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Better nurse work environments are associated with patient and nurse outcomes reflecting nursing care quality. Mechanisms through which the work environment influences nursing care quality are not well documented. Unfinished nursing care, electronic health records, and job satisfaction may be involved. Clear mechanistic pathways that explain how these variables might interact to influence care quality are lacking. This study examined how satisfaction with the electronic health record, unfinished care, the work environment, and job satisfaction collectively affect nursing care quality. A secondary analysis of cross-sectional data was performed using survey data collected from inpatient hospital staff nurses in a single U.S. state. Survey responses (n=916) were analyzed using bivariate correlations and path analysis. Moderate bivariate correlations were documented among all study variables. However, smaller effects were identified in the full path analysis model. The nurse work environment had direct and indirect effects (through unfinished nursing care and job satisfaction) on nursing care quality. Satisfaction with the electronic health records affected nursing care quality indirectly through an inverse relationship with unfinished nursing care. More research is needed to better understand the mechanisms through which the electronic health record influences the nurse work environment and nursing care quality are needed.

The purpose of this scoping review is to map and synthesize research studies addressing the factors that impact leadership behaviours of front-line nurse managers.Leadership is a fundamental component of the role of front-line nurse managers. Ineffective leadership is associated with costly outcomes; thus, organizations seek effective strategies to facilitate consistent demonstration of leadership behaviours.Using a scoping review methodology, findings from 26 empirical studies were mapped to identify barriers and facilitators of leadership among front-line nurse managers. Major categories included personal and environmental factors with subthemes of personal characteristics, competencies and social support.Available evidence captures the influence of personal characteristics, education, competency and formal social support on leadership capacity. The role of informal social support was not captured.Multiple personal and environmental factors influence the capacity for leadership behaviours among front-line nurse managers. Strategies such as leadership development programmes, mentorship and peer support programmes, and work environments that support relational and structural support may increase leadership capacity for front-line nurse managers.Senior nurse leaders can use the results of this review to guide implementation of evidence-based strategies to recruit and retain front-line nurse managers.

Conventional whole-body18F-FDG PET imaging provides a semi-quantitative evaluation of overall glucose metabolism without gaining insight into the specific transport and metabolic steps. Here we demonstrate the ability of total-body multiparametric18F-FDG PET to quantitatively evaluate glucose metabolism using macroparametric quantification and assess specific glucose delivery and phosphorylation processes using microparametric quantification for studying recovery from coronavirus disease 2019 (COVID-19).MethodsThe study included thirteen healthy subjects and twelve recovering COVID-19 subjects within eight weeks of confirmed diagnosis. Each subject had a dynamic18F-FDG scan on the uEXPLORER total-body PET/CT system for one hour. Semiquantitative standardized uptake value (SUV) and SUV ratio relative to blood (SUVR) were calculated for regions of interest (ROIs) in different organs to measure glucose utilization. Tracer kinetic modeling was performed to quantify microparametric rate constantsK1andk3that characterize18F-FDG blood-to-tissue delivery and intracellular phosphorylation, respectively, and a macroparameterKithat represents18F-FDG net influx rate. Statistical tests were performed to examine differences between the healthy controls and recovering COVID-19 subjects. Impact of COVID-19 vaccination was investigated. We further generated parametric images to confirm the ROI-based analysis.ResultsWe detected no significant difference in lung SUV but significantly higher lung SUVR andKiin the recovering COVID-19 subjects, indicating an improved sensitivity of kinetic quantification for detecting the difference in glucose metabolism. A significant difference was also observed in the lungs with the phosphorylation ratek3, but not with the delivery rateK1, which suggests it is glucose phosphorylation, not glucose delivery, that drives the observed difference of glucose metabolism in the lungs. Meanwhile, there was no or little difference in bone marrow metabolism measured with SUV, SUVR andKi, but a significant increase in bone-marrow18F-FDG delivery rateK1in the COVID-19 group (p< 0.05), revealing a difference of glucose delivery in this immune-related organ. The observed differences were lower or similar in vaccinated COVID-19 subjects as compared to unvaccinated ones. The organ ROI-based findings were further supported by parametric images.ConclusionsHigher lung glucose metabolism and bone-marrow glucose delivery were observed with total-body multiparametric18F-FDG PET in recovering COVID-19 subjects as compared to healthy subjects, which suggests continued inflammation due to COVID-19 during the early stages of recovery. Total-body multiparametric PET of18F-FDG delivery and metabolism can provide a more sensitive tool and more insights than conventional static whole-body18F-FDG imaging to evaluate metabolic changes in systemic diseases such as COVID-19.

With the majority of CD8+T cells residing and functioning in tissue, not blood, developing noninvasive methods forin vivoquantification of their biodistribution and kinetics in humans offers the means for studying their key role in adaptive immune response and memory. This study is the first report on using positron emission tomography (PET) dynamic imaging and compartmental kinetic modeling forin vivomeasurement of whole-body biodistribution of CD8+T cells in human subjects. For this, a89Zr-labeled minibody with high affinity for human CD8 (89Zr-Df-Crefmirlimab) was used with total-body PET in healthy subjects (N=3) and in COVID-19 convalescent patients (N=5). The high detection sensitivity, total-body coverage, and the use of dynamic scans enabled the study of kinetics simultaneously in spleen, bone marrow, liver, lungs, thymus, lymph nodes, and tonsils, at reduced radiation doses compared to prior studies. Analysis and modeling of the kinetics was consistent with T cell trafficking effects expected from immunobiology of lymphoid organs, suggesting early uptake in spleen and bone marrow followed by redistribution and delayed increasing uptake in lymph nodes, tonsils, and thymus. Tissue-to-blood ratios from the first 7 h of CD8-targeted imaging showed significantly higher values in the bone marrow of COVID-19 patients compared to controls, with an increasing trend between 2 and 6 months post-infection, consistent with net influx rates obtained by kinetic modeling and flow cytometry analysis of peripheral blood samples. These results provide the platform for using dynamic PET scans and kinetic modelling to study total-body immunological response and memory.

SARS-CoV-2 is a single-stranded RNA virus that causes coronavirus disease 2019 (COVID-19). Given its acute and often self-limiting course, components of the innate immune system are likely central in controlling virus replication thereby determining clinical outcome. Natural killer (NK) cells are innate lymphocytes with notable activity against a broad range of viruses, including RNA viruses1,2. NK cell function may be altered during COVID-19 despite increased representation of NK cells with an activated and ‘adaptive’ phenotype3,4. Here we show that viral load decline in COVID-19 correlates with NK cell status and that NK cells can control SARS-CoV-2 replication by recognizing infected target cells. In severe COVID-19, NK cells show remarkable defects in virus control, cytokine production and cell-mediated cytotoxicity despite high expression of cytotoxic effector molecules. Single-cell RNA-sequencing (scRNA-seq) of NK cells along the time course of the entire COVID-19 disease spectrum reveals a unique gene expression signature. Transcriptional networks of interferon-driven NK cell activation are superimposed by a dominant TGFβ response signature with reduced expression of genes related to cell-cell adhesion, granule exocytosis and cell-mediated cytotoxicity. In severe COVID-19, serum levels of TGFβ peak during the first 2 weeks of infection, and serum obtained from these patients profoundly inhibits NK cell function in a TGFβ-dependent manner. Our data reveal that untimely production of TGFβ is a hallmark of severe COVID-19 and may inhibit NK cell function and early virus control.

This article synthesizes theoretical perspectives related to nurse cognition. We present a conceptual model that can be used by multiple stakeholders to study and contemplate how nurses use clinical decision support systems, and specifically, Barcode-Assisted Medication Administration, to make decisions during the delivery of care. Theoretical perspectives integrated into the model include dual process theory, the Cognitive Continuum Theory, human factors engineering, and the Recognition-Primed Decision model. The resulting framework illustrates the process of nurse cognition during Barcode-Assisted Medication Administration. Additionally, the model includes individual or human and environmental factors that may influence nurse cognition and decision making. It is important to consider the influence of individual, human, and environmental factors on the process of nurse cognition and decision making. Specifically, it is necessary to explore the impact of heuristics and biases on clinician decision making, particularly related to the development of alarm and alert fatigue. Aided by the proposed framework, stakeholders may begin to identify heuristics and cognitive biases that influence the decision of clinicians to accept or override a clinical decision support system alert and whether heuristics and biases are associated with inappropriate alert override.

Quality improvement is paramount for patient safety. Leading change for quality improvement requires nurses with knowledge and skills beyond the clinical management of patients. In this study, staff nurses working in hospitals throughout Alabama were asked via an online survey to rate their quality improvement knowledge and skills using the new 10-item Quality Improvement Self-Efficacy Inventory (QISEI) and their perceptions of the nursing work environment using the Practice Environment Scale of the Nursing Work Index. Nurses ( N = 886) rated the basic quality improvement items higher than the more advanced items. Several nurse characteristics and the nursing work environment were associated with nurses’ ratings of their quality improvement knowledge and skills. Educators and administrators in health care organizations can use QISEI to gauge their nurses’ knowledge and skills and then develop continuous professional development opportunities aimed at improving quality and safety competencies.

One week after second vaccinations were administered, an outbreak of B.1.1.7 lineage severe acute respiratory syndrome coronavirus 2 infections occurred in a long-term care facility in Berlin, Germany, affecting 16/20 vaccinated and 4/4 unvaccinated residents. Despite considerable viral loads, vaccinated residents experienced mild symptoms and faster time to negative test results.

Purpose The main aim of this paper is to present baseline demographic and clinical characteristics and HRQOL in the two groups of the Patient Concerns Inventory (PCI) trial. The baseline PCI data will also be described. Methods This is a pragmatic cluster preference randomised control trial with 15 consultant clusters from two sites either ‘using' (n = 8) or ‘not using’ (n = 7) the PCI at a clinic for all of their trial patients. The PCI is a 56-item prompt list that helps patients raise concerns that otherwise might be missed. Eligibility was head and neck cancer patients treated with curative intent (all sites, stage of disease, treatments). Results From 511 patients first identified as eligible when screening for the multi-disciplinary tumour board meetings, 288 attended a first routine outpatient baseline study clinic after completion of their treatment, median (IQR) of 103 (71–162) days. At baseline, the two trial groups were similar in demographic and clinical characteristics as well as in HRQOL measures apart from differences in tumour location, tumour staging and mode of treatment. These exceptions were cluster (consultant) related to Maxillofacial and ENT consultants seeing different types of cases. Consultation times were similar, with PCI group times taking about 1 min longer on average (95% CL for the difference between means was from − 0.7 to + 2.2 min). Conclusion Using the PCI in routine post-treatment head and neck cancer clinics do not elongate consultations. Recruitment has finished but 12-month follow-up is still ongoing.

Coronavirus disease 2019 (COVID-19) is an acute infection of the respiratory tract that emerged in late 20191,2. Initial outbreaks in China involved 13.8% of cases with severe courses, and 6.1% of cases with critical courses3. This severe presentation may result from the virus using a virus receptor that is expressed predominantly in the lung2,4; the same receptor tropism is thought to have determined the pathogenicity—but also aided in the control—of severe acute respiratory syndrome (SARS) in 20035. However, there are reports of cases of COVID-19 in which the patient shows mild upper respiratory tract symptoms, which suggests the potential for pre- or oligosymptomatic transmission6–8. There is an urgent need for information on virus replication, immunity and infectivity in specific sites of the body. Here we report a detailed virological analysis of nine cases of COVID-19 that provides proof of active virus replication in tissues of the upper respiratory tract. Pharyngeal virus shedding was very high during the first week of symptoms, with a peak at 7.11 × 108 RNA copies per throat swab on day 4. Infectious virus was readily isolated from samples derived from the throat or lung, but not from stool samples—in spite of high concentrations of virus RNA. Blood and urine samples never yielded virus. Active replication in the throat was confirmed by the presence of viral replicative RNA intermediates in the throat samples. We consistently detected sequence-distinct virus populations in throat and lung samples from one patient, proving independent replication. The shedding of viral RNA from sputum outlasted the end of symptoms. Seroconversion occurred after 7 days in 50% of patients (and by day 14 in all patients), but was not followed by a rapid decline in viral load. COVID-19 can present as a mild illness of the upper respiratory tract. The confirmation of active virus replication in the upper respiratory tract has implications for the containment of COVID-19. Detailed virological analysis of nine cases of coronavirus disease 2019 (COVID-19) provides proof of active replication of the SARS-CoV-2 virus in tissues of the upper respiratory tract.

Trans-oral robotic surgery (TORS) was approved by the FDA in 2009 and over the past decade head and neck surgeons have adopted the technology for the benefit of their patients. Whilst the surgical methods have evolved, there has been little consideration about the pathological assessment of the specimens and a lack of understanding around the oncological principles that underpin minimally invasive surgical techniques in the head and neck region. This article will highlight the issues encountered during the reporting of TORS specimens. The challenges include identifying anatomical boundaries, block selection, assessment of resection margins, the use of intra-operative frozen sections, the assessment of tongue base mucosectomies for patients with head and neck cancer of unknown primary, and TORS for recurrent disease. The article will conclude with emerging innovations, including i-Knife, narrow band imaging and the potential of step serial sections to identify sub-clinical HPV-related oropharyngeal squamous cell carcinomas.

Background Evidence suggests that Magnet and non-Magnet hospitals differ with respect to quality of care. Purpose Our study examined registered nurse (RN) staffing over time in Magnet and non-Magnet hospitals using unit-level, publicly available data in New Jersey. Methods A secondary analysis of longitudinal RN staffing data was conducted using mandated, publicly reported data of 64 hospitals representing 12 nursing specialties across 8 years (2008-2015). Staffing ratios were trended over time to compare RN staffing changes in Magnet and non-Magnet hospitals. Results Staffing was comparable in Magnet and non-Magnet hospitals for 9 of 12 specialties. On average, from 2008 until 2015, RN staffing slightly increased, with a greater percent increase in Magnet hospitals (6.9%) than in non-Magnet hospitals (4.7%). Conclusions Over 8 years in New Jersey, RN staffing improved in Magnet and non-Magnet hospitals. Although there was a slight increase for Magnet hospitals, there was no meaningful difference in staffing for all 12 specialties.

Now is an exciting era of development in immunotherapy checkpoint inhibitors and their effect on the treatment of NPC. While the general prognosis of R/M disease is poor, immunotherapy offers some promise in a malignancy associated with EBV and characterized by a peritumoural immune infiltrate. Our study aims to review past and on-going clinical trials of monoclonal antibody therapies against the checkpoint inhibitors (e.g. PD1 and CTLA-4), in R/M NPC. All randomized and nonrandomized controlled trials involving immune checkpoint inhibitor interventions for treatment of NPC were included in the study. We utilized a validated "risk of bias" tool to assess study quality. Four separate Phase I-II trials report the potential of PD1 inhibitor treatment for patients with NPC. Within the observed groups, camrelizumab combined with chemotherapy achieved an objective response in 91% of patients as first-line treatment for metastatic NPC (PFS 68% at 1-year) but this was associated with a high rate of grade >3 adverse events (87%; CTCAE version 4.03). The remaining three studies focused on recurrent NPC disease in patients who had received at least one line of prior chemotherapy. Within this group, camrelizumab monotherapy achieved an objective response in 34% of patients (PFS 27% at 1-year; range across all three studies 20.5-34%). No NPC trial has yet reported on specific outcomes for non-PD1 checkpoint inhibitors but 11 on-going studies include alternative targets (e.g. PD-L1/CTLA-4) as combination or monotherapy treatments. In considering checkpoint immunotherapies for NPC, initial results show promise for anti-PD1 interventions. Further phase I-III trials are in progress to clarify clinical outcomes, fully determine safety profiles, and optimize drug combinations and administration schedules.

A multidisciplinary team (MDT) approach to cancer management is gold-standard. With an increasing disease incidence and growing research into human papillomavirus (HPV)-related oropharyngeal cancer (OPC), updated UK management guidelines were recently published. This study aimed to evaluate the MDT decision-making process among OPC patients at a tertiary centre. MDT meetings over a 12-month period were analysed retrospectively. MDT decisions were compared with guidelines and patient records examined to identify decision implementation. Reasons behind any discordant decisions were explored. This study included 140 OPC patients. Thirty-three (23.6%) were not tested for HPV. Patients over 70 years with a smoking history treated palliatively were less likely to be tested (P = 0.017). Eighty-five percent of MDT decisions followed guidelines with the majority not complying (76.2%) related to patient comorbidity. Ten decisions (7.1%) were not implemented. Reasons included: Seven due to patient choice, of which four patients (57.1%) were only seen following the MDT meeting, and three due to clinician decisions as new clinical information emerged. The majority of MDT decisions followed guidelines and any discordant decisions were justifiable. Discussing management options with patients beforehand facilitates decision implementation as decisions can potentially change after seeing the patient. Progress is still needed with regards to HPV testing. Reasons for not testing could include subliminal decision-making among clinicians, and patients falling between centres. Crucially, the role of the MDT in head and neck cancer should be to ratify decisions rather than making them, hence the need to see patients prior to MDT discussion.

Positron emission tomography (PET) is the most sensitive in vivo molecular imaging technique available. Small animal PET has been widely used in studying pharmaceutical biodistribution and disease progression over time by imaging a wide range of biological processes. However, it remains true that almost all small animal PET studies using mouse or rat as preclinical models are either limited by the spatial resolution or the sensitivity (especially for dynamic studies), or both, reducing the quantitative accuracy and quantitative precision of the results. Total-body small animal PET scanners, which have axial lengths longer than the nose-to-anus length of the mouse/rat and can provide high sensitivity across the entire body of mouse/rat, can realize new opportunities for small animal PET. This article aims to discuss the technical opportunities and challenges in developing total-body small animal PET scanners for mice and rats.

PurposeSix-19% of critically ill COVID-19 patients display circulating auto-antibodies against type I interferons (IFN-AABs). Here, we establish a clinically applicable strategy for early identification of IFN-AAB-positive patients for potential subsequent clinical interventions.MethodsWe analysed sera of 430 COVID-19 patients with severe and critical disease from four hospitals for presence of IFN-AABs by ELISA. Binding specificity and neutralizing activity were evaluated via competition assay and virus-infection-based neutralization assay. We defined clinical parameters associated with IFN-AAB positivity. In a subgroup of critically ill patients, we analyzed effects of therapeutic plasma exchange (TPE) on the levels of IFN-AABs, SARS-CoV-2 antibodies and clinical outcome.ResultsThe prevalence of neutralizing AABs to IFN-α and IFN-ω in COVID-19 patients was 4.2% (18/430), while being undetectable in an uninfected control cohort. Neutralizing IFN-AABs were detectable exclusively in critically affected, predominantly male (83%) patients (7.6% IFN-α and 4.6% IFN-ω in 207 patients with critical COVID-19). IFN-AABs were present early post-symptom onset and at the peak of disease. Fever and oxygen requirement at hospital admission co-presented with neutralizing IFN-AAB positivity. IFN-AABs were associated with higher mortality (92.3% versus 19.1 % in patients without IFN-AABs). TPE reduced levels of IFN-AABs in three of five patients and may increase survival of IFN-AAB-positive patients compared to those not undergoing TPE.ConclusionIFN-AABs may serve as early biomarker for development of severe COVID-19. We propose to implement routine screening of hospitalized COVID-19 patients according to our algorithm for rapid identification of patients with IFN-AABs who most likely benefit from specific therapies.

ImportanceData on immune responses following SARS-CoV-2 vaccinations/infections and on detection rate of SARS-CoV-2 infections in anti-CD20 treated patients with multiple sclerosis (pwMS) are important for guiding management of pwMS during the current SARS-CoV-2 pandemic. ObjectiveTo analyze humoral and cellular immune responses to SARS-CoV-2 vaccinations/infections and to determine the detection rate of SARS-CoV-2 infections in anti-CD20 treated pwMS. DesignProspective single-center cohort study from March 2020 to August 2021. SettingMS referral center, Charite - Universitatsmedizin Berlin, Germany. Participants222 consecutive pwMS (128 [57.7%] female, median [range] age 39 [17-81] years). 181 patients were on anti-CD20 therapy at study inclusion, 41 began anti-CD20 therapy during the study. Hospital employees (HE, n=19) served as controls. ExposurespwMS were exposed to anti-CD20 therapy for 169.5 patient years. 51 patients under anti-CD20 treatment, 14 patients before anti-CD20 treatment, and 19 HE were vaccinated twice against SARS-CoV-2. Main outcomesSARS-CoV-2 spike protein immunoglobulin (Ig)G (ELISA and immunofluorescence), IgA (ELISA), IgG to four recombinant SARS-CoV-2 antigens (solid phase immunoassay), neutralizing capacity of SARS-CoV-2 antibodies (plaque reduction neutralization test), SARS-CoV-2 IgG avidity (modified ELISA), and SARS- CoV-2 specific T cells (interferon-{gamma} release assay). ResultsFollowing two SARS-CoV-2 vaccinations, median (IQR) levels of SARS-CoV-2 spike protein IgG (OD ratio: 1.2 [0.1-5.1] vs. 9.0 [6.8-9.9] vs. 8.8 [8.0-9.4], p

As scaling of conventional memory devices has stalled, many high-end computing systems have begun to incorporate alternative memory technologies to meet performance goals. Since these technologies present distinct advantages and tradeoffs compared to conventional DDR* SDRAM, such as higher bandwidth with lower capacity or vice versa, they are typically packaged alongside conventional SDRAM in a heterogeneous memory architecture. To utilize the different types of memory efficiently, new data management strategies are needed to match application usage to the best available memory technology. However, current proposals for managing heterogeneous memories are limited, because they either (1) do not consider high-level application behavior when assigning data to different types of memory or (2) require separate program execution (with a representative input) to collect information about how the application uses memory resources. This work presents a new data management toolset to address the limitations of existing approaches for managing complex memories. It extends the application runtime layer with automated monitoring and management routines that assign application data to the best tier of memory based on previous usage, without any need for source code modification or a separate profiling run. It evaluates this approach on a state-of-the-art server platform with both conventional DDR4 SDRAM and non-volatile Intel Optane DC memory, using both memory-intensive high-performance computing (HPC) applications as well as standard benchmarks. Overall, the results show that this approach improves program performance significantly compared to a standard unguided approach across a variety of workloads and system configurations. The HPC applications exhibit the largest benefits, with speedups ranging from 1.4× to 7× in the best cases. Additionally, we show that this approach achieves similar performance as a comparable offline profiling-based approach after a short startup period, without requiring separate program execution or offline analysis steps.

ImportanceOnce-daily roflumilast cream, 0.3%, a potent phosphodiesterase 4 inhibitor, demonstrated efficacy and was well tolerated in a phase 2b trial of patients with psoriasis.ObjectiveTo evaluate the efficacy of roflumilast cream, 0.3%, applied once daily for 8 weeks in 2 trials of patients with plaque psoriasis.Design, Setting, and ParticipantsTwo phase 3, randomized, double-blind, controlled, multicenter trials (DERMIS-1 [trial 1; n = 439] and DERMIS-2 [trial 2; n = 442]) were conducted at 40 centers (trial 1) and 39 centers (trial 2) in the US and Canada between December 9, 2019, and November 16, 2020, and between December 9, 2019, and November 23, 2020, respectively. Patients aged 2 years or older with plaque psoriasis involving 2% to 20% of body surface area were enrolled. The dates of final follow-up were November 20, 2020, and November 23, 2020, for trial 1 and trial 2, respectively.InterventionsPatients were randomized 2:1 to receive roflumilast cream, 0.3% (trial 1: n = 286; trial 2: n = 290), or vehicle cream (trial 1: n = 153; trial 2: n = 152) once daily for 8 weeks.Main Outcomes and MeasuresThe primary efficacy end point was Investigator Global Assessment (IGA) success (clear or almost clear status plus ≥2-grade improvement from baseline [score range, 0-4]) at week 8, analyzed using a Cochran-Mantel-Haenszel test stratified by site, baseline IGA score, and intertriginous involvement. There were 9 secondary outcomes, including intertriginous IGA success, 75% reduction in Psoriasis Area and Severity Index (PASI) score, and Worst Itch Numeric Rating Scale score of 4 or higher at baseline achieving 4-point reduction (WI-NRS success) at week 8 (scale: 0 [no itch] to 10 [worst imaginable itch]; minimum clinically important difference, 4 points).ResultsAmong 881 participants (mean age, 47.5 years; 320 [36.3%] female), mean IGA scores in trial 1 were 2.9 [SD, 0.52] for roflumilast and 2.9 [SD, 0.45] for vehicle and in trial 2 were 2.9 [SD, 0.48] for roflumilast and 2.9 [SD, 0.47]) for vehicle. Statistically significantly greater percentages of roflumilast-treated patients than vehicle-treated patients had IGA success at week 8 (trial 1: 42.4% vs 6.1%; difference, 39.6% [95% CI, 32.3%-46.9%]; trial 2: 37.5% vs 6.9%; difference, 28.9% [95% CI, 20.8%-36.9%]; P P P P Conclusions and RelevanceAmong patients with chronic plaque psoriasis, treatment with roflumilast cream, 0.3%, compared with vehicle cream resulted in better clinical status at 8 weeks. Further research is needed to assess efficacy compared with other active treatments and to assess longer-term efficacy and safety.Trial RegistrationClinicalTrials.gov Identifiers: NCT04211363, NCT04211389

Purpose Adequate patient allocation is pivotal for optimal resource management in strained healthcare systems, and requires detailed knowledge of clinical and virological disease trajectories. The purpose of this work was to identify risk factors associated with need for invasive mechanical ventilation (IMV), to analyse viral kinetics in patients with and without IMV and to provide a comprehensive description of clinical course. Methods A cohort of 168 hospitalised adult COVID-19 patients enrolled in a prospective observational study at a large European tertiary care centre was analysed. Results Forty-four per cent (71/161) of patients required invasive mechanical ventilation (IMV). Shorter duration of symptoms before admission (aOR 1.22 per day less, 95% CI 1.10–1.37, p p p Conclusions Our results indicate a short duration of symptoms before admission as a risk factor for severe disease that merits further investigation and different viral load kinetics in severely affected patients. Median duration of hospitalisation of IMV patients was longer than described for acute respiratory distress syndrome unrelated to COVID-19.

INTRODUCTION The Centers for Medicare and Medicaid uses the standardized readmission ratio (SRR) to evaluate 30-day readmissions among dialysis providers in the U.S. Readmissions among dialysis recipients remains 37%. This study investigates associations among dialysis facilities and patient characteristics with facility's performance on the SRR. METHODS Descriptive, longitudinal, approach using multivariate regression analysis on data retrieved from the Dialysis Facility Report to evaluate the associations between facility-level (staffing, profit status, chain membership, clinic size, care, length of care, vascular access type, glomerular filtration rate (GFR), creatinine, hemoglobin, use of erythropoietin-stimulating agent, albumin, and primary dialysis modality) with the SRR. RESULTS Factors associated with a high SRR included nurse ratios, facility average GFR, and Northeast geographic location. Factors associated with a low SRR included patient care technician ratio, length of predialysis nephrology care, initiation of dialysis with an arteriovenous fistula, average hemoglobin, and Western geographic location. CONCLUSIONS This study defines the influence predialysis nephrology care has on dialysis facilities SRRs. Access to care, adequate preparation for dialysis, and transitional support affect facilities' performance; however, without an appropriate staffing model, dialysis facilities may continue to struggle to reduce readmissions.