Reliability of ChatGPT for performing triage task in the emergency department using the Korean Triage and Acuity Scale.

Background: Artificial intelligence (AI) technology can enable more efficient decision-making in healthcare settings. There is a growing interest in improving the speed and accuracy of AI systems in providing responses for given tasks in healthcare settings. Objective: This study aimed to assess the reliability of ChatGPT in determining emergency department (ED) triage accuracy using the Korean Triage and Acuity Scale (KTAS). Methods: Two hundred and two virtual patient cases were built. The gold standard triage classification for each case was established by an experienced ED physician. Three other human raters (ED paramedics) were involved and rated the virtual cases individually. The virtual cases were also rated by two different versions of the chat generative pre-trained transformer (ChatGPT, 3.5 and 4.0). Inter-rater reliability was examined using Fleiss' kappa and intra-class correlation coefficient (ICC). Results: The kappa values for the agreement between the four human raters and ChatGPTs were .523 (version 4.0) and .320 (version 3.5). Of the five levels, the performance was poor when rating patients at levels 1 and 5, as well as case scenarios with additional text descriptions. There were differences in the accuracy of the different versions of GPTs. The ICC between version 3.5 and the gold standard was .520, and that between version 4.0 and the gold standard was .802. Conclusions: A substantial level of inter-rater reliability was revealed when GPTs were used as KTAS raters. The current study showed the potential of using GPT in emergency healthcare settings. Considering the shortage of experienced manpower, this AI method may help improve triaging accuracy.

Prenatal cocaine exposure and self-reported behavioral adjustments from ages 12 to 21: environmental pathways.

BACKGROUND: In a birth-cohort study, we followed offspring with prenatal cocaine exposure (PCE) to investigate longitudinal associations of PCE with self-reported behavioral adjustment from early adolescence to emerging adulthood (EA). Environmental pathways (family functioning, non-kinship care, maltreatment) were specified as potential mediators of PCE. METHODS: Participants were 372 (190 PCE; 47% male), primarily Black, low socioeconomic status, enrolled at birth. Internalizing and externalizing behaviors were assessed using Youth Self-Report at ages 12 and 15 and Adult Self-Report at age 21. Extended random-intercept cross-lagged panel modeling was used to account for potential bidirectional relationships between internalizing and externalizing behaviors over time, examining potential mediators. RESULTS: Adjusting for covariates, significant indirect effects were found for each mediator at different ages. For family functioning, these were both internalizing (ß = 0.83, p = 0.04) and externalizing behaviors (ß = 1.58, p = 0.02) at age 12 and externalizing behaviors at age 15 (ß = 0.51, p = 0.03); for non-kinship care, externalizing behaviors at ages 12 (ß = 0.63, p = 0.02) and 15 (ß = 0.20, p = 0.03); and for maltreatment, both internalizing and externalizing behaviors at ages 15 (ß = 0.64, p = 0.02 for internalizing; ß = 0.50, p = 0.03 for externalizing) and 21 (ß = 1.39, p = 0.01 for internalizing; ß = 1.11, p = 0.01 for externalizing). Direct associations of PCE with internalizing and externalizing behaviors were not observed, nor cross-lagged relationships between internalizing and externalizing behaviors. CONCLUSIONS: Negative associations of PCE with behavioral adjustment persist into EA via environmental pathways, specifying intervention points to disrupt adverse pathways toward healthy development.

Prenatal Exposure to Intimate Partner Violence and Child Developmental Outcomes: A Scoping Review Study.

Pregnant women face an increased risk of intimate partner violence (IPV). In addition to the risk of violence faced by women, there is a dual concern for risk of harm to the fetus. Expanding knowledge on childbirth outcomes, other domains of children's development have been examined in recent literature. Yet, there is limited comprehensive knowledge in the area. This scoping review study, informed by ecobiodevelopmental theory, mapped evidence associating prenatal IPV exposure and children's development. We searched eight databases, including PubMed, CINAHL, and ERIC. Thirty-one empirical studies published in English that associated prenatal IPV exposure and children's development were eligible for our review. Included studies were published between 2006 and 2022, with 39% published in the most recent 5 years. Eighteen studies had sample sizes smaller than 500, and 21 were atheoretical; six failed to consider covariates. Reviewed studies showed adverse effects of prenatal IPV exposure on psychological, behavioral, physical health, and physiological outcomes, either directly or indirectly via mechanisms such as maternal behavioral health. Due to inconsistency in results and a lack of empirical evidence, however, social and cognitive outcomes were identified as needing further research to enhance our understanding of the global and domain-specific effects of prenatal IPV exposure. Prospective longitudinal studies, driven by theories of causal mechanisms, which adjust for empirically qualified confounders, will be critical to inform practice and policy to promote healthy development of prenatally IPV-exposed children. Incorporating strengths/asset-focused outcomes and examining contextual factors and sex/gender specific effects may advance the knowledge in this area.

Usefulness of The Rapid Antigen Test in Detecting SARS-CoV-2 for Infection Control in Hospitals.

BACKGROUND: We aimed at evaluating the diagnostic performance of rapid antigen test (RAT) compared to PCR for severe acute respiratory syndrome coronavirus 2 and the possible transmission of infection to close contacts from patients with negative RAT and positive polymerase chain reaction (PCR) results. MATERIALS AND METHODS: Patients/guardians urgently requiring admission to the ward on the same day had been hospitalized with RAT-negative result before the PCR results were available. We performed an epidemiologic investigation of the close contacts of those with negative RAT but positive PCR results after hospitalization. RESULTS: A total of 4,237 RATs were performed from March to August 2022. When the PCR test was used as the reference, RAT had a sensitivity of 28.8% (17/59; 95% confidence interval [CI]: 17.8 - 42.1), a specificity of 100% (4,220/4,220; 95% CI: 99.9 - 100.0), a positive predictive value of 100.0% (17/17; 95% CI: 100.0 - 100.0), and a negative predictive value of 99.0% (4,178/4,220; 95% CI: 99.3 - 99.8). The epidemiologic investigation revealed that among the 32 patients with negative RAT and subsequent positive PCR results after admission into multi-patient room, two (6.3%) showed secondary coronavirus disease 2019. CONCLUSION: The secondary transmission rate from patients with negative RAT and positive PCR results was low. Our data suggest that RAT may be useful for rapid exclusion of high transmissible cases. However, further evaluation using whole genome sequencing is needed to determine the potential for transmissibility in cases showing a negative RAT but a positive PCR result.

3D human anatomy augmentation over a mannequin for the training of nursing skills.

BACKGROUND: The in-depth understanding of human anatomy is the foundation for safety in nursing practice. Augmented reality is an emerging technology that can be used for integrative learning in nursing education. OBJECTIVE: The study aimed to develop a human anatomy-based skill training system and pilot test its usability and feasibility. METHODS: Twenty-seven nursing students participated in 3D anatomy-based skill training for intramuscular injection and Levin tube feeding using HoloLens 2. Various user interfaces including pictures, videos, animation graphics, and annotation boxes assisted users with a comprehensive understanding of the step-by-step procedures for these techniques. A one-group pre-post test was conducted to observe changes in skill performance competency, usability, and learning satisfaction. RESULTS: After study participation, a statistically significant improvement in skill performance competency (p< 0.05) was observed. The usability results showed that students were satisfied with the usefulness of the program (9.55 ± 0.49) and scored highly for the intention to participate in other educational programs (9.62 ± 0.59). A high level of learning satisfaction was achieved (9.55 ± 0.49), with positive responses in fostering students' engagement and excitement in the application of cutting-edge technology. CONCLUSION: The 3D anatomy-based nursing skill training demonstrated good potential to improve learning outcomes and facilitate engagement in self-directed practice. This can be integrated into undergraduate nursing education as an assistant teaching tool, contributing to the combination of knowledge and practice.

Causes of a Low Measles Seroprevalence among Young Healthcare Workers in Korea.

BACKGROUND: Sporadic measles outbreaks have continued to occur in Korea, mainly in adults in their 20s and 30s, most notably in 2014 and 2019. We here evaluated the possible causes of a low seroprevalance of measles by testing young healthcare workers (HCWs). MATERIALS AND METHODS: This study was conducted in a 2,743-bed tertiary-care hospital in Seoul between 2020 and 2021. We performed a measles antibody test (chemiluminescence immunoassay), measured the IgM/IgG index ratio, and conducted an avidity test at 1-month after Measles-Mumps-Rubella (MMR) vaccination in HCWs who had been seronegative for measles. Measles vaccination histories were obtained from the national vaccine registry. RESULTS: Of the 3,173 HCWs newly employed in our hospital during the study period, 54 with a negative measles IgG at commencement were enrolled. Thirty six (67%) of these subjects were female, and the median age was 25 years (interquartile range [IQR]: 24 - 27). Fourty nine (91%) showed seroconversion at 1 month after the first vaccination. Of these individuals, 38 received both measles IgM and IgG test, and all had an IgM/IgG index <1. Of the 49 seroconverters, all HCWs showed a high avidity index. According to the national immunization registry, 45 (83%) received at least 2 doses of an MMR vaccination. CONCLUSION: Secondary vaccine failure may underlie vaccine failure in young Korean adults. HCWs born after 1985 with a negative measles antibody may need only a single dose booster vaccination rather than a 2-dose vaccination regimen.

Ultrahigh-efficient material informatics inverse design of thermal metamaterials for visible-infrared-compatible camouflage.

Multispectral camouflage technologies, especially in the most frequently-used visible and infrared (VIS-IR) bands, are in increasing demand for the ever-growing multispectral detection technologies. Nevertheless, the efficient design of proper materials and structures for VIS-IR camouflage is still challenging because of the stringent requirement for selective spectra in a large VIS-IR wavelength range and the increasing demand for flexible color and infrared signal adaptivity. Here, a material-informatics-based inverse design framework is proposed to efficiently design multilayer germanium (Ge) and zinc sulfide (ZnS) metamaterials by evaluating only ~1% of the total candidates. The designed metamaterials exhibit excellent color matching and infrared camouflage performance from different observation angles and temperatures through both simulations and infrared experiments. The present material informatics inverse design framework is highly efficient and can be applied to other multi-objective optimization problems beyond multispectral camouflage.

Ultrathin Metal Film on Graphene for Percolation-Threshold-Limited Thermal Emissivity Control.

Translucent Au/graphene hybrid films are shown to be effective in reducing thermal emission from the underlying surfaces when the deposition thickness of Au is close to the percolation threshold. The critical Au deposition thickness for an abrupt change in emissivity is reduced from 15 nm (Si substrate) to a percolation-threshold-limited thickness of 8.5 nm (graphene/Si substrate) because of the chemical inertness of graphene leading to the deposited Au atoms forming a thin, crystalline layer. The effect of the graphene layer on the optical properties of the hybrid film is highlighted by a drastic increase in infrared absorptivity, whereas the visible absorptivity is marginally affected by the presence of a graphene layer. The level of thermal emission from the Au/graphene hybrid films with the percolation-threshold-limited Au thickness is stable even with high background temperatures of up to 300 °C and mechanical strains of ≈4%. As an example of a thermal management application, an anti-counterfeiting device is demonstrated; thermal-camouflage-masked text fabricated with an Au/graphene hybrid film is discernible only using a thermographic camera. Ultrathin metal film assisted by a graphene layer will provide a facile platform for thermal management with semi-transparency, flexibility, and transferability to arbitrary surfaces.

Directional Radiative Cooling via Exceptional Epsilon-Based Microcavities.

The advent of nanophotonics enables the regulation of thermal emission in the momentum domain as well as in the frequency domain. However, earlier attempts to steer thermal emission in a certain direction were restricted to a narrow spectrum or specific polarization, and thus their average (8-14 µm) emissivity (εav) and angular selectivity were nominal. Therefore, the practical uses of directional thermal emitters have remained unclarified. Here, we report broadband, polarization-irrelevant, amplified directional thermal emission from hollow microcavities covered with deep-subwavelength-thickness oxide shells. A hexagonal array of SiO2/AlOX (100/100 nm) hollow microcavities designed by Bayesian optimization exhibited εav values of 0.51-0.62 at 60°-75° and 0.29-0.32 at 5°-20°, yielding a parabolic antenna-shaped distribution. The angular selectivity peaked at 8, 9.1, 10.9, and 12 µm, which were identified as the epsilon-near-zero (via Berreman modes) and maximum-negative-permittivity (via photon-tunneling modes) wavelengths of SiO2 and AlOX, respectively, thus supporting phonon-polariton resonance mediated broadband side emission. As proof-of-concept experiments, we demonstrated that these exceptional epsilon-based microcavities could provide thermal comfort to users and practical cooling performance to optoelectronic devices.

Lipoteichoic acid of Streptococcus gordonii as a negative regulator of human dendritic cell activation.

Streptococcus gordonii, an opportunistic Gram-positive bacterium, causes an infective endocarditis that could be fatal to human health. Dendritic cells (DCs) are known to be involved in disease progression and immune responses in S. gordonii infection. Since lipoteichoic acid (LTA) is a representative virulence factor of S. gordonii, we here investigated its role in the activation of human DCs stimulated with LTA-deficient (ΔltaS) S. gordonii or S. gordonii LTA. DCs were differentiated from human blood-derived monocytes in the presence of GM-CSF and IL-4 for 6 days. DCs treated with heat-killed ΔltaS S. gordonii (ΔltaS HKSG) showed relatively higher binding and phagocytic activities than those treated with heat-killed wild-type S. gordonii (wild-type HKSG). Furthermore, ΔltaS HKSG was superior to wild-type HKSG in inducing phenotypic maturation markers including CD80, CD83, CD86, PD-L1, and PD-L2, antigen-presenting molecule MHC class II, and proinflammatory cytokines such as TNF-α and IL-6. Concomitantly, DCs treated with the ΔltaS HKSG induced better T cell activities, including proliferation and activation marker (CD25) expression, than those treated with the wild-type. LTA, but not lipoproteins, isolated from S. gordonii weakly activated TLR2 and barely affected the expression of phenotypic maturation markers or cytokines in DCs. Collectively, these results demonstrated that LTA is not a major immuno-stimulating agent of S. gordonii but rather it interferes with bacteria-induced DC maturation, suggesting its potential role in immune evasion.

Erratum: Correction of Funding in the Article "Rates of COVID-19 Infection Among Healthcare Workers in Designated COVID-19 Wards and General Wards".

This corrects the article on p. e308 in vol. 37, PMID: 36345254.

Structure and dynamics of the essential endogenous mycobacterial polyketide synthase Pks13.

Mycobacterium tuberculosis is currently the leading cause of death by any bacterial infection1. The mycolic acid layer of the cell wall is essential for viability and virulence, and the enzymes responsible for its synthesis are therefore front line targets for antimycobacterial drug development2,3. Polyketide synthase 13 (Pks13) is a module comprised of a closely symmetric parallel dimer of chains, each encoding several enzymatic and transport functions, that carries out the condensation of two different very long chain fatty acids to produce mycolic acids that are essential components of the mycobacterial cell wall. Consequently individual enzymatic domains of Pks13 are targets for antimycobacterial drug development4. To understand this machinery, we sought to determine the structure and domain trajectories of the dimeric multi-enzyme Pks13, a 2×198,426 Dalton complex, from protein purified endogenously from mycobacteria under normal growth conditions, to capture it with normal substrates bound trapped 'in action'. Structures of the multi-domain assembly revealed by cryogenic electron microscopy (cryoEM) define the ketosynthase (KS), linker, and acyltransferase (AT) domains, each at atomic resolution (1.8Å), with bound substrates defined at 2.4Å and 2.9Å resolution. Image classification reveals two distinct structures with alternate locations of the N-terminal acyl carrier protein (termed ACP1a, ACP1b) seen at 3.6Å and 4.6Å resolution respectively. These two structures suggest plausible intermediate states, related by a ~60Å movement of ACP1, on the pathway for substrate delivery from the fatty acyl-ACP ligase (FadD32) to the ketosynthase domain. The linking sequence between ACP1 and the KS includes an 11 amino acid sequence with 6 negatively charged side chains that lies in different positively charged grooves on the KS in ACP1a versus ACP1b structures. This charge complementarity between the extended chain and the grooves suggests some stabilization of these two distinct orientations. Other domains are visible at lower resolution and indicate flexibility relative to the KS-AT core. The chemical structures of three bound endogenous long chain fatty acid substrates with their proximal regions defined in the structures were determined by electrospray ionization mass spectrometry. The domain proximities were probed by chemical cross-linking and identified by mass spectrometry. These were incorporated into integrative structure modeling to define multiple domain configurations that transport the very long fatty acid chains throughout the multistep Pks13 mediated synthetic pathway.

Structure and dynamics of the essential endogenous mycobacterial polyketide synthase Pks13.

The mycolic acid layer of the Mycobacterium tuberculosis cell wall is essential for viability and virulence, and the enzymes responsible for its synthesis are targets for antimycobacterial drug development. Polyketide synthase 13 (Pks13) is a module encoding several enzymatic and transport functions that carries out the condensation of two different long-chain fatty acids to produce mycolic acids. We determined structures by cryogenic-electron microscopy of dimeric multi-enzyme Pks13 purified from mycobacteria under normal growth conditions, captured with native substrates. Structures define the ketosynthase (KS), linker and acyl transferase (AT) domains at 1.8 Å resolution and two alternative locations of the N-terminal acyl carrier protein. These structures suggest intermediate states on the pathway for substrate delivery to the KS domain. Other domains, visible at lower resolution, are flexible relative to the KS-AT core. The chemical structures of three bound endogenous long-chain fatty acid substrates were determined by electrospray ionization mass spectrometry.

Polarization-driven thermal emission regulator based on self-aligned GST nanocolumns.

The increasing advances in thermal radiation regulators have attracted growing interest, particularly in infrared sources, thermal management, and camouflage. Despite many advances in dynamic thermal emitters with great controllability, sustained external energy is required to maintain the desired emission. In this study, we present a polarization-driven thermal emission regulator based on a two-way control: i) phase change and ii) polarization tuning. Based on a conventional, non-volatile phase change material, i.e., Ge2Sb2Te5 (GST), we newly introduce an anisotropic medium for facile emissivity regulation without heat energy consumption. A rigorous coupled-wave analysis method provides design guidelines for finding optimal structural parameters. We utilized a simple glancing angle deposition process which induces tilted self-aligned nanocolumns with anisotropic properties. The fabricated sample shows polarization-sensitive thermal regulation through thermal imaging spectroscopic measurement. Additionally, we manufactured a multispectral visibly/thermally camouflaged patch that identifies encrypted information at a specific polarization state for a proof-of-concept demonstration.

Smart glasses and telehealth services by professionals in isolated areas in Korea: Acceptability and concerns.

BACKGROUND: Smart glass technology offers remote interaction between health professionals for telehealth, alleviating healthcare disparities in isolated areas. OBJECTIVE: To evaluate the professionals' perceptions of smart glass technology as a tool for telehealth and distance learning. METHOD: This mixed-method study on health professionals in 10 different island areas in Korea involved participants experiencing a smart glass-based telehealth system using the scenario of clinical consultation with remote specialists. A group pre- and post-test design was used to examine the change in attitude and perceived importance among health professionals about using smart glasses in telehealth. RESULTS: Forty-seven participants completed both pre-and post-evaluation of smart glasses. A positive, statistically significant change in participants' perceptions of smart glasses regarding their implications for telehealth and distance learning (p< 0.05) was found. Fifty-one health workers provided feedback on smart glasses, and a majority expressed their expectations of quality care with telehealth using advanced technology. The main concerns were patients' privacy issues and inadequate technology for seamless application. CONCLUSION: The incorporation of smart glass technology offers great potential to enrich telehealth as well as distance learning for unskilled health professionals in isolated areas. Future studies are needed to increase efforts to secure a high level of acceptance for clinical consultation with remote specialists on this newly developed device.

Prenatal cocaine exposure and substance use disorder in emerging adulthood at age 21.

BACKGROUND: Prenatal cocaine exposure (PCE) has been associated with child and adolescent externalizing behaviors and early substance use, yet few studies investigated its association with substance use disorder (SUD) in emerging adults. The present study examined the association of PCE with SUD in emerging adulthood, and whether childhood externalizing behaviors and adolescent substance use mediated the relationship. METHODS: Participants were 367 (187 PCE; 53% female) adults at age 21, primarily urban African American who were recruited at birth. PCE and exposure to alcohol, tobacco, and marijuana were determined using biologic assays for drug metabolites and/or maternal self-report at birth. Offspring externalizing problems were assessed using the Youth Self-Report at age 12, substance use and substance use-related problems via biologic assays and/or self-report at age 15, and SUD determined using DSM-5 diagnostic criteria at age 21. RESULTS: About 32.3% of the emerging adults were determined to have marijuana use disorder, 30.3% tobacco use disorder, and 15.5% alcohol use disorder. PCE was related to greater externalizing behaviors at age 12 (ß = 0.12, p = .042), which in turn was related to SUD (ß = 0.22, p = .008). PCE was also related to substance use, mainly marijuana, at age 15 (ß = 0.22, p = .011), which was related to SUD (ß = 0.51, p < .001). Total indirect effects including these two pathways were significant (ß = 0.19, p = .002). CONCLUSIONS: PCE may increase risk for SUD in emerging adulthood through childhood externalizing behaviors and adolescent substance use.

Constructing a Mixed Simulation With 360° Virtual Reality and a High-Fidelity Simulator: Usability and Feasibility Assessment.

Virtual reality technology has been adopted to overcome barriers of conventional simulation. This study was conducted to determine the impact of mixed simulation (a 360° virtual reality and a high-fidelity simulator) on learning how to provide nursing care for patients with arrhythmia. A total of 49 students were randomly assigned to intervention (n = 25) and control (n = 23) groups. They were given four arrhythmia cases with a 360° virtual reality system first followed by a manikin-based simulation. The mixed simulation group showed greater improvement in knowledge, higher decision-making competency in "knowing and acting" ( P = .025) and "seeking information from instructors" ( P = .049), and lower anxiety in "using resources to gather information" ( P = .031). Study participants achieved a good level of empathy (3.28 ± 0.72) and liked the program (4.56 ± 0.60). They were satisfied with the program (4.48 ± 0.65). These findings provide new insight into learning through blending of new technology. When the 360° virtual reality was used with existing manikin-based simulation, they effectively reinforced one another. The 360° virtual reality can be an effective strategy to ensure active participation to gain a comprehensive understanding of and empathy for patients.

The association of prenatal cocaine exposure with expressive and receptive language skills, phonological processing and reading ability at age 17.

OBJECTIVE: Prenatal cocaine exposure (PCE) has been associated with small but significant effects on language development in childhood and early adolescence. This study examined whether this association persists into later adolescence and what relationship language skills may have with reading proficiency in this population. METHODS: Enrolled were 338 (167 with PCE, 171 with NCE or no cocaine exposure) 17-year-olds recruited at birth who, together with their current caregiver, were seen as part of a 17-year follow-up. Participants were given assessments of reading achievement (WIAT-III), receptive and expressive language (CELF-IV), and phonological processing (CTOPP). Relationships between PCE status and language outcomes were modeled using multiple linear regression controlling for environmental and caregiver factors, and other prenatal substance exposures. RESULTS: Adolescents with PCE scored lower in areas of phonological processing and reading related skills compared to adolescents with NCE. PCE by sex interactions were identified on language, memory and spoken language comprehension, with lower scores for girls with PCE compared to girls with NCE. CONCLUSION: These findings suggest the persistence of PCE's relationship with phonological awareness well into adolescence. PCE was also associated with lower scores on measures of skills related to reading ability, which may be a manifestation of the observed deficits in phonological processing.

Rates of COVID-19 Infection Among Healthcare Workers in Designated COVID-19 Wards and General Wards.

BACKGROUND: To evaluate the effects of isolating coronavirus disease 2019 (COVID-19) patients in general wards, we compared the rates of COVID-19 infection in nurses and nursing assistants working in COVID-19 designated wards and in general wards of our hospital from 1 October 2021 to 21 April 2022. METHODS: This study was conducted in a 2,700-bed tertiary care hospital in Seoul, Korea. Designated wards comprised single, negative pressure rooms and a 100% outdoor air system. RESULTS: During the study period, a total of 2,698 nurses and nursing assistants were employed at our hospital, of whom 310 (11%) were working in the designated wards, and the remaining 2,388 (89%) in the general wards, and among whom 1,158 (43%) were diagnosed with COVID-19. The healthcare workers (HCWs) in the designated wards were less frequently diagnosed with COVID-19 than those in the general wards (31% vs. 45%, P < 0.001). During the period before patients with COVID-19 were isolated in general wards, and during the period after these cases were isolated in general ward, HCWs in designated wards were less frequently infected with the virus than those in general wards (7% vs. 11%, P = 0.039; and 23% vs. 33%, P < 0.001, respectively). CONCLUSION: HCWs in designated wards have a lower rate of contracting COVID-19 than those in general wards. A lack of exposure to undiagnosed cases and their caregivers, greater care with social distancing outside the hospital, higher rates of 3-dose vaccinations, and the use of isolation rooms with negative pressure may be associated with this finding.