BACKGROUND: Obesity affects over 10% of the world population and has significant public health implications. With rising recognition of the long-term effects of Long COVID (LC) coupled with new agents to facilitate weight loss, it is critical to understand the influence of obesity on LC. This study assessed the association of obesity with rates of LC and degree of LC-related mental and physical health outcomes among participants up to three years after initial infection. METHODS: This was a cross-sectional, multisite study of participants with SARS-CoV-2 infection from 12/11/2020–8/29/2022, with data collected through 4/2/2024. Surveys included validated tools for physical and mental health. Data were analyzed by self-reported new obesity (follow-up only), persistent obesity (baseline and follow-up), or no obesity. RESULTS: Of 3,663 participants, 547 (14.9%) had new obesity and 805 (21.9%) had persistent obesity. Compared with persons without obesity, LC was significantly more common among those with new (39.7% vs 22.8%; aOR: 1.9, 95% CI 1.5–2.4) or persistent obesity (39.1% vs 22.8%; aOR: 1.7, 95% CI 1.4–2.1). Regardless of chronicity and current LC status, obesity was associated with lower (worse) scores for PROMIS Physical (mean differences: 2.7–4.0) and Mental Health (mean differences: 1.7–3.6) function, worse moderate-to-severe fatigue (aOR: 1.3–2.1), worse dyspnea (aOR: 1.9–3.7), worse loneliness (aOR: 1.3–1.6), and insufficient activity (aOR for SNAP ≤ 4: 1.6–2.8; aOR for EVS ≤ 150 min/week: 2.0–3.1). CONCLUSIONS: Participants with obesity had higher rates of LC and worse physical and mental health outcomes, regardless of LC status. These findings raise key questions about obesity interventions to treat LC and a possible role for obesity management before the next pandemic. TRIAL REGISTRATION: NCT04610515

Importance Although US opioid overdose deaths have recently declined, mortality remains higher than before the COVID-19 pandemic, and the role of naloxone in opioid-associated out-of-hospital cardiac arrest (OA-OHCA) remains uncertain. The American Heart Association has identified a critical evidence gap regarding the role of naloxone in resuscitation care. Objective To assess the association between naloxone administered by emergency medical services (EMS) clinicians and outcomes in patients with suspected OA-OHCA. Design, Setting, and Participants This retrospective cohort study of adults (aged ≥18 years) with EMS-treated OHCA used data from the California Resuscitation Outcomes Consortium from January 1, 2021, to December 31, 2022. The primary cohort was patients with OA-OHCA, identified using the Naloxone Cardiac Arrest Decision Instrument (NACARDI) as age younger than 50 years and unwitnessed cardiac arrest. Additional analyses were conducted in patients with EMS-presumed drug-related OHCA and all patients with OHCA. Data were analyzed between November 2024 and July 2025. Exposure Naloxone administration during EMS resuscitation. Main Outcomes and Measures The primary outcome was survival to hospital discharge. Secondary outcomes were favorable neurologic outcome and return of spontaneous circulation (ROSC). Inverse probability weighted regression was used to estimate naloxone treatment effects as absolute risk differences (ARDs). Results Among 3811 patients meeting NACARDI criteria (median patient age, 37 years [IQR, 30-43 years]; 2792 [73.3%] male), 1251 (32.8%) received naloxone and 2560 (67.2%) did not. Survival to hospital discharge occurred in 101 patients (8.1%) who received naloxone vs 112 (4.4%) who did not. Favorable neurologic outcome occurred in 92 (7.4%) vs 84 (3.3%) and sustained ROSC in 177 (14.1%) vs 245 (9.6%), respectively. After adjustment for patient, OHCA incident, and agency-level factors, naloxone was associated with improved survival to hospital discharge (ARD, 2.75 percentage points [pp]; 95% CI, 1.25 to 4.26 pp), favorable neurologic outcome (ARD, 3.18 pp; 95% CI, 1.79 to 4.57 pp), and sustained ROSC (ARD, 3.27 pp; 95% CI, 1.11 to 5.43 pp). In sensitivity analyses of patients who received epinephrine, naloxone was not associated with improved survival to hospital discharge (adjusted ARD, 0.31 pp; 95% CI, −0.09 to 1.58 pp) or the other clinical outcomes. Conclusions and Relevance In this cohort study, among patients with suspected OA-OHCA, EMS-administered naloxone was associated with improved survival and neurologic status and sustained ROSC. These findings support the need for a randomized trial to assess the effects of naloxone in opioid-associated cardiac arrest.

BACKGROUND:Measles cases are increasing in the U.S., raising concern about gaps in adult measles, mumps, and rubella (MMR) vaccination, which is poorly captured by current surveillance. Emergency departments (EDs) act as safety-nets for underserved populations and can help identify gaps in adult MMR uptake. We assessed adult MMR up-to-date status, knowledge, and willingness to receive vaccination in the ED, nationally. METHODS:We conducted a cross-sectional survey of adults aged 18-64 at ten U.S. EDs from April-December 2024. Participants completed a structured survey assessing MMR knowledge, self-reported vaccination status, reasons for non-receipt, and willingness to receive MMR in the ED. Outcomes were summarized as proportions with 95% confidence intervals (CIs). Multivariable logistic regression identified factors associated with not being up to date and willingness to accept vaccination. RESULTS:Among 2456 participants, 25.0% (95% CI 23.3-26.7%) had not heard of the MMR vaccine, and 44.0% (42.5-46.4%) were not up to date. Factors associated with being unvaccinated included male sex (OR 2.21 [1.84-2.66]), African American (non-Hispanic) race (OR 2.27 [1.75-2.96]), Hispanic ethnicity (OR 1.98 [1.49-2.62]), non-English speakers (OR 1.53 [1.12-2.09]), and lack of primary care access (OR 1.25 [1.01-1.58]). Among those not up to date, 36.5% (33.6-39.4%) were willing to receive MMR vaccine if offered in the ED. CONCLUSIONS:Substantial gaps in adult MMR vaccination persist, especially among underserved populations. ED-based strategies might support targeted vaccine education and delivery during periods of increased transmission.

BACKGROUND:Influenza vaccination is a core public health measure but uptake rates in underserved populations are largely unknown. OBJECTIVE:In a national sample of emergency department (ED) patients we sought to determine knowledge and up-to-date status of the influenza vaccine; acceptance of influenza vaccination if offered in the ED; and reasons for not being up-to-date and declining vaccination. METHODS:We conducted this cross-sectional study of adult patients at ten US EDs from April-December 2024. Research personnel asked participants standardized questions about their knowledge, uptake and willingness to accept the influenza vaccine if offered during their ED visit. We report primary outcomes as frequency percentages with 95% confidence intervals (CIs) and performed multivariable logistic regression to identify factors associated with outcomes. RESULTS:Of 4326 patients approached, 3285 (75.9%) participated; 96.0% (95%CI, 95.5-96.3%) had heard of the influenza vaccine, 77.6% (76.2-79.0%) reported having ever received it, and 58.4% (56.7-60.1%) were not up to date. Factors associated with not being up-to-date included African American race (adjusted odds ratio [aOR] 1.28), lack of primary care (aOR 2.61), and lack of insurance (aOR 1.54). Among participants who were not up-to-date, 37.0% (95%CI, 34.7-39.3%) reported they would accept influenza vaccination if offered. CONCLUSIONS:Although awareness of the influenza vaccine was high among ED patients, more than half were not up-to-date. Over one-third of those not up-to-date would accept influenza vaccination if offered during their ED visit. These findings highlight the potential for ED-based influenza vaccination surveillance, messaging and delivery programs.

INTRODUCTION:The prevalence of opioid-associated out-of-hospital cardiac arrest (OA-OHCA) is increasing in the United States. Naloxone administration during OA-OHCA has been associated with improved clinical outcomes, but identifying OA-OHCA in the field remains challenging. Previous work demonstrated association between non-shockable cardiac rhythms and OA-OHCA, suggesting that cardiac rhythm may help identify patients likely to benefit from naloxone. In this work, we assessed the association of naloxone with clinical outcomes for patients with OHCA, stratifying by presenting cardiac rhythm. METHODS:We used 2019-2020 data from the ESO Data Collaborative in this retrospective cohort study. Cases were classified a priori according to presenting rhythm (shockable rhythm, pulseless electrical activity [PEA], asystole). The exposure was prehospital naloxone administration and outcomes of interest were prehospital ROSC and survival to hospital discharge. We utilized logistic regression and adjusted propensity-score matching to determine associations with outcomes. RESULTS:We analyzed 40,333 cases in which 7567 (18.8%) patients received naloxone. Before matching, the rate of prehospital ROSC was 21.5% and survival to hospital discharge was 9.0%. After propensity score matching, patients in PEA who received naloxone had similar rates of ROSC (OR 1.09, 95%CI 0.90-1.31) and higher survival (OR 1.46, 95%CI 1.11-1.92). Naloxone administration was not associated with differences in either outcome in patients presenting with shockable rhythms or asystole. Given the retrospective nature of this work, we were unable to fully address selection bias or resuscitation time bias and cannot comment on causality. CONCLUSION:In this national cohort, naloxone administration was associated with improved survival to hospital discharge for OHCA patients in PEA. No association was found between naloxone and clinical outcomes for OHCA patients with shockable rhythms or asystole. Prospective, randomized trials are needed to assess for true causality.

Background: Outcomes after mild traumatic brain injury (mTBI) without neuroimaging or blood biomarker abnormalities are poorly characterized. We evaluated 6-month outcomes in this population. Methods: We analyzed prospective TRACK-TBI data from 18 US Level I trauma centers between 2014 and 2018. Participants aged 17 years or older presented within 24 hours of injury with a Glasgow Coma Scale score of 15 and clinical signs of mTBI. Patients with negative head CT and MRI and non-elevated glial fibrillary acidic protein and ubiquitin C-terminal hydrolase-L1 concentrations (CT−/MRI−/BNE) were compared with patients who had positive imaging or elevated biomarkers and with orthopedic trauma controls. The primary outcome was incomplete functional recovery at 6 months, defined as a Glasgow Outcome Scale–Extended score below 8. Secondary outcomes were persistent post-concussive symptoms, psychological distress, and impaired quality of life. Findings: We included 578 patients with mTBI (98 CT−/MRI−/BNE and 480 imaging-positive or biomarker-positive) and 168 orthopedic controls. In the CT−/MRI−/BNE group, median age was 27.5 years and 54% were male. At 6 months, 65% had incomplete all-cause functional recovery, 43% had persistent post-concussive symptoms, 30% had psychological distress, and 37% had impaired quality of life. Outcomes were similar to or worse than those in imaging-positive or biomarker-positive patients and worse than those in orthopedic controls. Pre-injury psychiatric history was associated with incomplete TBI-attributable recovery (adjusted odds ratio [aOR] 3.2, 95% CI 1.2–9.1), persistent symptoms (3.1, 1.1–8.4), psychological distress (7.2, 2.1–24.0), and impaired quality of life (9.3, 2.9–30.0). Interpretation: Negative CT, MRI, and acute blood biomarker findings do not identify a uniformly low-risk mTBI population. Pre-injury psychiatric history could inform emergency-department risk stratification and targeted post-discharge follow-up.

This cluster randomized clinical trial examines whether tailored messaging about updated COVID-19 vaccines and simple inquiry about vaccine acceptance during an emergency department visit increase patients' vaccine uptake within 30 days. QuestionDo tailored messaging interventions about updated COVID-19 vaccines and simple inquiry about vaccine acceptance increase vaccine uptake among emergency department (ED) patients within 30 days of the ED visit?FindingsIn this 3-arm, cluster randomized clinical trial of 852 participants across 6 EDs, neither a tailored messaging intervention nor inquiry about vaccine acceptance significantly increased 30-day vaccine uptake compared with usual care.MeaningThese findings suggest that tailored messaging and simple inquiry alone may be insufficient to increase updated COVID-19 vaccine uptake among ED patients. ImportancePatient uptake of updated COVID-19 vaccines is crucial for reducing severe outcomes, yet national uptake remains low.ObjectiveTo determine if tailored messaging or simple inquiry about vaccine acceptance increases 30-day uptake of updated COVID-19 vaccines among emergency department (ED) patients.Design, Setting, and ParticipantsThis 3-arm, cluster randomized clinical trial conducted from January 29 to June 18, 2024, enrolled adult ED patients who had not received a COVID-19 vaccine in the prior 6 months across 6 EDs in San Francisco, California; Philadelphia, Pennsylvania; Houston, Texas; and Durham, North Carolina.InterventionsIntervention M involved tailored messaging about updated COVID-19 vaccines and inquiry about vaccine acceptance. Intervention Q involved only inquiry about vaccine acceptance. Usual care (no messaging or vaccine acceptance questions) served as the control.Main Outcomes and MeasuresThe primary outcome was updated COVID-19 vaccine receipt within 30 days of the ED visit, assessed via electronic health record review and follow-up telephone calls. Secondary outcomes included vaccine acceptance and vaccination during the ED visit. Outcomes were also compared between study sites that had the updated COVID-19 vaccine available and those that did not.ResultsOf 852 participants (median age, 47 years [IQR, 33-63 years]; 464 [54.5%] women), 247 (29.0%) were in the intervention M group, 273 (32.0%) in the intervention Q group, and 332 (39.0%) in the control group. Vaccine uptake at 30 days was not significantly higher in either the intervention M group compared with control (14 participants [5.7%] vs 10 [3.0%]; absolute difference, 2.7 percentage points [pp] [95% CI, -0.8 to 6.3 pp]) or the intervention Q group compared with control (11 [4.0%] vs 10 [3.0%]; absolute difference, 1.0 pp [95% CI, -2.0 to 4.2 pp]). However, at sites where vaccines were available, the intervention M group had higher uptake compared with control (13 of 132 [9.8%] vs 5 of 150 [3.3%]; absolute difference, 6.5 pp [95% CI, 0.5-12.5 pp]).Conclusions and RelevanceIn this cluster randomized clinical trial of adult ED patients, tailored messaging and simple inquiry alone did not significantly increase 30-day updated COVID-19 vaccine uptake among patients. The slight increase in uptake among participants in the EDs that had access to the updated COVID-19 vaccines suggested that vaccine availability was an effect modifier, underscoring the importance of opportunity and convenience in vaccine delivery.Trial RegistrationClinicalTrials.gov Identifier: NCT06156215

IMPORTANCE:The mandatory service of essential workers during the COVID-19 pandemic was associated with high job stress, increased SARS-CoV-2 exposure, and limited time for recovery following infection. Understanding outcomes for frontline workers can inform planning for future pandemics. OBJECTIVE:To compare patient-reported outcomes by employment type and SARS-CoV-2 status. DESIGN:Data from the INSPIRE registry, which enrolled COVID-positive and COVID-negative adults between 12/7/2020-8/29/2022 was analyzed. Patient-reported outcomes were collected quarterly over 18 months. SETTING:Participants were recruited across eight US sites. PARTICIPANTS:Employed INSPIRE participants who completed a short (3-month) and long-term (12-18 month) survey. EXPOSURE:SARS-CoV-2 index status and employment type (essential healthcare worker [HCW], essential non-HCW, and non-essential worker ["general worker"]). MAIN OUTCOMES AND MEASURES:PROMIS-29 (mental and physical health summary) and PROMIS Cognitive SF-CF 8a (cognitive function) scores were assessed at baseline, short-term (3-months), and long-term (12-18 months) timepoints using GEE modeling. RESULTS:Of the 1,463 participants: 53.5% were essential workers (51.4% HCWs, 48.6% non-HCWs) and 46.5% were general workers. Most associations between outcomes and employment type became non-significant after adjusting for sociodemographics, comorbidities, COVID-19 vaccination, and SARS-CoV-2 variant period. However, among COVID-negative participants, essential HCWs had higher cognitive scores at baseline (β: 3.91, 95% CI [1.32, 6.50]), short term: (β: 3.49, 95% CI: [0.80, 6.18]) and long-term: (β: 3.72, 95% CI: [0.98, 6.46]) compared to general workers. Among COVID-positive participants, essential non-HCWs had significantly worse long-term physical health summary scores (β:-1.22, 95% CI: [-2.35, -0.09]) compared to general workers. CONCLUSIONS AND RELEVANCE:Differences in outcomes by worker status were largely explained by baseline characteristics. However, compared to general workers, essential HCW status had higher cognitive function in the absence of SARS-CoV-2 infection at all timepoints, while essential non-HCWs were most vulnerable to poor recovery in long-term physical health following SARS-CoV-2 infection. Preparation efforts for future pandemics may consider enhanced protection and post-infection resources for frontline workers.

Background The COVID-19 pandemic is a dynamic public health issue that requires up-to-date surveillance data to guide healthcare and public policy interventions. Objectives We sought to address gaps in COVID-19 surveillance data of underserved populations by assessing self-reported COVID-19 positivity rates in a national sample of patients in emergency departments (EDs). Methods We used data from two cross-sectional survey studies of adult patients presenting to 19 US EDs during two periods: Period 1 (December 2020 - March 2021) and Period 2 (December 2022 - December 2023). Results In Period 1(n= 2101), 333 (15.8%) reported having had a positive COVID-19 test. Positivity rates were significantly higher in Hispanic vs White (non-Hispanic) participants (21.7% vs 14.3%; difference 7.4%, 95% CI [3.2 - 11.8%]) and non-English vs English speakers (21.5% vs 14.5%; difference 7.0%, 95% CI [2.9 -11.5%]). In Period 2 (n= 3658), 1674 (45.8%) reported having had a positive COVID-19 test. Positivity rates were significantly higher in women vs men (50.3% vs 40.6%, difference 9.6%, 95% CI [6.4 -12.8%]); White (non-Hispanic) vs African American (non-Hispanic) participants (47.9% vs 39.1%; difference 8.8%, 95% CI [4.8 - 12.8%]); Hispanic vs White (non-Hispanic) participants (52.8% vs 47.9%; difference 4.9%, 95% CI [0.5 - 9.3%]); and non-English vs English speakers (49.3% vs 45.0%; difference 4.2%, 95% CI [0.05 - 8.4%]). Conclusions We found that Hispanics had higher rates of prior positive COVID-19 tests that persisted throughout the pandemic. In the later pandemic period, women had significantly higher rates of prior positive COVID-19 tests than men.

Background:Long-term sequelae after SARS-CoV-2 infection may impact health-related quality-of-life (HRQoL), yet it is unknown how HRQoL changes during recovery. We compared patient-reported HRQoL among adults with COVID-19-like illness who tested SARS-CoV-2 positive (COVID+) with those who tested negative (COVID-). Methods:Participants in this prospective, multicenter, longitudinal registry study were enrolled from December 2020 through August 2022 and completed 3-month follow-up assessments until 12 months after enrollment. Participants were adults (≥18 years) with acute symptoms suggestive of COVID-19 who received a Food and Drug Administration-approved SARS-CoV-2 test. Participants received questions from PROMIS-29 (subscales: physical function, anxiety, depression, fatigue, social participation, sleep disturbance, and pain interference) and PROMIS SF-8a (cognitive function). Latent transition analysis was used to identify meaningful patterns in HRQoL scores over time; 4 HRQoL categories were compared descriptively and using multivariable regression. Inverse probability weighting was used to adjust for covariate imbalance. Results:There were 1096 (75%) COVID+ and 371 (25%) COVID-. Four distinct well-being classes emerged: optimal overall, poor mental, poor physical, and poor overall HRQoL. COVID+ participants were more likely to return to the optimal HRQoL class compared to COVID- participants. The most substantial transition from poor physical to optimal HRQoL occurred by 3 months, whereas movement from poor mental to optimal HRQoL occurred by 9 months. Conclusions:In adults with COVID-19-like illness, COVID+ participants demonstrated meaningful recovery in their physical HRQoL by 3 months after infection, but mental HRQoL took longer to improve. Suboptimal HRQoL at 3 to 12 months after infection remained in approximately 20%. Trial Registration:NCT04610515.

BACKGROUND:Up to fifteen percent of out-of-hospital cardiac arrests (OHCAs) are precipitated by occult drug overdose - cases without history or evidence of drug use that are often attributed to a non-overdose cause. The NAloxone Cardiac ARrest Decision Instrument (NACARDI) was derived to help emergency medical service (EMS) providers rapidly identify patients at higher risk of occult opioid-associated (OA)-OHCAs during resuscitation. In this analysis we externally validate NACARDI in an independent cohort of OHCA patients. METHODS:We conducted a retrospective validation using data from EMS-attended OHCA patients and coroner records in Ontario, Canada between 2020-2021. Inclusion criteria were age ≥18 years and OHCA death with a coroner record. Exclusion criteria were EMS-suspected drug overdose or known cause of the OHCA. NACARDI consists of two criteria: patient age and unwitnessed cardiac arrest. Two cut-offs for patient age were assessed for this validation: <50 years (NACARDI-50) and <60 years (NACARDI-60). The primary outcome was coroner adjudicated cause of death. We calculated screening characteristics and receiver operating characteristic (ROC) curves using standard formulae. RESULTS:Of 2904 OHCA cases without an obvious cause, 791 had coroner evaluations and 121 (15.3 %) were adjudicated as occult OA-OHCA. NACARDI-60 had: sensitivity 82.6 % (95 %CI 74.9-88.4 %), specificity 77.1 % (95 %CI 73.8-80.1 %), negative predictive value 96.1 % (95 %CI 94.1-97.4 %), and positive predictive value 39.4 % (95 %CI 33.6-45.5 %). NACARDI-50 had: sensitivity 63.6 % (95 %CI 54.4-72.2 %), specificity 89.3 % (95 %CI 86.7-91.5 %), negative predictive value 93.2 % (95 %CI 90.9-95.0 %), and positive predictive value 51.7 % (95 %CI 43.4-59.9 %). ROC curves for both NACARDI-50 and NACARDI-60 demonstrated excellent discrimination for occult OA-OHCA. CONCLUSION:In this external validation cohort, NACARDI had a sensitivity and specificity sufficiently high to aid in the real-time identification of occult OA-OHCA in the field. NACARDI has the potential to guide targeted interventions for OA-OHCA.

Long COVID definitions vary widely, and no consensus exists on how to accurately measure its prevalence, complicating both clinical care and research. To assess long COVID prevalence using various definitions from published literature. This prospective, multicenter cohort study used data from the longitudinal Innovative Support for Patients With SARS-CoV-2 Infections Registry (INSPIRE). Participants aged 18 years or older with symptoms suggestive of COVID-19 illness at the time of their index SARS-CoV-2 test enrolled at 8 sites across the US from December 11, 2020, through August 29, 2022, with follow-up surveys collected through February 28, 2023. Positive or negative SARS-CoV-2 test result at the time of acute symptoms. Long COVID prevalence among INSPIRE participants with a positive vs negative index SARS-CoV-2 test, based on long COVID definitions in published literature. Secondary outcomes were sensitivity and specificity of published definitions compared with self-reported long COVID. A total of 4575 INSPIRE participants were included (mean [SD] age, 40.40 [14.58] years). Most were female (3013 of 4448 [67.7%]) and aged 18 to 49 years (3338 of 4541 [73.5%]). Applying 5 published definitions for long COVID yielded a prevalence that ranged from 30.84% (95% CI, 29.33%-32.40%) to 42.01% (95% CI, 40.37%-43.66%) at 3 months and 14.23% (95% CI, 13.01%-15.55%) to 21.94% (95% CI, 20.47%-23.47%) at 6 months postinfection; in the 5 comparator studies, reported prevalence of long COVID at 1 to 5 months postinfection ranged from 2.6% (≥84 days) to 47.4% (3-5 months) and at 6 or more months postinfection ranged from 10.0% (95% CI, 8.8%-11.0%) to 61.9% (6-11 months). Using participants' self-reported long COVID as a criterion standard, existing published definitions had low-to-moderate sensitivity (up to 66.32% [95% CI, 62.59%-69.90%] at 3 months and 45.53% [95% CI, 41.51%-49.60%] at 6 months) and high specificity (up to 81.29% [95% CI, 79.32%-83.15%] at 3 months and 94.26% [95% CI, 92.98%-95.37%]) at 6 months. In this cohort study, variability in long COVID prevalence across published definitions highlights the need for a standardized, validated definition to improve clinical recognition and research comparability, ultimately guiding more accurate diagnosis and treatment strategies.

OBJECTIVES:One-in-six cases of atraumatic out-of-hospital cardiac arrest (OHCA) in North America are thought to be precipitated by opioid overdose, but many of these cases are not obvious and there is no gold standard used by emergency medical service (EMS) personnel to identify opioid-associated (OA)-OHCA. The NAloxone Cardiac ARrest Decision Instrument (NACARDI) was developed and validated to identify potential OA-OHCA, however it has not yet been used in the field. We sought to prospectively assess the inter-rater reliability and acceptability of NACARDI in real-world OHCA. METHODS:Emergency medical service clinicians evaluated the NACARDI criteria during acute resuscitations of patients with OHCA in San Francisco between September 2022-February 2024. The NACARDI rule utilized in this study consisted of two criteria: patient age <60 years and unwitnessed cardiac arrest. Clinicians completed a short survey that included free-text questions, multiple choice question, and Likert-type scales rating NACARDI's ease of use, describing when during the resuscitation they were able to assess NACARDI, and identifying potential barriers. In cases where two clinicians completed NARCADI assessments for a single OHCA case, we calculated a kappa coefficient of agreement. RESULTS:Emergency medical service clinicians evaluated 149 cases of OHCA and completed 198 surveys - 100 (67.1%) cases had one survey response and 49 (32.9%) had survey responses from two EMS personnel. Clinicians were able to ascertain NACARDI criteria "prior to or during the first cardiac rhythm check" in 80.3% of cases. NACARDI was reported as "easy to use" by 83.3% of respondents. The overall Kappa coefficient for NACARDI was 0.73 (95%CI 0.51-0.95). The three most common reasons why NACARDI criteria were deemed difficult to ascertain were chaotic scene, language barrier, and unreliable bystander accounts. CONCLUSIONS:There was reasonable agreement in how NACARDI was interpreted for OHCA cases and the majority of surveyed EMS clinicians found NACARDI easy to use. These findings suggest that NACARDI can be reliably and easily used by EMS clinicians during acute OHCA resuscitations to identify OA-OHCA patients, potentially informing inclusion criteria for future research studies and guiding targeted interventions for this patient population.

Importance:Patient uptake of updated COVID-19 vaccines is crucial for reducing severe outcomes, yet national uptake remains low. Objective:To determine if tailored messaging or simple inquiry about vaccine acceptance increases 30-day uptake of updated COVID-19 vaccines among emergency department (ED) patients. Design, Setting, and Participants:This 3-arm, cluster randomized clinical trial conducted from January 29 to June 18, 2024, enrolled adult ED patients who had not received a COVID-19 vaccine in the prior 6 months across 6 EDs in San Francisco, California; Philadelphia, Pennsylvania; Houston, Texas; and Durham, North Carolina. Interventions:Intervention M involved tailored messaging about updated COVID-19 vaccines and inquiry about vaccine acceptance. Intervention Q involved only inquiry about vaccine acceptance. Usual care (no messaging or vaccine acceptance questions) served as the control. Main Outcomes and Measures:The primary outcome was updated COVID-19 vaccine receipt within 30 days of the ED visit, assessed via electronic health record review and follow-up telephone calls. Secondary outcomes included vaccine acceptance and vaccination during the ED visit. Outcomes were also compared between study sites that had the updated COVID-19 vaccine available and those that did not. Results:Of 852 participants (median age, 47 years [IQR, 33-63 years]; 464 [54.5%] women), 247 (29.0%) were in the intervention M group, 273 (32.0%) in the intervention Q group, and 332 (39.0%) in the control group. Vaccine uptake at 30 days was not significantly higher in either the intervention M group compared with control (14 participants [5.7%] vs 10 [3.0%]; absolute difference, 2.7 percentage points [pp] [95% CI, -0.8 to 6.3 pp]) or the intervention Q group compared with control (11 [4.0%] vs 10 [3.0%]; absolute difference, 1.0 pp [95% CI, -2.0 to 4.2 pp]). However, at sites where vaccines were available, the intervention M group had higher uptake compared with control (13 of 132 [9.8%] vs 5 of 150 [3.3%]; absolute difference, 6.5 pp [95% CI, 0.5-12.5 pp]). Conclusions and Relevance:In this cluster randomized clinical trial of adult ED patients, tailored messaging and simple inquiry alone did not significantly increase 30-day updated COVID-19 vaccine uptake among patients. The slight increase in uptake among participants in the EDs that had access to the updated COVID-19 vaccines suggested that vaccine availability was an effect modifier, underscoring the importance of opportunity and convenience in vaccine delivery. Trial Registration:ClinicalTrials.gov Identifier: NCT06156215.

Current models of vaccination coverage screening and surveillance might miss underserved populations whose only health care access occurs in emergency departments (EDs). During April-December 2024, a survey of non-critically ill adult patients evaluated in 10 EDs in eight U.S. cities across five states was conducted to ascertain patients' vaccination knowledge, self-reported vaccination coverage, and willingness to receive vaccines in an ED. Among 4,326 patients approached by the research team, 3,285 (75.9%) agreed to participate. Non-Hispanic Black or African American (Black), non-Hispanic White, and Hispanic or Latino (Hispanic) persons each accounted for approximately 30% of participants; 17.9% spoke Spanish as their primary language; 7.8% had unstable or marginal housing; and 21.0% lacked a source of primary health care. Approximately one half (49.4%) had not heard of one or more CDC-recommended vaccines for their age group, and 85.9% had not received one or more of the recommended vaccines. Factors associated with not being up to date with recommended vaccinations included non-Hispanic Black race and ethnicity (adjusted odds ratio [aOR] = 1.93; 95% CI = 1.32-2.85), lack of primary health care (aOR = 2.91; 95% CI = 1.74-5.13), and lack of health insurance (aOR = 3.01; 95% CI = 1.27-8.82). Among 2,821 participants who were not up to date with recommended vaccines, 46.4% said that they would accept one or more missing vaccines if they could be provided during their ED visit, and 86.7% of these persons said they would accept all missing vaccines. The primary reasons for missed vaccine doses were that the participant was unaware of or had not been offered the vaccines. EDs could be explored as additional sites to offer vaccination screening, recommendations, counseling, and referrals to increase vaccination coverage among underserved populations.

Background Although short-term outcomes of Long COVID have been described, longer-term physical and mental health outcomes of Long COVID are less well-established. This study sought to assess differences in long-term physical and mental health outcomes extending up to three years among those with current, resolved, and no Long COVID, as well as duration of Long COVID and vaccination status. Methods This was a prospective, multisite, study of participants with SARS-CoV-2 infection from 12/7/2020-8/29/ 2022, with data collected through 4/2/2024. Surveys included validated tools for physical and mental health. Data were analyzed by Long COVID status (never-had, resolved, current), Long COVID duration and vaccination status. Findings Of 3663 participants, 2604 (71.1%) never had Long COVID, 994 (27.1%) reported current Long COVID, and 65 (1.8%) reported resolved Long COVID. Compared to never having Long COVID, current Long COVID had lower/ worse scores for Patient-Reported Outcomes Measurement Information System (PROMIS) version 29 Physical (7.8; 95% confidence interval [CI] 7.3-8.3) and Mental Health (9.4; 95% CI 8.8-10.1) and higher likelihood of moderate-to-high stress (adjusted odds ratio [aOR]: 2.0; 95% CI 1.6-2.4), moderate-to-high loneliness (aOR: 1.6; 95% CI 1.4-2.0), moderate-to-severe fatigue (aOR: 3.0; 95% CI 2.5-3.7), insufficient activity (aOR for Speedy Nutrition and Physical Activity Assessment <= 4: 0.6; 95% CI 0.5-0.7; aOR for Exercise Vital Sign <= 150 min/week: 0.7, 95% CI 0.6-1.0), and worse dyspnea (aOR: 5.0; 95% CI 4.3-5.8). Resolved Long COVID had lower scores for PROMIS Physical by 2.0 (95% CI 0.2-3.8) and Mental Health by 2.3 (95% CI 0.2-4.4) than the never-had-Long COVID cohort. Number of COVID-19 vaccinations was associated with better outcomes across all measures. Interpretation Among participants followed up to 3 years after initial infection, those with current Long COVID had worse physical and mental health outcomes. The majority of those with Long COVID did not resolve, with less than 2% having resolved Long COVID. The resolved Long COVID cohort had moderately worse physical and mental health compared with those never-having-Long COVID. COVID-19 vaccination was associated with better outcomes. Copyright (c) 2025 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

BackgroundInfluenza vaccine uptake is low among underserved populations whose primary health care access occurs in emergency departments. We sought to determine whether implementation of two interventions would increase 30-day influenza vaccine uptake in unvaccinated patients in the emergency department.MethodsThis three-group, prospective, cluster-randomized controlled trial compared two interventions with a control group in noncritically ill, adult patients in the emergency department who were not vaccinated for influenza in the current vaccine season. The unit of randomization was individual calendar days. Participants received either Intervention M (an influenza vaccine messaging platform consisting of a video, one-page flyer, and scripted message, followed by a vaccine acceptance question and provider notification if participants indicated vaccine acceptance), Intervention Q (no messaging but the vaccine acceptance question and provider notification), or control (usual care/no intervention). The primary outcome was receipt of an influenza vaccine at 30 days ascertained by electronic health record review and telephone follow-up, comparing the Intervention M group with the control group. Secondary outcomes included comparisons of 30-day vaccine uptake in Intervention Q versus control and Intervention M versus Intervention Q.ResultsBetween October 2022 and February 2023, a total of 767 trial participants were enrolled at six emergency departments in five U.S. cities. Median age was 46 years; 353 (46%) participants were female, 274 (36%) were African American, and 158 (21%) were Latinx; 126 (16%) lacked health insurance, and 244 (32%) lacked primary care. The Intervention M, Intervention Q, and control groups had 30-day vaccine uptakes of 41%, 32%, and 15%, respectively (P<0.0001 for Intervention M vs. control). Comparing Intervention M versus Intervention Q, the adjusted difference in 30-day vaccine uptake was 8.7 percentage points (95% confidence interval, -0.1 to 17.6 percentage points).ConclusionsImplementation of influenza vaccine messaging platforms (video clips, printed materials, and verbal scripts) improved 30-day vaccine uptake among unvaccinated patients in the emergency department. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT05836818.)

Introduction: Estimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8% to 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical Methods: We conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 and 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or Results: From 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50-79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023. Conclusion: Drug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.

Study objectiveIn the early months of the coronavirus disease 2019 (COVID-19) pandemic and before vaccine availability, there were concerns that infected emergency department (ED) health care personnel could present a threat to the delivery of emergency medical care. We examined how the pandemic affected staffing levels and whether COVID-19 positive staff were potentially infectious at work in a cohort of US ED health care personnel in 2020.MethodsThe COVID-19 Evaluation of Risks in Emergency Departments (Project COVERED) project was a multicenter prospective cohort study of US ED health care personnel conducted from May to December 2020. During surveillance, health care personnel completed weekly electronic surveys and underwent periodic serology and nasal reverse transcription polymerase chain reaction testing for SARS-CoV-2, and investigators captured weekly data on health care facility COVID-19 prevalence and health care personnel staffing. Surveys asked about symptoms, potential exposures, work attendance, personal protective equipment use, and behaviors.ResultsWe enrolled 1,673 health care personnel who completed 29,825 person weeks of surveillance. Eighty-nine (5.3%) health care personnel documented 90 (0.3%; 95% confidence interval [CI] 0.2% to 0.4%) person weeks of missed work related to documented or concerns for COVID-19 infection. Health care personnel experienced symptoms of COVID-19 during 1,256 (4.2%) person weeks and worked at least one shift whereas symptomatic during 1,042 (83.0%) of these periods. Seventy-five (4.5%) participants tested positive for SARS-CoV-2 during the surveillance period, including 43 (57.3%) who indicated they never experienced symptoms; 74 (98.7%; 95% CI 90.7% to 99.9%) infected health care personnel worked at least one shift during the initial period of infection, and 71 (94.7%) continued working until laboratory confirmation of their infection. Physician staffing was not associated with the facility or community COVID-19 levels within any time frame studied (Kendall tau’s 0.02, 0.056, and 0.081 for no shift, one-week time shift, and 2-week time shift, respectively).ConclusionsDuring the first wave of the pandemic, COVID-19 infections in ED health care personnel were infrequent, and the time lost from the workforce was minimal. Health care personnel frequently reported for work while infected with SARS-CoV-2 before laboratory confirmation. The ED staffing levels were poorly correlated with facility and community COVID-19 burden.