versus 62.2% per new guidelines. Of the 3,206 PWH with HTN, 887 (27.7%) had a recent BP ≤129/≤79 mm Hg, 1,196 (37.3%) had a BP 130-139/80-89 mm Hg, and 1,123 (35.0%) had a BP ≥140/≥90 mm Hg. After adjusting for socio-demographics, cardiovascular risk factors, and co-morbidities, factors associated with HTN control included age 60-69 (vs. <40) years (aOR: 1.42; 95% CI: 1.03-1.98), Hispanic (vs. non-Hispanic Black) race/ethnicity (aOR 1.49; 95% CI: 1.04-2.15), receipt of HIV care at a hospital-based (vs. community-based) clinic (aOR 1.21; 95% CI: 1.00-1.47), being unemployed (aOR 1.42; 95% CI: 1.11-1.83), and diabetes (aOR 1.35; 95% CI: 1.13-1.63). In a large urban cohort of PWH, nearly two-thirds had HTN and less than one-third of those met new guideline criteria. Our data suggest that more aggressive HTN control is warranted among PWH, with additional attention to younger patients and non-Hispanic Black patients.

Association Between Geospatial Access to Trauma Center Care and Motor Vehicle Crash Mortality in the United States.

BACKGROUND: Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States (US). Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality. METHODS: This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). ACS and state-verified level I-III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws. RESULTS: We identified 92,398 crash fatalities over the four-year study period. Trauma centers mapped included 217 level I, 343 level II, and 495 level III trauma centers. The median county predicted access time was 47 min (IQR 26-71 min). Median county MVC mortality was 12.5 deaths/100,000 person-years (IQR 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 min vs. <15 min; MRR 1.36; 95%CI 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties (p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality. CONCLUSIONS: Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities. LEVEL OF EVIDENCE: Level III, Epidemiological.

Adherence to ECCO Guidelines for Management of Iron Deficiency and Anemia in Inflammatory Bowel Diseases Among Israeli Adult and Pediatric Gastroenterologists.

OBJECTIVES: The consensus guidelines of the European Crohn's and Colitis Organization (ECCO) for the diagnosis and treatment of iron deficiency anemia (IDA) were published in 2015. We examined the management practices of both adult gastroenterologists (AGs) and pediatric gastroenterologists (PGs) in Israel in treating ID among patients with inflammatory bowel disease (IBD). METHODS: An 18-question multiple-choice anonymous questionnaire was electronically delivered to AGs and PGs. Questions explored 3 areas of interest: physician demographics, adherence to ECCO guidelines, and management practices of IDA in patients with IBD. RESULTS: Completed questionnaires were returned by 72 AGs and 89 PGs. Practice setting and years of practice were similar. A large majority of AGs and PGs (89% and 92%, respectively) measure complete blood count (CBC) and serum ferritin (S-Fr) at least every 3 months in outpatients with active IBD, as recommended by the ECCO guidelines. In contrast, in IBD patients in remission, only 53% and 26% of AGs and PGs, respectively ( P < 0.001), reported adherence to ECCO guidelines, measuring CBC and S-Fr every 6 months. The ECCO treatment guidelines recommend that intravenous (IV) iron should be considered the first-line treatment in patients with clinically active IBD, with previous oral iron intolerance and those with a hemoglobin level <10 g/dL. Study results indicate that only 43% of AGs recommend IV iron for these indications, compared to 54% of PGs ( P > 0.1). CONCLUSIONS: In this study we have demonstrated a relatively low level of adherence to ECCO guideline recommendations among both AGs and PGs, regarding the management of IDA in patients with IBD.

Effectiveness of COVID-19 vaccines at preventing emergency department or urgent care encounters and hospitalizations among immunocompromised adults: An observational study of real-world data across 10 US states from August-December 2021.

BACKGROUND: Immunocompromised (IC) persons are at increased risk for severe COVID-19 outcomes and are less protected by 1-2 COVID-19 vaccine doses than are immunocompetent (non-IC) persons. We compared vaccine effectiveness (VE) against medically attended COVID-19 of 2-3 mRNA and 1-2 viral-vector vaccine doses between IC and non-IC adults. METHODS: Using a test-negative design among eight VISION Network sites, VE against laboratory-confirmed COVID-19-associated emergency department (ED) or urgent care (UC) events and hospitalizations from 26 August-25 December 2021 was estimated separately among IC and non-IC adults and among specific IC condition subgroups. Vaccination status was defined using number and timing of doses. VE for each status (versus unvaccinated) was adjusted for age, geography, time, prior positive test result, and local SARS-CoV-2 circulation. RESULTS: We analyzed 8,848 ED/UC events and 18,843 hospitalizations among IC patients and 200,071 ED/UC events and 70,882 hospitalizations among non-IC patients. Among IC patients, 3-dose mRNA VE against ED/UC (73% [95% CI: 64-80]) and hospitalization (81% [95% CI: 76-86]) was lower than that among non-IC patients (ED/UC: 94% [95% CI: 93-94]; hospitalization: 96% [95% CI: 95-97]). Similar patterns were observed for viral-vector vaccines. Transplant recipients had lower VE than other IC subgroups. CONCLUSIONS: During B.1.617.2 (Delta) variant predominance, IC adults received moderate protection against COVID-19-associated medical events from three mRNA doses, or one viral-vector dose plus a second dose of any product. However, protection was lower in IC versus non-IC patients, especially among transplant recipients, underscoring the need for additional protection among IC adults.

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada.

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Prevalence and Correlates of Cardiovascular, Pulmonary, Cancer, and Mental Health Comorbidities Among Adults With HIV Who Smoke.

ABSTRACT: Using data from the D.C. Cohort Longitudinal HIV Study, we examined (a) diagnosed mental health and (b) cardiovascular, pulmonary, or cancer (CPC) comorbidity among adults with HIV who smoked. Among 8,581 adults, 4,273 (50%) smoked; 49% of smokers had mental health, and 13% of smokers had a CPC comorbidity. Among smokers, non-Hispanic Black participants had a lower risk for mental health (prevalence ratio [PR]: 0.69; 95% confidence interval [CI] [0.62-0.76]) but a higher risk for CPC (PR: 1.17; 95% CI [0.84-1.62]) comorbidity. Male participants had a lower risk for mental health (PR: 0.88; 95% CI [0.81-0.94]) and CPC (PR: 0.68; 95% CI [0.57-0.81]) comorbidity. All metrics of socioeconomic status were associated with a mental health comorbidity, but only housing status was associated with a CPC comorbidity. We did not find any association with substance use. Gender, socioeconomic factors, and race/ethnicity should inform clinical care and the development of smoking cessation strategies for this population.

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

INTRODUCTION: In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. METHODS: This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. RESULTS: Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. CONCLUSION: This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

Predictors of support for anti-weight discrimination policies among Canadian adults.

Introduction: Weight discrimination of individuals with overweight or obesity is associated with adverse mental and physical health. Weight discrimination is prevalent in many sectors such as within workplaces, where individuals with overweight and obesity are denied the same opportunities as individuals with lower weight status, regardless of performance or experience. The purpose of this study was to understand the Canadian public's support or opposition of anti-weight discrimination policies and predictors of support. It was hypothesized that Canadians will show support of anti-weight discrimination policies to some extent. Methods: A secondary analysis was conducted on a previous cross-sectional sample of Canadian adults (N = 923, 50.76% women, 74.4% White) who responded to an online survey assessing weight bias and support of twelve anti-weight discrimination policies related to societal policies (e.g., implementing laws preventing weight discrimination) and employment-related policies (e.g., making it illegal to not hire someone due to their weight). Participants completed the Causes of Obesity Questionnaire (COB), the Anti-Fat Attitudes Questionnaire (AFA) and the Modified Weight Bias Internalization Scale (WBIS-M). Multiple logistic regressions were used to determine predictors of policy support. Results: Support for policies ranged from 31.3% to 76.9%, with employment anti-discrimination policies obtaining greater support than societal policies. Identifying as White and a woman, being over the age of 45 and having a higher BMI were associated with an increased likelihood of supporting anti-weight discrimination policies. There were no differences between the level of support associated with attributing obesity to behavioral or non-behavioral causes. Explicit weight bias was associated with a reduced likelihood of supporting 8/12 policies. Weight Bias Internalization was associated with an increased likelihood of supporting all societal policies but none of the employment policies. Conclusions: Support for anti-weight discrimination policies exists among Canadian adults, and explicit weight bias is associated with a lower likelihood of supporting these policies. These results highlight the need for education on the prevalence and perils of weight discrimination which may urge policy makers to consider weight bias as a form of discrimination that must be addressed. More research on potential implementation of anti-weight discrimination policies in Canada is warranted.

Estimation of COVID-19 mRNA Vaccine Effectiveness and COVID-19 Illness and Severity by Vaccination Status During Omicron BA.4 and BA.5 Sublineage Periods.

Importance: Recent SARS-CoV-2 Omicron variant sublineages, including BA.4 and BA.5, may be associated with greater immune evasion and less protection against COVID-19 after vaccination. Objectives: To evaluate the estimated vaccine effectiveness (VE) of 2, 3, or 4 doses of COVID-19 mRNA vaccination among immunocompetent adults during a period of BA.4 or BA.5 predominant circulation; and to evaluate the relative severity of COVID-19 in hospitalized patients across Omicron BA.1, BA.2 or BA.2.12.1, and BA.4 or BA.5 sublineage periods. Design, Setting, and Participants: This test-negative case-control study was conducted in 10 states with data from emergency department (ED) and urgent care (UC) encounters and hospitalizations from December 16, 2021, to August 20, 2022. Participants included adults with COVID-19-like illness and molecular testing for SARS-CoV-2. Data were analyzed from August 2 to September 21, 2022. Exposures: mRNA COVID-19 vaccination. Main Outcomes and Measures: The outcomes of interest were COVID-19 ED or UC encounters, hospitalizations, and admission to the intensive care unit (ICU) or in-hospital death. VE associated with protection against medically attended COVID-19 was estimated, stratified by care setting and vaccine doses (2, 3, or 4 doses vs 0 doses as the reference group). Among hospitalized patients with COVID-19, demographic and clinical characteristics and in-hospital outcomes were compared across sublineage periods. Results: During the BA.4 and BA.5 predominant period, there were 82 229 eligible ED and UC encounters among patients with COVID-19-like illness (median [IQR] age, 51 [33-70] years; 49 682 [60.4%] female patients), and 19 114 patients (23.2%) had test results positive for SARS-CoV-2; among 21 007 hospitalized patients (median [IQR] age, 71 [58-81] years; 11 209 [53.4%] female patients), 3583 (17.1 %) had test results positive for SARS-CoV-2. Estimated VE against hospitalization was 25% (95% CI, 17%-32%) for receipt of 2 vaccine doses at 150 days or more after receipt, 68% (95% CI, 50%-80%) for a third dose 7 to 119 days after receipt, and 36% (95% CI, 29%-42%) for a third dose 120 days or more (median [IQR], 235 [204-262] days) after receipt. Among patients aged 65 years or older who had received a fourth vaccine dose, VE was 66% (95% CI, 53%-75%) at 7 to 59 days after vaccination and 57% (95% CI, 44%-66%) at 60 days or more (median [IQR], 88 [75-105] days) after vaccination. Among hospitalized patients with COVID-19, ICU admission or in-hospital death occurred in 21.4% of patients during the BA.1 period vs 14.7% during the BA.4 and BA.5 period (standardized mean difference: 0.17). Conclusions and Relevance: In this case-control study of COVID-19 vaccines and illness, VE associated with protection against medically attended COVID-19 illness was lower with increasing time since last dose; estimated VE was higher after receipt of 1 or 2 booster doses compared with a primary series alone.

HIV Risk Perception, Willingness to Use PrEP, and PrEP Uptake Among Young Men who have Sex with Men in Washington, DC.

Low HIV risk perception is a barrier to PrEP uptake, but few studies have examined risk perception and PrEP uptake among young men who have sex with men (YMSM). We performed a secondary analysis of data collected in 2016 from YMSM ages 16-25 in the Washington, DC metropolitan area who participated in a cross-sectional online survey that aimed to identify strategies for engaging YMSM in PrEP services. Of 188 participants, 115 (61%) were considered eligible for PrEP. Among PrEP-eligible participants who had never used PrEP, 53%, 71%, and 100% with low, moderate, and high risk perception, respectively, were willing to use PrEP (Fisher's exact test p = 0.01). Odds of PrEP willingness were greater among those with moderate/high versus low risk perception (adjusted odds ratio [OR] = 5.62, 95% CI = 1.73-18.34). HIV risk perception was not significantly associated with self-reported PrEP use. These findings suggest the importance of risk perception as a correlate of willingness to use PrEP, which is a key step in existing frameworks of PrEP uptake.

Descriptive Analysis of Clinical Encounters by Emergency Medical Services Physicians Using the RE-AIM Framework.

CONTEXT: Emergency medical services (EMS) medicine continues to expand and mature as a recognized subspeciality within emergency medicine. In the United States, EMS physicians historically supported training, protocol development, and EMS clinician credentialing. In the past, only limited programs existed in which prehospital physicians were engaged in the direct and routine care of prehospital patients; however, a growing number of EMS programs are recognizing the value and impact of direct EMS physician involvement in prehospital patient care. PROGRAM: A large suburban, volunteer-based EMS agency implemented a volunteer prehospital physician program where providers routinely responded to emergency calls for service. IMPLEMENTATION: Beginning in November 2019, a cadre of board-certified physicians completed a field preceptorship and local protocol orientation. Once complete, the physicians were released to function and respond independently to high acuity emergency calls or any call at their discretion. Prehospital physicians were authorized to utilize their full scope of practice and expected to provide field mentorship to traditional prehospital clinicians. EVALUATION: This study systematically evaluated a prehospital physician program for public health relevance, sustainability, and population health impact using the RE-AIM framework. A retrospective descriptive analysis was performed on the role and responses by a cohort of prehospital physicians using dispatch data and electronic medical records. DISCUSSION: Over the 17-month study period, 9 prehospital physicians responded to 482 calls, predominately cardiac arrests, traumatic injuries, and cardiac/chest pain. The physicians performed 99 procedures and administered 113 medications. Ultimately, the program added physician-level care to the prehospital setting in an ongoing and sustainable way. The routine placement of physicians in the prehospital environment can help benefit patients by enhancing access to advanced clinical knowledge and skills, while also benefiting EMS clinicians through opportunities for enhanced patient-side training, education, and medical control.