Background/Objectives: Recent in vitro data suggest that remdesivir might be less likely than nirmatrelvir–ritonavir to be associated with COVID-19 rebound. We compared the incidence of symptom rebound in our remdesivir-treated cohort with rates reported in the literature for nirmatrelvir–ritonavir. Methods: We performed a retrospective cohort study of VA Boston Healthcare System patients who were nursing home residents or inpatients treated with remdesivir for mild to moderate COVID-19 that met clinical criteria for nirmatrelvir–ritonavir treatment between 05/2022 and 10/2024. Electronic health records were reviewed for evidence of symptom rebound in daily clinical evaluations and outside hospital care notes for 15–20 days after the diagnosis of COVID-19. Rates for nirmatrelvir–ritonavir were identified via a literature review. Results: Among 194 patients treated with remdesivir, 39 were excluded due to concurrent antiviral use, hypoxia, or ICU-level care. The average age of the remaining 155 patients was 75.1 ± 11.9 years; 147 patients (95%) were male. Evidence of symptom rebound was found in 1 of 155 (0.6%) remdesivir-treated patients, which is a rate lower than that reported in all 12 studies of nirmatrelvir–ritonavir symptom rebound during the Omicron era. Conclusions: Our finding of low rates of COVID-19 symptom rebound after treatment with remdesivir are consistent with the hypothesis that rebound may be less frequent after treatment with remdesivir than with nirmatrelvir–ritonavir.

Virtual care, including synchronous and asynchronous telehealth, remote patient monitoring, and the collection and interpretation of patient-generated health data (PGHD), has the potential to transform healthcare delivery and increase access to care. The Veterans Health Administration (VHA) Office of Health Services Research and Development (HSR&D) convened a State-of-the-Art (SOTA) Conference on Virtual Care to identify future virtual care research priorities. Participants were divided into three workgroups focused on virtual care access, engagement, and outcomes. In this article, we report the findings of the Outcomes Workgroup. The group identified virtual care outcome areas with sufficient evidence, areas in need of additional research, and areas that are particularly well-suited to be studied within VHA. Following a rigorous process of literature review and consensus, the group focused on four questions: (1) What outcomes of virtual care should we be measuring and how should we measure them?; (2) how do we choose the “right” care modality for the “right” patient?; (3) what are potential consequences of virtual care on patient safety?; and (4) how can PGHD be used to benefit provider decision-making and patient self-management?. The current article outlines key conclusions that emerged following discussion of these questions, including recommendations for future research.

Experimental evidence suggests that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) remains viable within aerosols with a half-life of approximately 3 hours; however, it remains unclear how long airborne SARS-CoV-2 can transmit infection. Whole genome sequencing during an outbreak suggested inroom transmission of SARS-CoV-2 to two patients admitted nearly 2 and 5 hours, respectively, after discharge of an asymptomatic infected patient. These findings suggest that airborne SARS-CoV-2 may transmit infection for over 4 hours, even in a hospital setting. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.

Experimental evidence suggests that SARS-CoV-2 remains viable within aerosols with a half-life of approximately 1-3 hours, though changes in aerosol microenvironment may shorten viability to minutes. However, it remains unclear how long airborne SARS-CoV-2 can transmit infection. Whole genome sequencing of nasopharyngeal samples obtained from patients on an outbreak unit suggested in-room transmission of the delta variant, AY3 lineage, of SARS-CoV-2 to two patients admitted 1 hour, 43 minutes and 4 hours, 45 minutes after discharge of an asymptomatic infected patient. These findings suggest that airborne SARS-CoV-2 may transmit infection for nearly 5 hours, even in a hospital setting.

COVID-19 led to a rapid increase in telemental health care via video or phone. It is important to examine contributors to the choice of video versus phone, as video may be more effective and preferred by patients. Medical mental health (MH) providers (e.g., psychiatrists) may conduct more phone and less video visits than nonmedical MH providers (e.g., psychologists). This study examined whether medical and nonmedical providers' perceptions of the quality and complexity of phone and video MH care may contribute to differences in use. A 32-item survey of 414 providers (79.5% response rate) assessed perceptions of care quality, factors contributing to modality choice, and telehealth challenges. The types of visits completed by providers in the months prior to the survey were extracted from administrative data. Medical and nonmedical providers generally viewed video care as higher quality and more preferred than phone, although to a lesser extent among medical providers. Nonmedical providers' decision making was more impacted by research regarding the modalities' relative effectiveness. Medical providers more frequently endorsed video challenges, including patient technical difficulties and lack of patient training. Administrative data demonstrated that medical providers conducted fewer video appointments than nonmedical providers. Medical providers may be less aware of research demonstrating that video care is effective and preferred by patients, and the complexity of video visits may be a barrier to use. Streamlining video processes, increasing technical support, and disseminating research that compares the quality of video and phone care may increase video use among medical providers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sickness presenteeism among healthcare workers (HCW) risks nosocomial infection, but its prevalence among HCW with COVID-19 is unknown. Contemporaneous interviews revealed a sickness presenteeism prevalence of 49.8% among 255 HCW with symptomatic COVID-19. Presenteeism prevalence did not differ among HCW with and without specific COVID-19 symptoms or direct patient care.

Alcohol readily crosses the placenta and may disrupt fetal development. Harm from prenatal alcohol exposure (PAE) is determined by the dose, pattern, timing and duration of exposure, fetal and maternal genetics, maternal nutrition, concurrent substance use, and epigenetic responses. A safe dose of alcohol use during pregnancy has not been established. PAE can cause fetal alcohol spectrum disorders (FASD), which are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth. FASD are a leading preventable cause of birth defects and developmental disability. The prevalence of FASD in 76 countries is >1% and is high in individuals living in out-of-home care or engaged in justice and mental health systems. The social and economic effects of FASD are profound, but the diagnosis is often missed or delayed and receives little public recognition. Future research should be informed by people living with FASD and be guided by cultural context, seek consensus on diagnostic criteria and evidence-based treatments, and describe the pathophysiology and lifelong effects of FASD. Imperatives include reducing stigma, equitable access to services, improved quality of life for people with FASD and FASD prevention in future generations. Fetal alcohol spectrum disorders (FASD) are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth. This Primer discusses the epidemiology, pathophysiology, diagnosis and treatment of FASD.

IMPORTANCE Aerosol-borne SARS-CoV-2 has not been linked specifically to nosocomial outbreaks. OBJECTIVE To explore the genomic concordance of SARS-CoV-2 from aerosol particles of various sizes and infected nurses and patients during a nosocomial outbreak of COVID-19. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients and nursing staff in a US Department of Veterans Affairs inpatient hospital unit and long-term-care facility during a COVID-19 outbreak between December 27, 2020, and January 8, 2021. Outbreak contact tracing was conducted using exposure histories and screening with reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2. Size-selective particle samplers were deployed in diverse clinical areas of a multicampus health care system from November 2020 to March 2021. Viral genomic sequences from infected nurses and patients were sequenced and compared with ward nurses station aerosol samples. EXPOSURE SARS-CoV-2. MAIN OUTCOMES AND MEASURES The primary outcome was positive RT-PCR results and genomic similarity between SARS-CoV-2 RNA in aerosols and human samples. Air samplers were used to detect SARS-CoV-2 RNA in aerosols on hospital units where health care personnel were or were not under routine surveillance for SARS-CoV-2 infection. RESULTS A total of 510 size-fractionated air particle samples were collected. Samples representing 3 size fractions (>10 mu m, 2.5-10 mu m, and <2.5 mu m) obtained at the nurses station were positive for SARS-CoV-2 during the outbreak (3 of 30 samples [10%]) and negative during 9 other collection periods. SARS-CoV-2 partial genome sequences for the smallest particle fraction were 100% identical with all 3 human samples; the remaining size fractions shared >99.9% sequence identity with the human samples. Fragments of SARS-CoV-2 RNA were detected by RT-PCR in 24 of 300 samples (8.0%) in units where health care personnel were not under surveillance and 7 of 210 samples (3.3%; P = .03) where they were under surveillance. CONCLUSIONS AND RELEVANCE In this cohort study, the finding of genetically identical SARSCoV-2 RNA fragments in aerosols obtained from a nurses station and in human samples during a nosocomial outbreak suggests that aerosols may have contributed to hospital transmission. Surveillance, along with ventilation, masking, and distancing, may reduce the introduction of community-acquired SARS-CoV-2 into aerosols on hospital wards, thereby reducing the risk of hospital transmission.

IMPORTANCE Clinician attitudes toward telehealth may impact utilization rates, and findings may differ based on specialty. OBJECTIVE To determine whether clinician beliefs regarding telehealth quality and ease of use were associated with the proportion of care delivered via video, phone, and in-person across specialties. DESIGN, SETTING, AND PARTICIPANTS This survey study used a voluntary, anonymous survey conducted from August to September 2021 in the Department of Veterans Affairs New England Healthcare System (VANEHS). Mental health (MH), primary care (PC), and specialty care (SC) clinicians were invited to participate. Data were analyzed from October 2021to January 2022. EXPOSURES Participation in a 32-item survey. MAIN OUTCOMES AND MEASURES The main outcomes were clinicians' views on relative quality of video, phone, and in-person care; factors contributing to clinicians' modality choice; telehealth challenges; and clinician modality preferences and utilization when treating new and established patients. RESULTS There were 866 survey respondents (estimated 64% response rate); 52 respondents reported no video or phone telehealth use in the 3 months priorto survey completion and were excluded, resulting in a final sample of 814 respondents. Respondents were divided among MH (403 respondents [49.5%]), PC (153 respondents [18.8%]), and SC (258 respondents [31.7%]). Compared with PC and SC clinicians, MH clinicians rated the quality of video care the highest (eg, compared with in-person care with masks when treating new patients: chi(2) = 147.8; P < .001) and were more likely to prefer video over phone when treating both new (chi(2) = 26.6; P < .001) and established (chi(2) = 100.4; P < .001) patients remotely. PC and SC clinicians were more likely to rate phone care as being at least equivalent in quality to video for both new (chi(2) = 263; P < .001) and established (chi(2) = 33.5; P < .001) patients. PC and SC clinicians were also more likely to endorse challenges of video care, including patient barriers and the inability to conduct a physical examination (chi(2) = 292.0; P < .001). Most PC and SC clinicians either had no preference (46 PC respondents [36.2%); 59 SC respondents [28.4%]) or preferred phone (36 PC respondents [28.3%]: 67 SC respondents [32.2%]) for remote care of established patients. Findings aligned with utilization rates within VANEHS, with MH clinicians conducting significantly more of their encounters via video (36 734 encounters [40.3%]) than PC (3201 encounters [3.9%]) and SC (1157 encounters [4.9%)) clinicians. CONCLUSIONS AND RELEVANCE These findings suggest that clinician attitudes regarding telehealth quality and ease of use were associated with utilization rates. Moving forward, clinician use of telehealth may be impacted by additional data regarding the relative effectiveness of modalities as well as improvements in video telehealth workflows.

The authors have no conflict of interest.

Abstract We describe relapse of COVID-19 symptoms and SARS-CoV-2 viral load following nirmatrelvir/ritonavir (NM/R) in 8 non-immunocompromised patients aged 31 to 71-years-old. Most patients improved rapidly after treatment with NM/R and had negative antigen or PCR tests prior to relapse on Days 9-12 of their illness. Relapse symptoms were described most frequently as cold symptoms, though some patients experiencing a recurrence of fatigue and headache. All relapses resolved without additional antiviral treatment. Viral load during relapse was comparable to levels during initial infection. Sequencing in three patients indicated that relapse was not due to a treatment-emergent mutation or infection with a different viral strain. One patient transmitted SARS-CoV-2 to two family members during relapse. The presence of high viral load and the occurrence of one transmission event suggest that patients with relapse should isolate until antigen testing is negative.

Rebound of SARS-CoV-2 Infection after Nirmatrelvir-Ritonavir TreatmentTo the Editor: Nirmatrelvir is an inhibitor of the main protease in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has been shown to block viral replication and reduce disease severity in unvaccinated persons at risk for the progression of coronavirus disease 2019 . 1 Here, we describe the occurrence of rebound symptoms and viral replication after treatment with nirmatrelvir combined with ritonavir.Patient 1, a 71-year-old man with asthma, reported having rhinorrhea, sore throat, congestion, cough, fatigue, malaise, chills, fever (temperature, 38.4°C), and a positive rapid antigen test for SARS-CoV-2.A 5-day course of nirmatrelvirritonavir was started on the same day.He was asymptomatic from day 2 through day 8. On days 9 through 12, while the patient was still isolating, he had a return of typical cold symptoms with rhinorrhea, sore throat, and congestion along with increased asthma symptoms.SARS-CoV-2 viral load was determined from anterior nasal swabs according to the cycle threshold (Ct) on quantitative reverse-transcriptasepolymerase-chain-reaction (RT-PCR) assay and indirectly from results of antigen testing.Peaks of symptoms and viral load coincided on days 1 and 9 (Fig. 1 and Fig. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).Whole-genome viral sequencing identified the BA.1.20subvariant of the SARS-CoV-2 B.1.1.529(omicron) variant from day 1 through day 11.Patient 2, a 69-year-old man, had cold symptoms and positive results on rapid antigen testing and PCR assay on day 0 through day 3.A 5-day course of nirmatrelvir-ritonavir was started on day 1.The patient was asymptomatic with negative results on rapid antigen testing and intermittent PCR assays from day 4 to day 9. Mild cold symptoms and positive results on both rapid antigen testing and RT-PCR assay recurred on day 10 and lasted for 3 days.Patient 3, a 50-year-old woman who lived in the same household with Patient 2, had a similar pattern of rebound symptoms and viral load after treatment with nirmatrelvir-ritonavir.Viral sequencing identified the omicron BA.2.9 subvariant in these two patients.In all three patients who have been described here, there were no muta-The New England Journal of Medicine Downloaded from nejm.org

This article is part of a Festschrift commemorating the 50th anniversary of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Established in 1970, first as part of the National Institute of Mental Health and later as an independent institute of the National Institutes of Health, NIAAA today is the world's largest funding agency for alcohol research. In addition to its own intramural research program, NIAAA supports the entire spectrum of innovative basic, translational, and clinical research to advance the diagnosis, prevention, and treatment of alcohol use disorder and alcohol-related problems. To celebrate the anniversary, NIAAA hosted a 2-day symposium, "Alcohol Across the Lifespan: 50 Years of Evidence-Based Diagnosis, Prevention, and Treatment Research," devoted to key topics within the field of alcohol research. This article is based on Dr. Charness' presentation at the event. NIAAA Director George F. Koob, Ph.D., serves as editor of the Festschrift.

This cohort study of health care workers in a metropolitan Veterans Administration network examines the association of SARS-CoV-2 infection after receiving a single dose of mRNA-1273 vaccine compared with no vaccination.

To the Editor — To date, > 6 million tests for COVID-19 have been performed in the United States, with the vast majority utilizing nasopharyngeal sampling. 1 The need for large-scale testing in the COVID-19 pandemic has created a global shortage of commercial nasopharyngeal swabs. One approach to this shortage has been the 3-dimensional (3D) printing of nasopharyngeal swabs. Swabs printed on a 3D printer (3D swab) differ somewhat from commer-cially produced swabs: they having larger heads, less flexibility, and a plastic rather than cotton or polyester fiber tip. These 3D swabs are class 1 medical devices, and their diagnostic efficacy has been validated through field testing. 2 Guidance on the safe collection of nasopharyngeal samples using commercial swabs is available in text and video format 3,4 ; however, no data are available on the adverse effects of either commercial or 3D swabs, making it difficult to assess their relative safety. To expand testing at our medical center, we printed the Northwell prototype 3D swab using specifications obtained from the technology transfer office at the University of South Florida.

This cohort study examines the association of vaccination status and detection of SARS-CoV-2 infection in health care personnel at long-term residential facilities.

Abstract Among 3926 healthcare personnel in a multisite healthcare system, the minimal population prevalence of coronavirus disease 2019 (COVID-19) was 4.4% (bootstrap 95% confidence interval [CI], 3.7%–5.0%), and the infection fatality rate was 0.6% (bootstrap 95% CI, 0.0%–1.7%). Rates reflected both local community prevalence and hospital exposures but not specifically exposure on COVID-19 units.