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This study aimed to evaluate veno-venous collaterals between bidirectional cavopulmonary shunt and total cavopulmonary connection.
Methods:
Patients who underwent staged total cavopulmonary connection between 1995 and 2022 were reviewed. Veno-venous collaterals between bidirectional cavopulmonary shunt and total cavopulmonary connection were depicted using angiograms. The prevalence of veno-venous collaterals, the risks for the development of veno-venous collaterals, and the impact of veno-venous collaterals on outcomes were analysed.
Results:
In total, 586 patients were included. Veno-venous collaterals were found in 72 (12.3%) patients. Majority of veno-venous collaterals originated from the superior caval vein and drained into the inferior caval vein. Before bidirectional cavopulmonary shunt, mean pulmonary artery pressure (16.3 vs. 14.5 mmHg, p = 0.018), and trans-pulmonary gradient (9.5 vs. 8.0 mmHg, p = 0.030) were higher in patients with veno-venous collaterals compared to those without. Veno-venous collaterals intervention was performed in 32 (5.5%) patients, in a median of 29 (16–152) days after bidirectional cavopulmonary shunt. Before total cavopulmonary connection, pulmonary artery pressure (10.3 vs. 9.4 mmHg, p = 0.015) and ventricular end-diastolic pressure (8.4 vs. 7.6 mmHg, p = 0.035) were higher, and arterial oxygen saturation (SaO2, 80.6 vs. 82.6 %, p = 0.018) was lower in patients with veno-venous collaterals compared to those without. More palliations before total cavopulmonary connection (p < 0.001, odds ratio: 1.689) were an independent risk for the development of veno-venous collaterals. Veno-venous collaterals did not affect survival after total cavopulmonary connection (92.8 vs. 92.7% at 10 years, p = 0.600).
Conclusions:
The prevalence of veno-venous collaterals between bidirectional cavopulmonary shunt and total cavopulmonary connection was 12%. Veno-venous collaterals may be induced by the elevated pulmonary artery pressure and trans-pulmonary gradient, and also by more previous palliations. However, they had no impact on clinical outcomes following total cavopulmonary connection.
Depressive symptoms remaining after antidepressant treatment increase the risk of relapse and recurrence. We aimed to analyze the distribution and main drivers of remaining symptoms in patients with a major depressive episode.
Methods
Two independent samples of 8,229 and 5,926 patients from two large naturalistic studies were retrospectively analyzed. DSM-IV criteria for major depressive episodes were assessed during two face-to-face visits with clinicians: before the prescription of a new antidepressant, and after 6 weeks of treatment. The Hospital Anxiety and Depression Scale (HADS) was used to assess baseline severity of anxiety and depression.
Results
In both samples, two clusters of remaining symptoms were observed. The first cluster encompassed symptoms related to a negative emotional and cognitive bias and was specifically driven by the baseline severity of depression. The second cluster encompassed neurovegetative symptoms and was specifically driven by the baseline severity of anxiety.
Conclusions
The baseline anxiety-depressive balance of patients could be considered to adapt the treatment, focusing on emotional and cognitive symptoms with patients with high baseline severity of depression, and neurovegetative symptoms with patients with high baseline anxiety severity.
Childhood maltreatment is linked with later depressive symptoms, but not every maltreated child will experience symptoms later in life. Therefore, we investigate whether genetic predisposition for depression (i.e., polygenic score for depression, PGSDEP) modifies the association between maltreatment and depressive symptoms, while accounting for different types of maltreatment and whether it was evaluated through prospective and retrospective reports. The sample included 541–617 participants from the Quebec Longitudinal Study of Child Development with information on maltreatment, including threat, deprivation, assessed prospectively (5 months–17 years) and retrospectively (reported at 23 years), PGSDEP and self-reported depressive symptoms (20–23 years). Using hierarchical linear regressions, we found that retrospective, but not prospective indicators of maltreatment (threat/deprivation/cumulative) were associated with later depressive symptoms, above and beyond the PGSDEP. Our findings also show the presence of gene–environment interactions, whereby the association between maltreatment (retrospective cumulative maltreatment/threat, prospective deprivation) and depression was strengthened among youth with higher PGSDEP scores. Consistent with the Diathesis-Stress hypothesis, our findings suggest that a genetic predisposition for depression may exacerbate the putative impact of maltreatment on later depressive symptoms, especially when maltreatment is retrospective. Understanding the gene–environment interplay emerging in the context of maltreatment has the potential to guide prevention efforts.
Declining labor force participation of older men throughout the 20th century and recent increases in participation have generated substantial interest in understanding the effect of public pensions on retirement. The National Bureau of Economic Research's International Social Security (ISS) Project, a long-term collaboration among researchers in a dozen developed countries, has explored this and related questions. The project employs a harmonized approach to conduct within-country analyses that are combined for meaningful cross-country comparisons. The key lesson is that the choices of policy makers affect the incentive to work at older ages and these incentives have important effects on retirement behavior.
The spatial distribution of the dominant matrix minerals present in the middle-Proterozoic Athabasca Group sandstone (kaolin, illite, sudoite, dravite, hematite) was studied at a regional scale in the Shea Creek region (Saskatchewan, Canada), in which two epigenetic unconformity-type uranium deposits have been discovered. 3D models of matrix mineral distribution were derived from normative mineral calculations and 3D interpolation using whole-rock geochemical analyses of sandstone samples collected from both mineralized and barren areas. The calculations were constrained by information obtained from petrographic and crystal-chemical clay mineralogical studies on representative samples. The 3D mineral distribution models were compared to the lithostratigraphy and structural features of the Athabasca Group sandstone to ascertain the source and mobility of the main elements involved in the sandstone host-rock alteration processes related to the U mineralization. The distribution of Al is conformable with the lithostratigraphy throughout the studied area, regardless of proximity to basement-rooted structures and U ore bodies. The distribution of illite displays similar features, but the intensity of the illitization of kaolin decreases with increasing distance from the structures and U ore bodies. Hematite bleaching and neoformation of sudoite and dravite were restricted to the vicinity of the fault zones above the U ore bodies. The spatial configurations of the mineral anomalies show that syn-ore fluids flowed from the basement towards the sandstone cover via the fault zones, as described in current metallogenic models. Although Al remained immobile (mass transfer), the anomalous K, B and Mg present in the host-rock alteration haloes were probably imported from the basement rocks (mass transport). Unlike B and Mg, K migrated laterally at least several kilometers from the basement-rooted faults. The mineral distribution models were used to quantify the volume of altered sandstone (10−2−10−1 km3) and the amounts of K, Mg and B which were imported to the alteration haloes above the Shea Creek U ore bodies: 186,000 t of K, 66,000 t of Mg, and 11,000 t of B above the Anne ore body, and 24,000 t of K, 185,000 t of Mg, and a similar 11,000 t of B above the Colette ore body.
Physical pain is a common issue in people with bipolar disorder (BD). It worsens mental health and quality of life, negatively impacts treatment response, and increases the risk of suicide. Lithium, which is prescribed in BD as a mood stabilizer, has shown promising effects on pain.
Methods
This naturalistic study included 760 subjects with BD ( FACE-BD cohort) divided in two groups: with and without self-reported pain (evaluated with the EQ-5D-5L questionnaire). In this sample, 176 subjects were treated with lithium salts. The objectives of the study were to determine whether patients receiving lithium reported less pain, and whether this effect was associated with the recommended mood-stabilizing blood concentration of lithium.
Results
Subjects with lithium intake were less likely to report pain (odds ratio [OR] = 0.59, 95% confidence interval [CI], 0.35–0.95; p = 0.036) after controlling for sociodemographic variables, BD type, lifetime history of psychiatric disorders, suicide attempt, personality traits, current depression and anxiety levels, sleep quality, and psychomotor activity. Subjects taking lithium were even less likely to report pain when lithium concentration in blood was ≥0.5 mmol/l (OR = 0.45, 95% CI, 0.24–0.79; p = 0.008).
Conclusions
This is the first naturalistic study to show lithium’s promising effect on pain in subjects suffering from BD after controlling for many confounding variables. This analgesic effect seems independent of BD severity and comorbid conditions. Randomized controlled trials are needed to confirm the analgesic effect of lithium salts and to determine whether lithium decreases pain in other vulnerable populations.
Converging evidence suggests that a subgroup of bipolar disorder (BD) with an early age at onset (AAO) may develop from aberrant neurodevelopment. However, the definition of early AAO remains unprecise. We thus tested which age cut-off for early AAO best corresponds to distinguishable neurodevelopmental pathways.
Methods
We analyzed data from the FondaMental Advanced Center of Expertise-Bipolar Disorder cohort, a naturalistic sample of 4421 patients. First, a supervised learning framework was applied in binary classification experiments using neurodevelopmental history to predict early AAO, defined either with Gaussian mixture models (GMM) clustering or with each of the different cut-offs in the range 14 to 25 years. Second, an unsupervised learning approach was used to find clusters based on neurodevelopmental factors and to examine the overlap between such data-driven groups and definitions of early AAO used for supervised learning.
Results
A young cut-off, i.e. 14 up to 16 years, induced higher separability [mean nested cross-validation test AUROC = 0.7327 (± 0.0169) for ⩽16 years]. Predictive performance deteriorated increasing the cut-off or setting early AAO with GMM. Similarly, defining early AAO below 17 years was associated with a higher degree of overlap with data-driven clusters (Normalized Mutual Information = 0.41 for ⩽17 years) relatively to other definitions.
Conclusions
Early AAO best captures distinctive neurodevelopmental patterns when defined as ⩽17 years. GMM-based definition of early AAO falls short of mapping to highly distinguishable neurodevelopmental pathways. These results should be used to improve patients' stratification in future studies of BD pathophysiology and biomarkers.
An experiment was performed using stereo particle image velocimetry (SPIV) in the Laboratoire de Mécanique des Fluides de Lille boundary layer facility to determine all the derivative moments needed to estimate the average dissipation rate of the turbulence kinetic energy $\epsilon = 2 \nu \langle {\mathsf{s}}_{ij}{\mathsf{s}}_{ij} \rangle$, where ${\mathsf{s}}_{ij}$ is the fluctuating strain rate and $\langle ~\rangle$ denotes ensemble averages. Also measured were all the moments of the full average deformation rate tensor, as well as all of the first, second and third fluctuating velocity moments except those involving pressure. The Reynolds number was $Re_\theta = 7634$ or $Re_\tau = 2598$. The present paper gives the measured average dissipation, $\epsilon$ and the derivative moments comprising it. The results are compared with the earlier measurements of Balint, Wallace & Vukolavcevic (J. Fluid Mech., vol. 228, 1991, pp. 53–86) and Honkan & Andreopoulos (J. Fluid Mech., vol. 350, 1997, pp. 29–96) at lower Reynolds numbers and to new results from a plane channel flow DNS at comparable Reynolds number. Of special interest is the prediction by George & Castillo (Appl. Mech. Rev., vol. 50, 1997, pp. 689–729) and Wosnik, Castillo & George (J. Fluid Mech., vol. 421, 2000, pp. 115–145) that $\epsilon ^+ \propto {x_2^+}^{-1}$ for streamwise homogeneous flows and a nearly indistinguishable power law, $\epsilon \propto {x_2^+}^{\gamma -1}$, for boundary layers. In spite of the modest Reynolds number, the predictions seem to be correct. Then the statistical character of the velocity derivatives is examined in detail, and a particular problem is identified with the breakdown of local homogeneity inside $x_2^+ = 100$. A more general alternative for partially homogeneous turbulence flows is offered which is consistent with the observations. With the help of DNS, the spatial characteristics of the dissipation very near the wall are also examined in detail.
This study aims at providing estimates on the transmission risk of SARS-CoV-2 in schools and day-care centres. We calculated secondary attack rates (SARs) using individual-level data from state-wide mandatory notification of index cases in educational institutions, followed by contact tracing and PCR-testing of high-risk contacts. From August to December 2020, every sixth of overall 784 independent index cases was associated with secondary cases in educational institutions. Monitoring of 14 594 institutional high-risk contacts (89% PCR-tested) of 441 index cases during quarantine revealed 196 secondary cases (SAR 1.34%, 0.99–1.78). SARS-CoV-2 infection among high-risk contacts was more likely around teacher-indexes compared to student-/child-indexes (incidence rate ratio (IRR) 3.17, 1.79–5.59), and in day-care centres compared to secondary schools (IRR 3.23, 1.76–5.91), mainly due to clusters around teacher-indexes in day-care containing a higher mean number of secondary cases per index case (142/113 = 1.26) than clusters around student-indexes in schools (82/474 = 0.17). In 2020, SARS-CoV-2 transmission risk in educational settings was low overall, but varied strongly between setting and role of the index case, indicating the chance for targeted intervention. Surveillance of SARS-CoV-2 transmission in educational institutions can powerfully inform public health policy and improve educational justice during the pandemic.
Background: Sink drains can act as breeding grounds for multidrug-resistant (MDR) bacteria, leading to outbreaks. Drains provide a protected humid environment where nutrient-rich substances are available. Recent and growing installation of water and energy conservation devices have led to increased frequency of drain blockage due to biofilm accumulation. Ineffective drainage may lead to backflow and accumulation of water in the sink during use, increasing the risk of contaminated aerosols formation or direct contamination of surrounding material and equipment. Cleaning and disinfection procedures of sink drains need to be improved to prevent amplification and dispersion of MDR bacteria. The objective of this study was to investigate alternatives to reduce the biofilm and risk of contamination through aerosols. Methods: Sink drains from patient rooms were randomly selected in the neonatal intensive care unit of a 450-bed pediatric hospital. We tested 4 approaches: (1) new drain; (2) self-disinfecting heating-vibration drain; (3) chemical disinfection with 20 ppm chlorine for 30 minutes; and (4) thermal disinfection with > 90°C water for 30 minutes. A special device was used during disinfection to increase the disinfectant contact time with the biofilm. Treatments were conducted weekly, with prior sampling of drain water. Other drains were also sampled weekly, including a control drain with no intervention. Bacterial loads were evaluated using flow cytometry and heterotrophic plate counts. The drains were made of stainless steel, a heat-conductive material. Results: Preliminary results show that chlorine disinfection had a small impact (<1 log) on culturable bacteria at 48 hours after disinfection but not after a week or repeated weekly disinfection. Thermal disinfection using boiling water is promising, showing an important decrease of 4 log in culturable cells after 48 hours and a concentration still 100× lower 1 week after the disinfection. Repeated weekly thermal disinfection maintained lower culturable levels in the drain. No culturable cells were detected in water from the self-disinfecting drain 2 months after installation, whereas the new drain became fully colonized to concentrations similar to those of drains prior to interventions during the same period. Conclusions: Thermal disinfection of drains is a promising alternative to chlorine. This solution is interesting because it is nontoxic and easy to perform, requiring a small volume of hot water. The rapid recolonization of the new drain suggests that replacing contaminated drains is not a sustainable solution and would need to be paired with a thermal disinfection program to maintain low culturable cells.
A 70-year-old man was referred because his balance had deteriorated in recent months. While he had only occasionally fallen over the previous 3 years, he now described a strong and consistent tendency to fall backward. He planned to retire as soon as possible partly because of this issue, but also because his productivity at work had decreased. His wife noted that he had been uncharacteristically impatient at home, but denied any memory difficulties.
A 72-year-old woman was seen with her husband at the movement disorder clinic. She was referred by her attending neurologist who has been following her for 9 years for Parkinson’s disease (PD). Her symptoms had begun 10 years ago, with a left arm tremor that progressively worsened to affect the left side of her body and her right arm. The tremor was accompanied by generalized slowness of movement and stiffness. She was put on l-3,4-dihydroxyphenylalanine (L-DOPA) 8 years ago with a good initial response. Doses were progressively increased over the years. When seen at the clinic, she was taking L-DOPA/carbidopa (referred to as L-DOPA) 100/25 mg 1.5 pills every 3 hours from 6:00 a.m. to midnight, a total of 10.5 pills daily. Sometimes, she had to take an extra pill at night because of difficulty turning over in bed. She believed the effect of the antiparkinsonian medication was not lasting more than 2.5 hours and felt uncomfortable, with tremor resurgence, about 30 min before taking the next L-DOPA dose. Approximately 1 hour after L-DOPA intake, she would present fidgetiness and mild abnormal movements that were not bothersome but that were noticed by her husband and children. She had a few accidental falls. She sometimes experienced dizziness upon standing up rapidly. Approximately 1 year ago, she began experiencing visual hallucinations (VHs) that were, at times, frightening and prevented the neurologist from increasing L-DOPA doses. Most of the times, the VHs consisted of bugs, but on a few occasions they encompassed faces of unknown people. She had to be put on quetiapine 25 mg a.m. and 50 mg at bedtime to alleviate these VHs. Her husband was also concerned that she had become more forgetful in the past year. She was more apathetic and was not interested in going out anymore. At times, she was going through episodes of confusion. She was also experiencing episodes of daytime sleepiness and would have to nap for at least 1 hour every afternoon.
This 62-year-old former accountant presented to a neurologist with complaints of a right hand tremor, slowness, and gait difficulties. He was diagnosed with Parkinson’s disease (PD) and received pramipexole up to 1.5 mg tid. On this medication, he reported being well for 2 years. After 3 years of evolution, levodopa/carbidopa was introduced because of a worsening of his parkinsonism. His tremor was initially significantly improved by levodopa, but the effect was lost after less than a year. Higher doses caused episodes of hypotension and also spasms of his neck and toes which were treated with clonazepam. At the fifth year, he developed significant freezing of gait and needed a walker to ambulate safely.
Bashir Bashir, Amos Goldberg, and seventeen contributors have produced a powerful and incisive book that deserves the attention of everyone interested in central European history. Bashir and Goldberg's volume engages readers methodologically as well as intellectually, politically, ethically, and personally. It challenges us to think, write, and do things differently, to take risks, and to welcome the invigorating and disruptive presence of people in every aspect of our work.
The EVOSHEEP project combines archaeozoology, geometric morphometrics and genetics to study archaeological sheep assemblages dating from the sixth to the first millennia BC in eastern Africa, the Levant, the Anatolian South Caucasus, the Iranian Plateau and Mesopotamia. The project aims to understand changes in the physical appearance and phenotypic characteristics of sheep and how these related to the appearance of new breeds and the demand for secondary products to supply the textile industry.
Secondary hyperparathyroidism (SHPT) is a consequence of non-dialysis chronic kidney disease (ND-CKD), causing disturbances in metabolic parameters including increased phosphate and parathyroid hormone (PTH) and reduced calcium serum level, which can cause bone disease, extra-skeletal calcification and increased cardiac disease risk through vascular and visceral calcification. According to Kidney Disease Improving Global Outcomes (KDIGO) guidelines in 2017, treatment with paricalcitol is no longer recommended in early stage CKD due to increased risk of hypercalcemia. Prolonged release calcifediol (PRC) has been developed as a novel treatment for SHPT in ND-CKD. The objective of this study was to compare the efficacy and safety of PRC versus paricalcitol by assessing biomarkers such as PTH, calcium and phosphate.
Methods
To identify relevant randomized control trials (RCTs) to be included in the network meta-analysis (NMA), a systematic literature search was performed in PubMed. All analyses were performed with a frequentist random-effects NMA. Comparisons were made between the overall treatment effects of the two drugs (including all studies, with fixed and titrated dosage regimens), and between low fixed doses (PRC: 30 μg/day, paricalcitol: 1 μg/day) and high fixed doses (PRC: 60 μg/day, paricalcitol: 2 μg/day).
Results
Nine RCTs, comprising a total of 1,426 patients, were included in the analyses. No statistically significant differences in PTH reduction were found. Paricalcitol showed significantly larger increases in calcium when overall effects and high doses were analyzed. No differences in effects on phosphate were observed. Although effect sizes and statistical significance levels vary somewhat across analyses, the general pattern of similar PTH reductions and larger increases in calcium from paricalcitol are observed in all analyses.
Conclusions
The non-inferiority shown by PRC in lowering PTH and the tendency to increase calcium serum levels observed with paricalcitol treatment indicates that PRC might be used as an equally effective but potentially safer alternative to paricalcitol in treating patients with SHPT.
Background: Nosocomial infections cause 4%–56% mortality in newborns. Several epidemiological studies have shown that transmission of opportunistic pathogens from the sink to the patient, including Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Serratia marcescens are associated with nosocomial infections in neonatal intensive care units (NICUs). In this project, we aimed to develop fast, accurate, and high-throughput multilocus sequence typing assays (HiMLST-Illumina) to detect opportunistic pathogens to assess their distribution in the sink environment of NICUs and their transfer to patients. Methods: Genome sequences of P. aeruginosa (n = 45), S. maltophilia (n = 23) and S. marcescens (n = 34) strains were retrieved from public genome databases to build their pangenomes, using the open-source PGAdb-builder server. The core genome was identified for each opportunistic pathogen and was searched for genes displaying the highest polymorphism. The minimal number of loci to include in a HiMLST-Illumina assay was determined by comparing topology of phylogenetic trees of concatenated loci based on genome similarity, computed as the average nucleotide identity (ANI) score. The primers used for HiMLST-Illumina schemes were designed in silico on a conserved domain and were tested on reference strains of each species. Results: Bioinformatics analyses showed that 3–4 loci (<300 base pairs per locus) distinguished strains with the same performances than ANI scores. The assays were tested using opportunistic pathogen isolates and environmental DNA originating from NICU sinks. The HiMLST-Illumina analysis of environmental DNA revealed the presence of at least 1 of the 3 studied opportunistic pathogens in 50% of sampled drains (n = 20). In a previous sampling, P. aeruginosa was isolated on selective culture media before and 48 hours after disinfection of a sink drain with chlorine. S. marcescens was also isolated from another sink 2 weeks after disinfection. Identification of the isolates was confirmed by HiMLST-Illumina analyses and will be typed to compare with clinical isolates. Conclusions: Initial in silico tests predict a high discriminating power of the HiMLST-Illumina method, suggesting that it would be possible to quickly identify strains of interest in a large number of samples. The power of this method is also in the possibility for molecular typing without a need for cultivation. Preliminary results suggest that sinks are readily colonized by opportunistic pathogens. This HiMLST-Illumina scheme will be applied in a 2-year intensive survey of NICUs in 3 hospitals in Montreal to evaluate the performance of new sink designs in limiting bioaerosol production and transmission of opportunistic pathogens to patients.
Free-living amoeba of the genus Acanthamoeba are ubiquitous protozoa involved in opportunistic and non-opportunistic infection in humans, such as granulomatous amoebic encephalitis and amoebic keratitis. Both infections have challenging characteristics such as the formation of the resistant cysts in infected tissues, hampering the treatment and most usual diagnosis depending on time-consuming and/or low sensitivity techniques. The use of monoclonal antibodies presents itself as an opportunity for the development of more effective alternative diagnostic methods, as well as an important and useful tool in the search for new therapeutic targets. This study investigated the possibility of using a previously produced monoclonal antibody (mAb3), as a diagnostic tool for the detection of Acanthamoeba trophozoites by direct and indirect flow cytometry and immunofluorescence. Immunoprecipitation assay and mass spectrometry allowed the isolation of the antibody's target and suggested it is a transporter part of the CPA (cation: proton antiporter) superfamily. In vitro tests indicate an important role of this target in Acanthamoeba's encystment physiology. Our results support the importance of studying the role of CPA2 transporters in the context of acanthamoebiasis, as this may be a way to identify new therapeutic candidates.
In this study, we aimed to capture perspectives of healthcare workers (HCWs) on coronavirus disease 2019 (COVID-19) and infection prevention and control (IPAC) measures implemented during the early phase of the COVID-19 pandemic.
Design:
A cross-sectional survey of HCWs.
Participants:
HCWs from the Hospital for Sick Children, Toronto, Canada.
Intervention:
A self-administered survey was distributed to HCWs. We analyzed factors influencing HCW knowledge and self-reported use of personal protective equipment (PPE), concerns about contracting COVID-19 and acceptance of the recommended IPAC precautions for COVID-19.
Results:
In total, 175 HCWs completed the survey between March 6 and March 10: 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (8%), and 14 other employees (8%). Most of the respondents were from the emergency department (n = 58, 33%) and the intensive care unit (n = 58, 33%). Only 86 respondents (50%) identified the correct donning order; only 60 (35%) identified the correct doffing order; but the majority (n = 113, 70%) indicated the need to wash their hands immediately prior to removal of their mask and eye protection. Also, 91 (54%) respondents felt comfortable with recommendations for droplet and/or contact precautions for routine care of patients with COVID-19. HCW occupation and concerns about contracting COVID-19 outside work were associated with nonacceptance of the recommendations (P = .016 and P = .036 respectively).
Conclusion:
As part of their pandemic response plans, healthcare institutions should have ongoing training for HCWs that focus on appropriate PPE doffing and discussions around modes of transmission of COVID-19.