Acute Flaccid Paralysis in an 11-Year-Old.

ABSTRACT: Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and subsequent release of intracellular components into the systemic circulation. We report a case of rhabdomyolysis causing acute paralysis from underlying and unrecognized hypothyroidism in an 11-year-old girl. To date, publications of rhabdomyolysis secondary to hypothyroidism have been limited, especially in the pediatric population. Early intervention with intravenous fluids and levothyroxine led to resolution of our patient's symptoms and is overall important in preventing the serious sequela of rhabdomyolysis including renal failure, cardiac dysrhythmias, compartment syndrome, and disseminated intravascular coagulation.

Os Odontoideum Discovered After Minor Cervical Trauma.

Minor cervical spine injury is a common cause of pediatric emergency department visits. We present a case of a 10-year-old boy with transient paresthesia after minor cervical trauma found to have a rare cervical spine abnormality requiring surgical fusion. We present and discuss the management options for os odontoideum.

Finger counting: an alternative method for estimating pediatric weights.

OBJECTIVES: We compared the accuracy of a conceptually simple pediatric weight estimation technique, the finger counting method, with other commonly used methods. METHODS: We prospectively collected cross-sectional data on a convenience sample of 207 children aged 1 to 9 presenting to our pediatric emergency department. Bland-Altman plots were constructed to compare the finger counting method to the Broselow tape method, parental estimate, the Luscombe formula, and the advanced pediatric life support (APLS) formula. Proportions within 10% and 20% of measured weight were compared. RESULTS: Mean difference and range of agreement in kilograms for Bland-Altman plots were as follows: -1.8 (95% confidence interval [CI], -2.3 to -1.3) and 15.4 (95% CI, 13.6-17.2) for the finger counting method; -1.4 (95% CI, -2.0 to -0.9) and 15.8 (95% CI, 13.9-17.6) for the Broselow method; -0.02 (95% CI, -0.53 to 0.49) and 14.8 (95% CI, 13-16.6) for parental estimate; 0.2 (95% CI, -0.33 to 0.72) and 15.3 (95% CI, 13.5-17.2) for the Luscombe formula; and -3.8 (95% CI, -4.4 to -3.2) and 17.2 (95% CI, 15.2-19.2) for the APLS formula. The finger counting method estimated weights within 10% in 59% of children (95% CI, 52%-65%) and within 20% in 87% of children (95% CI, 81%-91%). Proportions within 10% were similar for all methods, except the APLS method, which was lower. CONCLUSIONS: The finger counting method is an acceptable alternative to the Broselow method for weight estimation in children aged 1 to 9 years. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula.

Pediatric procedural sedation with propofol using a higher initial bolus dose.

OBJECTIVES: We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed. METHODS: This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale. RESULTS: Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm. CONCLUSIONS: A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

Emergency Department Volumes After State-Wide Lockdown Orders Across the United States During the COVID-19 Pandemic: COVID-19 lockdown and emergency volume.

OBJECTIVE: The objective of this study was to describe changes in emergency department volumes after statewide lockdown in a network of hospitals across the United States during the COVID-19 global pandemic. METHODS: A retrospective study was performed utilizing data on daily volumes across multiple emergency departments from a centralized data warehouse from a private for-profit hospital system during the COVID-19 pandemic. The mean daily volumes of 148 emergency departments were evaluated across 16 states in relation to each state's governmental statewide lockdown orders. Comparisons of the same period in the prior year were evaluated for percent changes in volumes. We also compared pre-lockdown to post-lockdown volumes. A separate analysis was made for the pediatric ED volumes. RESULTS: The 2020 post-lockdown volumes compared to the same 2019 dates revealed a mean percent change of -43.09%. The overall post-lockdown volumes compared to the pre-lockdown volumes had a mean percent change of -45.00%. The pediatric data revealed a greater mean percentage change in volumes of -71.52% (post-lockdown compared to 2019) and -69.03% (post-lockdown compared to pre-lockdown). CONCLUSIONS: This study found an overall decrease in volumes among 148 emergency departments across 16 states when compared to the comparable period pre-global pandemic.

New-Onset Paroxysmal Atrial Fibrillation in a Healthy Male With Post-COVID-19 Painless Thyroiditis: A Case Report.

Painless thyroiditis is a variant of thyroiditis without the typical neck pain and is otherwise similar to subacute thyroiditis, which is a known post-viral condition and has been associated with coronavirus disease 2019 (COVID-19) infections. While it is usually self-limiting, it can lead to thyrotoxicosis that can predispose individuals to cardiac dysrhythmias, including atrial fibrillation. There has been a clear association between COVID-19 and subacute thyroiditis with a few case reports describing atrial fibrillation. We present a case of a healthy patient with new-onset atrial fibrillation secondary to painless thyroiditis. This report highlights the rare entity of painless thyroiditis leading to atrial fibrillation with rapid ventricular response in a patient who recently recovered from COVID-19. Physicians should consider the potential association of painless thyroiditis in patients with new-onset atrial fibrillation who recently recovered from COVID-19.

Case Report of a Child with Colocolic Intussusception with a Primary Lead Point.

Intussusception is the telescoping of bowel into an adjacent segment of bowel and has an associated risk for bowel ischemia and perforation. The classic triad of abdominal pain, blood in stool, and an abdominal mass is present in less than 40% of pediatric cases and is less common in older children.1 Ultrasound has a high sensitivity and specificity for the diagnosis of intussusception, and once diagnosed, treatment modalities include reduction by either ultrasound or fluoroscopic guided air or hydrostatic enema. The risk of recurrence after successful reduction occurs in up to 12% of pediatric patients and occurs more frequently in older children and children with a pathologic lead point.2 We present a case of a 6-year-old child with colocolic intussusception that was successfully reduced and recurred within five days due to a large colonic polyp. Topics: Intussusception, lead point, pediatrics.

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity.

BACKGROUND: Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group. METHODS: An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White). RESULTS: A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients. DISCUSSION: Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

Mapping Surgical Intervention Trajectories in Seriously Ill Children Receiving Palliative Care.

BACKGROUND/PURPOSE: Despite the prevalence of surgical intervention in seriously ill children, data is scarce regarding interventions performed based on type of serious illness. We therefore sought to evaluate the surgical interventions performed from the time of serious illness diagnosis to the present in a cohort of children receiving palliative care, including identification of the surgical specialists involved in these procedures. METHODS: We conducted a retrospective cohort analysis of surgical interventions in 197 children enrolled in a multicenter prospective cohort study (Pediatric Palliative Care Research Network SHARE Study). All surgical interventions were abstracted via clinical record review. RESULTS: 189 (of 197, 96%) patients (45% female) with an average of 5.3 complex, chronic conditions (CCC) underwent 3331 surgical interventions (median = 13) by 21 specialist teams (most commonly general surgeons). Those with hematologic malignancies underwent intervention most frequently, followed by children with respiratory, genetic/metabolic, and gastrointestinal/genitourinary (GI/GU) diagnoses. Children with cardiovascular disease, malignancies, and prematurity had the shortest time between diagnosis and first intervention and between diagnosis and pediatric palliative care (PPC) services. By contrast, those with genetic, neurologic, and respiratory diagnoses had significantly longer intervals between diagnosis and intervention. CONCLUSIONS: Nearly all seriously ill children receiving PPC undergo surgical intervention, and many undergo tens of interventions by a variety of subspecialist teams. Surgical intervention differs by serious illness type, with children with more acutely life-limiting illnesses undergoing high-volume, high-risk interventions in the immediate post-diagnosis period. Those with chronic, life-limiting illnesses undergo a higher lifetime volume of interventions that are relatively lower risk and more evenly distributed over time. LEVEL OF EVIDENCE: N/A.

Cost Difference in Performing Total Knee Arthroplasty at Ambulatory Surgical Centers Compared With Hospital-Based Outpatient Departments: Observational Study.

BACKGROUND: As total knee arthroplasty (TKA) further transitions toward an outpatient procedure, it becomes important to identify the resource utilization after TKAs at different outpatient facilities. The objective of this study was to determine the 90-day cost of patients who underwent TKAs at an ambulatory surgical center (ASC) or a hospital outpatient department (HOPD). METHODS: An observational cohort study was conducted using the Marketscan database with patients who had a TKA at an ASC or HOPD between January 1st, 2019, and October 2nd, 2021. The primary outcome was cost in a 90-day period (including the day of surgery), with inpatient admissions and ED visits as secondary outcomes. Multivariable regression analyses were conducted, adjusting for patient characteristics. RESULTS: The study population consisted of 47,261 patients with 7,874 ASC patients and 39,387 HOPD patients. 90-day costs for ASC patients were lower compared with HOPD patients ($35,634 ± 19,030 vs. $38,096 ± 24,389, P < 0.001). 90-day inpatient admission rates were lower for ASC than HOPD patients (2.5% vs. 4.8%, P < 0.001). 90-day ED visits for ASC patients were lesser compared with HOPD patients (8.9% vs. 12.7%, P < 0.001). CONCLUSION: Patients with TKAs at an ASC had an overall lower cost, inpatient admissions, and ED visits over a 90-day period compared with HOPD patients. Future consideration for which outpatient facilities patients have their TKA at is necessary as TKAs shift toward bundle payments and outpatient procedures.

Glandular trichome development, morphology, and maturation are influenced by plant age and genotype in high THC-containing cannabis (Cannabis sativa L.) inflorescences.

BACKGROUND: Glandular capitate trichomes which form on bract tissues of female inflorescences of high THC-containing Cannabis sativa L. plants are important sources of terpenes and cannabinoids. The influence of plant age and cannabis genotype on capitate trichome development, morphology, and maturation has not been extensively studied. Knowledge of the various developmental changes that occur in trichomes over time and the influence of genotype and plant age on distribution, numbers, and morphological features should lead to a better understanding of cannabis quality and consistency. METHODS: Bract tissues of two genotypes-"Moby Dick" and "Space Queen"-were examined from 3 weeks to 8 weeks of flower development using light and scanning electron microscopy. Numbers of capitate trichomes on upper and lower bract surfaces were recorded at different positions within the inflorescence. Observations on distribution, extent of stalk formation, glandular head diameter, production of resin, and extent of dehiscence and senescence were made at various time points. The effects of post-harvesting handling and drying on trichome morphology were examined in an additional five genotypes. RESULTS: Two glandular trichome types-bulbous and capitate (sessile or stalked)-were observed. Capitate trichome numbers and stalk length were significantly (P = 0.05) greater in "Space Queen" compared to "Moby Dick" at 3 and 6 weeks of flower development. Significantly more stalked-capitate trichomes were present on lower compared to upper bract surfaces at 6 weeks in both genotypes, while sessile-capitate trichomes predominated at 3 weeks. Epidermal and hypodermal cells elongated to different extents during stalk formation, producing significant variation in length (from 20 to 1100 µm). Glandular heads ranged from 40 to 110 µm in diameter. Maturation of stalked-capitate glandular heads was accompanied by a brown color development, reduced UV autofluorescence, and head senescence and dehiscence. Secreted resinous material from glandular heads appeared as droplets on the cuticular surface that caused many heads to stick together or collapse. Trichome morphology was affected by the drying process. CONCLUSION: Capitate trichome numbers, development, and degree of maturation were influenced by cannabis genotype and plant age. The observations of trichome development indicate that asynchronous formation leads to different stages of trichome maturity on bracts. Trichome stalk lengths also varied between the two genotypes selected for study as well as over time. The variability in developmental stage and maturation between genotypes can potentially lead to variation in total cannabinoid levels in final product. Post-harvest handling and drying were shown to affect trichome morphology.

Workforce Attrition Among Male and Female Physicians Working in US Academic Hospitals, 2014-2019.

Importance: Retaining female physicians in the academic health care workforce is necessary to serve the needs of sociodemographically diverse patient populations. Objective: To investigate differences in rates of leaving academia between male and female physicians. Design, Setting, and Participants: This cohort study used Care Compare data from the Centers for Medicare & Medicaid Services for all physicians who billed Medicare from teaching hospitals from March 2014 to December 2019, excluding physicians who retired during the study period. Data were analyzed from November 11, 2021, to May 24, 2022. Exposure: Physician gender. Main Outcome and Measures: The primary outcome was leaving academia, which was defined as not billing Medicare from a teaching hospital for more than 1 year. Multivariable logistic regression was conducted adjusting for physician characteristics and region of the country. Results: There were 294 963 physicians analyzed (69.5% male). The overall attrition rate from academia was 34.2% after 5 years (38.3% for female physicians and 32.4% for male physicians). Female physicians had higher attrition rates than their male counterparts across every career stage (time since medical school graduation: <15 years, 40.5% vs 34.8%; 15-29 years, 36.4% vs 30.3%; ≥30 years, 38.5% vs 33.3%). On adjusted analysis, female physicians were more likely to leave academia than were their male counterparts (odds ratio, 1.25; 95% CI, 1.23-1.28). Conclusions and Relevance: In this cohort study, female physicians were more likely to leave academia than were male physicians at all career stages. The findings suggest that diversity, equity, and inclusion efforts should address attrition issues in addition to recruiting more female physicians into academic medicine.

Validation of a Clinical Prediction Rule for Distinguishing Bacterial and Aseptic Meningitis in Pediatric Patients.

Introduction The treatments and prognosis of bacterial meningitis differ greatly from those of aseptic meningitis, making early identification and differentiation essential. Several different clinical prediction rules have been developed to distinguish bacterial meningitis from aseptic meningitis. We sought to validate one clinical prediction rule for pediatric patients utilizing a centralized data warehouse that collects daily data from 184 hospitals across the United States. Methods We retrospectively collected data on all patients aged 29 days to 14 years who presented to Hospital Corporation of America (HCA) Healthcare hospitals from January 1, 2016, to May 31, 2021, with a diagnosis of meningitis. Our study replicated the original study of the meningitis score for emergencies (MSE) for the pediatric clinical prediction rule and assigned 3 points for procalcitonin (PCT) >1.2 ng/dL, 2 points for CSF protein >80 mg/dL, and 1 point for each of the other variables of C-reactive protein (CRP) >40 mg/L and CSF absolute neutrophil count >1000 cells per mm3. Patients were categorized either as having bacterial or aseptic meningitis. Using the clinical prediction rule, a calculation of the sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic (ROC) curve was performed. Results The optimum test characteristic was found to have a score of ≥ 3, showing a sensitivity of 92.86% (95% CI, 83.3-100), a specificity of 65.22% (95% CI, 51.5-79), a positive predictive value of 61.90% (95% CI, 47.2-76.6), and a negative predictive value of 93.75% (95% CI, 85.4-100). The ROC curve from this study showed an area under the curve (AUC) of 0.7892 (95% CI, 0.681-0.897). Conclusion Our study validated a high sensitivity for distinguishing bacterial meningitis from aseptic meningitis, suggesting the clinical prediction rule has clinical utility as a predictive screening tool. Although the original MSE advised a cutoff score of ≥1, our study suggests that a score ≥3 would give the best test performance.

Time to surgery: A health equity metric in breast cancer patients.

BACKGROUND: We evaluated whether time to surgery by race can be a health equity metric of surgical access. METHODS: An observational analysis was performed using the National Cancer Database from 2010 to 2019. Inclusion criteria were women with stage I-III breast cancer. We excluded women with multiple cancers and whose diagnosis was made at a different hospital. The primary outcome variable was surgery within 90 days of diagnosis. RESULTS: A total of 886,840 patients were analyzed, with 76.8% White and 11.7% Black patients. 11.9% of patients experienced delayed surgery, which was significantly more common in Black patients than White patients. On adjusted analysis, Black patients were still significantly less likely to receive surgery within 90 days when compared to White patients (OR 0.61, 95% CI 0.58-0.63). CONCLUSION: The delay in surgery experienced by Black patients highlights the contribution of system factors in cancer inequity and should be a focus for targeted interventions.

Effect of Resident Involvement on Trauma Patient Outcomes: A Single-Institution Review.

OBJECTIVE: The purpose of this study was to examine the mortality difference and other outcome measures amongst trauma patients with residents involved in the initial management versus those that were managed by attending physicians only without resident involvement. DESIGN: Retrospective review. Chi-square, Fisher's tests were used to analyze the outcomes, diagnostics, and interventions using the presence of residents in the initial care of patients as an independent variable. Linear and logistic regression were used to estimate adjusted outcomes. SETTING: Riverside Community Hospital, Riverside California (State-designated level I trauma center) PARTICIPANTS: Data on all trauma patients ≥18 years old that were admitted between July 1, 2018 and June 30, 2020 was collected retrospectively (total 2644 trauma patients). Trauma patients that were transferred from outside facilities were excluded from the study. RESULTS: There was no significant difference in mortality associated with resident involvement in both unadjusted and adjusted analysis. Patients treated by residents, however, had more comorbidities (higher CCI) and were more severely injured (higher ISS). On adjusted analysis, higher ISS was independently associated with resident presence. There was also a statistically significant increase in the use of diagnostic studies and therapeutic interventions in the resident-present group. CONCLUSIONS: Involvement of residents in the initial management of our trauma patient population was associated with no difference in overall mortality or morbidity, despite higher injury severity in the resident treated patient group.

Pediatric emergency department census during major sporting events.

OBJECTIVES: Our study attempted to evaluate the effects of major sporting events on the census of a pediatric emergency department (ED) in the United States specifically related to the National Football League Super Bowl, National Basketball Association (NBA) Finals, and Major League Baseball World Series. METHODS: We performed a retrospective data analysis of our pediatric ED census on the number of visits during major sporting events over a 5-year period. Data during the same period 1 week after the major sporting event were collected for comparison as the control. We evaluated the medians of 2-hour increments around the event start time. Subgroup analysis was performed for games involving the local sporting teams. RESULTS: Our results showed no significant difference in ED census during the sporting events, except in the post 6 to 8 hours of the NBA finals. Subgroup analysis of the Los Angeles Lakers showed the same significant findings in the post 6 to 8 hours of the NBA finals. CONCLUSIONS: No major difference in pediatric ED census is observed during the most major sporting events in the United States.

Neonatal hyperbilirubinemia: recommendations for diagnosis and management in the emergency department.

Hyperbilirubinemia is one the most common reasons for emergency department visits for the neonate. Most cases of unconjugated hyperbilirubinemia are benign. Although rare, unrecognized or untreated pathologic unconjugated hyperbilirubinemia can lead to the development of acute bilirubin encephalopathy and, ultimately, kernicterus. This issue reviews the emergency department evaluation and management of neonatal hyperbilirubinemia and discusses how to recognize acute bilirubin encephalopathy, with the goal of preventing kernicterus. Recommendations are provided for risk stratification and determining the need for phototherapy or exchange transfusion, using nomograms to plot total serum bilirubin levels and taking into consideration hyperbilirubinemia and neurotoxicity risk factors.

Tibial Spine Fracture in an Adolescent Male After Minor Injury: A Case Report.

CASE PRESENTATION: A 13-year-old male presented with right knee pain and swelling from a basketball injury. The right knee exam demonstrated minimal swelling, decreased range of motion secondary to pain, and generalized tenderness. A radiograph of the right knee revealed a tibial spine fracture. DISCUSSION: Tibial spine fractures are avulsion fractures of the spine of the tibia at the insertion site of the anterior cruciate ligament. The incidence of avulsion fractures is higher in adolescents because the region of the apophyseal growth plate between the soft-tissue attachment site and the body of the bone is weaker in that age group. Tibial spine avulsion fractures are relatively uncommon and occur annually in approximately three per 100,000 children.

The Effect on Length of Stay After Implementation of Discharging Low Acuity Patients From Triage.

Introduction Overcrowding in the emergency department is a complex and challenging issue across the nation. The increasing number of patients seeking care in the emergency department leads to overcrowding and therefore decreased available rooms and slower throughput. As part of a quality improvement project to improve throughput, we implemented a policy encouraging the discharge of non-emergent patients directly from triage. Methods This was a retrospective pre- vs post-implementation analysis of a discharge process from triage to decrease emergency department length of stay. We implemented a policy that allowed the physician assistant to discharge lower acuity patients directly from triage. We collected daily length of stay metrics for a two-week period prior to and a two-week period after the implementation of the policy. Total and daily pre- and post-implementation length of stay means were compared and reported. Results There was a total of 1044 (pre-implementation) and 1063 (post-implementation) patients evaluated during the study period. There was a significant mean difference improvement in the overall length of stay post-implementation of 18.43 minutes (95% CI, 15.45 - 21.40). When comparing the differences for the day of the week, all days showed a statistically significant mean improvement in the length of stay of greater than 10%. Conclusion Discharging low acuity patients directly from triage can lead to a reduction in length of stay. Future studies are needed to determine the impact of different confounders on the length of stay of patients who are discharged from triage, as well as studies to evaluate the outcomes of patients that have been discharged from triage.

COVID-19 hospitalization rate in children across a private hospital network in the United States: COVID-19 hospitalization rate in children.

OBJECTIVES: There are limited studies with varying results evaluating the rate of hospitalizations of pediatric patients tested for COVID-19 in the United States. More information in the pediatric COVID-19 literature is needed. The objective of this study was to describe the rates of positive tests, hospitalization, severe disease, and mortality for COVID-19 in children. MATERIAL AND METHODS: We performed a retrospective analysis of data collected from a data warehouse from 184 hospitals across the United States. All cases of pediatric patients who were tested for COVID-19 were analyzed for test positivity, hospitalization, severe disease, and mortality. A separate subgroup analysis for ages < 1 year, 1-4 years, 5-8 years, 9-14 years, and 15-17 years was performed. RESULTS: Of 24,781 patient encounters, we found a test positivity rate of 11.15% (95% CI: 10.76-11.55). There were 142 admissions out of the 2,709 symptomatic patients, 5.24% (95% CI: 4.43-6.15) admission rate. Of those admitted, we found that 54.93% (78/142) were admitted to the PICU, but only 22 of the 142 admissions, 15.49% (95% CI: 9.97-22.51), were determined to have severe COVID-19 disease. One patient died during the study period giving an overall pediatric mortality rate of 0.04% (95% CI: 0.00-0.21). CONCLUSION: In our sample, we found a test positivity rate of 11.15%. We also report a 5.24% hospitalization rate with 15.49% of admitted patients with severe disease. Lastly, we also report a very low mortality rate of 0.04% of all patients who tested positive for COVID-19.