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Background Long COVID is a multisystem condition that negatively impacts daily function. Pacing is a self-management strategy to mitigate symptoms. Our aim was to describe experiences of pacing from the perspectives of adults living with Long COVID. Methods We conducted a community-engaged qualitative descriptive study involving one-on-one online interviews with adults living with Long COVID from Canada, Ireland, United Kingdom, and United States to explore experiences of disability. We asked participants about strategies they used to deal with health challenges living with Long COVID. Interviews were audio recorded and transcribed verbatim. We analyzed data using group-based content analytical techniques. Results Among the 40 participants living with Long COVID, the majority were women ( n  = 25; 63%), white ( n  = 29;73%) and heterosexual ( n  = 30;75%). The median age of participants was 39 years (25th, 75th percentile: 32, 49). Most participants ( n  = 37;93%) used pacing to mitigate or prevent symptoms. Participants described experiences of pacing across five main areas: (1) using pacing as a living strategy (pacing to mitigate multidimensional health challenges; applying pacing to many types of activities; process of pacing experienced as a moving target; pacing experienced as a helpful strategy, but not a cure for Long COVID); (2) learning how to pace (acquiring knowledge about pacing; developing strategies and skills to support pacing); (3) encountering challenges with pacing (learning how to pace; experiencing inequitable access to pacing; experiencing stigma and judgement; undergoing psychological and emotional adjustment from beliefs of ‘fighting’ or ‘pushing through’ to balancing rest with activity; making sacrifices; and encountering unexpected obstacles); (4) experiencing consequences of not pacing; and (5) conceptualising and describing pacing using analogies or metaphors. Conclusions Pacing is a challenging and complex strategy used to mitigate symptoms of Long COVID. Healthcare providers should work collaboratively with patients to further refine and implement this strategy, when appropriate.

ABSTRACT BACKGROUND Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined. METHODS A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding. RESULTS Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]). CONCLUSION Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.

Web-based surveys involving self-reported questionnaires are vulnerable to fraudulent responses. Advancements in artificial intelligence and bots have introduced additional challenges to preventing and identifying fraudulent responses to online questionnaires. This study aimed to describe our experiences with fraudulent responses, strategies for preventing and identifying fraudulent responses, lessons learned when conducting a web-based survey with adults living with Long COVID, and recommendations for web-based survey research. The Long COVID and Episodic Disability Study is an international community-engaged study among adults living with Long COVID in Canada, Ireland, the United Kingdom, and the United States. We conducted a longitudinal web-based survey, with online administration of a self-reported questionnaire at 2 timepoints (Time 1 and Time 2), 1 week apart. We recruited through Long COVID community groups using social media, emails, and word of mouth. The survey was disrupted by fraudulent responses, including bots. To defend data integrity, we implemented the following strategies: (1) pausing our initial launch (Wave 1), (2) developing and implementing screening criteria to identify fraudulent responses, and (3) relaunching the web-based survey (Wave 2) with revised recruitment strategies and questionnaire design to prevent and identify fraudulent responses. We received 4663 responses for Time 1 and 1281 responses for Time 2, of which we retained 798 of 4663 (17%) responses and 629 of 1281 (49%) responses. Strategies for preventing fraudulent responses included enabling survey protection features in survey software, shutting down compromised survey links, avoiding recruitment via public social media groups, and removing mention of a financial incentive from recruitment materials. Strategies for identifying fraudulent responses included monitoring response completion times, start and end time stamps, geolocation, and screening for suspicious email address characteristics and duplicates. Our lessons learned fell into the following three areas: (1) survey-design and implementation to prevent and identify fraudulent and bot-generated responses, (2) recruitment strategies to mitigate the risk of disruption by bots, and (3) responding to disruptions caused by fraudulent and bot responses. We recommend the following tactics to prevent and mitigate the risks of fraudulent and bot responses when administering online web-based questionnaires: (1) review current literature and connect with researchers and Research Ethics Boards about strategies before launching, (2) invest in survey software with rigorous information security technology, (3) use bot-detection features available in survey software before launching, (4) design questionnaire items to identify bots and fraudulent actors, (5) tailor criteria for identifying fraudulent and bot responses to the characteristics of the target population, (6) avoid recruitment in public social media groups, (7) engage community leaders in tailored and targeted recruitment, (8) avoid advertising incentives, (9) shut down compromised links rapidly, (10) communicate with the Research Ethics Board about disruptions, and (11) combine automated and manual methods to identify potentially fraudulent responses on time.

The author explored the self-efficacy in students with low American College Testing (ACT) scores in an experiential learning environment in a private four-year institution of higher education. Prior to this study it was unknown if students with low ACT scores prior to entering higher education reported a change in personal self-efficacy after being educated in an experiential learning environment. The primary research question was: How do students with low ACT scores describe self-efficacy in an experiential learning environment in higher education? The research methodology is basic qualitative, and the researcher used semi-structured interviews with follow-up questions to facilitate the exploratory nature of the study. The theoretical framework was experiential learning theory and self-efficacy theory. The author used a non-probability sampling strategy with a purposive sampling design and frame of a private four-year residential higher education institution. Qualified participants were students with an ACT composite score of 20 or less, a confirmed completion of an experiential level course, age 18 or older by the interview, and confirmed noncontact with the researcher prior to the study. The sample included a cross-section of gender, ethnicity, age, major, and background. The author discovered that low ACT-scoring students are able to excel not only academically, but also by increasing self-confidence, through experiential learning in higher education. However, the researcher found a notable issue in a definitive understanding of what constitutes experiential learning exercises by faculty, administration, and students.

Over the last decade, the U.S. Armed Forces has been engaged in two major conflicts within the Middle East: Iraq and Afghanistan. Since that time, the saturation of women embedded within units in which males are the majority, has gradually increased to over 15% of the U.S. Armed Forces (Blank, 2008). Because the ratio of men-to-women is higher, the likelihood increases that women may experience some form of gender discrimination (i.e., lower rank, refusal of command slots, non-combat units) throughout their military career (Donovan & Drasgow, 1999). The aim of this qualitative research is to gain a deeper understanding of gender discrimination as experienced by women service members and veterans and how they coped and understood their experiences. The conversations with military women were conducted through semi-structured interviews and analyzed via an interpretative phenomenological analysis (IPA). I hope the findings of the proposed qualitative research study contribute to enhancing the working knowledge of mental health professionals alike, through a multicultural awareness of the lived-experience of military women.

Key Points Clostridium difficile infection (CDI) is a continually evolving global health-care problem Community-onset CDI is increasing and multiple potential reservoirs of infection exist including environmental sources, animals, asymptomatic patients and symptomatic patients Highly discriminatory typing techniques such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis offer the potential for illuminating previously under-recognized routes of C. difficile transmission The optimal approach to sampling and testing for CDI remains a contentious issue Multi-step algorithms are recommended to improve diagnostic sensitivity and specificity Clostridium difficile infection (CDI) is a global health-care problem and represents an important infection in both health-care facilities and the wider community. Here, the authors describe advances in understanding of CDI epidemiology, transmission and diagnosis, which are all key factors in the management of CDI. Clostridium difficile infection (CDI) continues to affect patients in hospitals and communities worldwide. The spectrum of clinical disease ranges from mild diarrhoea to toxic megacolon, colonic perforation and death. However, this bacterium might also be carried asymptomatically in the gut, potentially leading to 'silent' onward transmission. Modern technologies, such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis, are helping to track C. difficile transmission across health-care facilities, countries and continents, offering the potential to illuminate previously under-recognized sources of infection. These typing strategies have also demonstrated heterogeneity in terms of CDI incidence and strain types reflecting different stages of epidemic spread. However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. Diagnostic strategies for C. difficile are complicated both by the wide range of bacterial targets and tests available and the need to differentiate between toxin-producing and non-toxigenic strains. Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.

Sleep is an essential state of decreased activity and alertness but molecular factors regulating sleep duration remain unknown. Through genome-wide association analysis in 446,118 adults of European ancestry from the UK Biobank, we identify 78 loci for self-reported habitual sleep duration ( p  < 5 × 10 −8 ; 43 loci at p  < 6 × 10 −9 ). Replication is observed for PAX8 , VRK2 , and FBXL12/UBL5/PIN1 loci in the CHARGE study ( n  = 47,180; p  < 6.3 × 10 −4 ), and 55 signals show sign-concordant effects. The 78 loci further associate with accelerometer-derived sleep duration, daytime inactivity, sleep efficiency and number of sleep bouts in secondary analysis ( n  = 85,499). Loci are enriched for pathways including striatum and subpallium development, mechanosensory response, dopamine binding, synaptic neurotransmission and plasticity, among others. Genetic correlation indicates shared links with anthropometric, cognitive, metabolic, and psychiatric traits and two-sample Mendelian randomization highlights a bidirectional causal link with schizophrenia. This work provides insights into the genetic basis for inter-individual variation in sleep duration implicating multiple biological pathways. Sleep is essential for homeostasis and insufficient or excessive sleep are associated with adverse outcomes. Here, the authors perform GWAS for self-reported habitual sleep duration in adults, supported by accelerometer-derived measures, and identify genetic correlation with psychiatric and metabolic traits

Mucosal infections pose a significant global health burden. Antigen-specific tissue-resident T cells are critical to maintaining barrier immunity. Previous studies in the context of systemic infection suggest that memory CD8+ T cells may also provide innate-like protection against antigenically unrelated pathogens independent of T cell receptor engagement. Whether bystander T cell activation is also an important defense mechanism in the mucosa is poorly understood. Here, we investigated whether innate-like memory CD8+ T cells could protect against a model mucosal virus infection, herpes simplex virus 2 (HSV-2). We found that immunization with an irrelevant antigen delayed disease progression from lethal HSV-2 challenge, suggesting that memory CD8+ T cells may mediate protection despite the lack of antigen specificity. Upon HSV-2 infection, we observed an early infiltration, rather than substantial local proliferation, of antigen-nonspecific CD8+ T cells, which became bystander-activated only within the infected mucosal tissue. Critically, we show that bystander-activated CD8+ T cells are sufficient to reduce early viral burden after HSV-2 infection. Finally, local cytokine cues within the tissue microenvironment after infection were sufficient for bystander activation of mucosal tissue memory CD8+ T cells from mice and humans. Altogether, our findings suggest that local bystander activation of CD8+ memory T cells contributes a fast and effective innate-like response to infection in mucosal tissue.

Infection with West Nile virus (WNV) leads to a range of disease outcomes, including chronic infection, though lack of a robust mouse model of chronic WNV infection has precluded identification of the immune events contributing to persistent infection. Using the Collaborative Cross, a population of recombinant inbred mouse strains with high levels of standing genetic variation, we have identified a mouse model of persistent WNV disease, with persistence of viral loads within the brain. Compared to lines exhibiting no disease or marked disease, the F1 cross CC(032x013)F1 displays a strong immunoregulatory signature upon infection that correlates with restraint of the WNV-directed cytolytic response. We hypothesize that this regulatory T cell response sufficiently restrains the immune response such that a chronic infection can be maintained in the CNS. Use of this new mouse model of chronic neuroinvasive virus will be critical in developing improved strategies to prevent prolonged disease in humans.

Cardiovascular risk is increased in transgender persons using gender-affirming hormone therapy. To gain insight into the mechanism by which sex hormones affect cardiovascular risk in transgender persons, we investigated the effect of hormone therapy on markers of inflammation and hemostasis. In this exploratory study, 48 trans women using estradiol patches plus cyproterone acetate (CPA) and 47 trans men using testosterone gel were included. They were between 18 and 50 years old and did not have a history of cardiovascular events. Measurements were performed before and after 3 and 12 months of hormone therapy. After 12 months, in trans women, systemic and endothelial inflammatory markers decreased (hs-CRP -66%, (95% CI -76; -53), VCAM-1-12%, (95% CI -16; -8)), while platelet activation markers increased (PF-4 +17%, (95% CI 4; 32), β-thromboglobulin +13%, (95% CI 2; 24)). The coagulation marker fibrinogen increased transiently, after 3 months (+15%, (95% CI 1; 32)). In trans men, hs-CRP increased (+71%, (95% CI 19; 145)); platelet activation and coagulation markers were not altered. In both trans women and trans men, leptin and adiponectin changed towards reference values of the experienced gender. Platelet activation and coagulation marker concentrations increased in trans women using transdermal estradiol plus CPA, but not in trans men using testosterone. Also, concentrations of inflammatory markers decreased in trans women, while hs-CRP increased in trans men. Our results indicate that hormone therapy may affect hemostasis in transgender persons, which could be an underlying mechanism explaining the increased cardiovascular risk in this population.