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There is increasing awareness that many long-term care (LTC) residents may have experienced trauma or post-traumatic stress disorder (PTSD) in their lifetimes, conditions that can be comorbid with dementia and/or complex mental health conditions. In Canada, health care aides provide the vast majority of direct care to such residents. This qualitative study explored their experiences working with residents whose responsive behaviors may indicate past trauma or PTSD. In Fall 2024, we conducted open-ended interviews with 24 care aides from 6 urban LTC homes in Alberta, Canada. Initial interview topics built on insights from 13 separate interviews conducted in 2023. Questions were iterated throughout data collection and the data analyzed using Braun and Clarke's reflexive thematic analysis approach. Our participants broadly reflected the demographic make-up of Alberta's care aide workforce: 91.7% female, 79.2% from racialized groups and 70.8% speaking English as an additional language. We identified 3 overarching themes in their experiences: (1) care aides regularly suspected some responsive behaviors to be trauma-related but seldom named these as such; (2) their strategies for managing these behaviors and providing personalized care involved adapting existing skills and innovating new ones; and (3) resident care connected to possible past trauma was complex and compounded current workplace challenges and struggles. Two improvements could help care aides working with residents with suspected trauma backgrounds: greater understanding of trauma and knowledge of trauma terminology, and use of a trauma-informed care framework. Such changes would likely improve resident quality of life by helping care aides better differentiate responsive behaviors, deliver targeted and individualized care, and avoid resident retraumatization. Implementation of trauma-informed care, however, needs to build on existing care aide expertise to facilitate uptake and ensure sustainability.

Precise temporal control of protein abundance is essential for dissecting dynamic cellular processes. While degron-based systems enable rapid protein depletion in eukaryotic cells, comparable tools are lacking for bacterial effectors delivered into host cells during infection. Here, we establish AIDE (Auxin-Inducible Degradation of Effectors), a host-directed degradation platform that harnesses the ubiquitin-proteasome system to selectively eliminate secreted bacterial proteins, including membrane-integrated effectors. By integrating a minimal auxin-inducible degron (AID) tag into effector genes, AIDE enables rapid, reversible, and spatially confined degradation while preserving native expression and secretion. We apply AIDE to Chlamydia trachomatis and show, that the membrane-integrated deubiquitinase Cdu1 suppresses autophagy early and later promotes developmental transitions, whereas the integral membrane fusogen IncA remains continuously required to maintain homotypic inclusion fusion. This AIDE platform provides minute-scale, spatiotemporal control over bacterial effector activity and offers a broadly applicable framework for dissecting virulence mechanisms and host-pathogen interactions across diverse secretion-dependent pathogens.

Auditory event-related potential (ERP) brain-computer interfaces (BCIs) offer communication support for individuals with amyotrophic lateral sclerosis (ALS) who eventually progress to completely locked-in states. However, individual-specific BCI pipeline optimization is technically demanding and time-consuming, leaving substantial room for performance improvement in practice. A central challenge is increasing selection speed while maintaining reliable classification accuracy, since slower selections reduce the sense of agency and undermine the motivational and feedback dynamics essential for sustained BCI use. We investigated whether an AI coding assistant could address this challenge for individual patients. A three-class auditory ERP-BCI was optimized for a single ALS patient using Claude Code (Anthropic, Inc.), which iteratively generated and evaluated 23 optimization scripts over approximately 24 hours with minimal human-in-the-loop oversight. The resulting AI-Designed ERP classifier (AIDE) was evaluated on 189 EEG trials spanning 3.5 years using five cross-validation strategies. For the baseline models, halving the stimulus repetitions to shorten selection time degraded classification accuracy; AIDE prevented this degradation, achieving 85.03% mean cross-validation accuracy (selection time 17 s; ITR 2.92 bits/min). This doubled the information transfer rate from 1.43 to 2.92 bits/min. Accuracy exceeded 84% across four of five cross-validation strategies. Feature space visualization revealed that the AI autonomously selected and combined EEG features established in prior studies into an effective discriminative architecture, without domain-specific algorithmic guidance from the human researcher. In addition, online test confirmed 66.7% accuracy for AIDE versus 50.0% for the baseline model. These findings provide proof of concept that single-subject BCI performance can be improved via a single prompt, offering an efficient pathway to individualized optimization in clinical and research settings.

Caregivers play a critical role in patient care across the pre- and post-transplant periods. However, the demands of caregiving can negatively impact caregivers' own physical and psychosocial well-being. The Transplant Wellness Program (TWP) is a behavior change intervention that provides exercise support for pre- and post-kidney, pre- and post-liver, and post-lung transplant patients but has not yet included transplant caregivers. Thus, the purpose of this study was to explore the experiences and needs of organ transplant caregivers to inform the development of caregiver-specific support resources for the TWP. Semi-structured interviews with family caregivers of patients receiving kidney or liver transplant in the TWP were conducted and recorded via Zoom. Interview recordings were transcribed verbatim and analyzed using conventional content analysis. Eight interviews were conducted, with caregivers in both the pre- (n = 4) and post-transplant (n = 4) periods. Four categories resulted from the data: caregiver strain, life changes, individual wellness needs, and caregiving needs. Nine sub-categories further described caregivers' experiences and opportunities for wellness support. The caregiving experience was characterized by feelings of overwhelm, stress, and uncertainty. This study highlights the need for comprehensive services such as exercise classes, peer support programs, and tangible aide to support transplant caregivers' well-being. Three caregiver resources were built out of this study and integrated into the TWP.

In May 2022, mpox (formerly monkeypox) spread to non-endemic countries rapidly. Human judgment is a forecasting approach that has been sparsely evaluated during the beginning of an outbreak. We collected-between May 19, 2022 and July 31, 2022-1275 forecasts from 442 individuals of six questions about the mpox outbreak where ground truth data are now available. Individual human judgment forecasts and an equally weighted ensemble were evaluated, as well as compared to a random walk, autoregressive, and doubling time model. We found (1) individual human judgment forecasts underestimated outbreak size, (2) the ensemble forecast median moved closer to the ground truth over time but uncertainty around the median did not appreciably decrease, and (3) compared to computational models, for 2-8 week ahead forecasts, the human judgment ensemble outperformed all three models when using median absolute error and weighted interval score; for one week ahead forecasts a random walk outperformed human judgment. We propose two possible explanations: at the time a forecast was submitted, the mode was correlated with the most recent (and smaller) observation that would eventually determine ground truth. Several forecasts were solicited on a logarithmic scale which may have caused humans to generate forecasts with unintended, large uncertainty intervals. To aide in outbreak preparedness, platforms that solicit human judgment forecasts may wish to assess whether specifying a forecast on logarithmic scale matches an individual's intended forecast, support human judgment by finding cues that are typically used to build forecasts, and, to improve performance, tailor their platform to allow forecasters to assign zero probability to events.

Granulocytic anaplasmosis is a zoonotic disease that affects various domestic mammals (dogs, horses, and, more rarely, cats). In ruminants, it is better known as tick-borne fever (TBF) and is responsible for significant economic losses on European livestock farms, mainly due to a drop in milk production, abortions, and immunosuppression, which can lead to secondary infections. The disease is caused by the strictly intracellular bacterium Anaplasma phagocytophilum, whose biological vectors are ticks of the genus Ixodes. Other blood-feeding arthropods may be involved in transmitting this bacterium, notably Stomoxys calcitrans, a major ectoparasite of livestock that is implicated in transmitting other pathogens, including bacteria of the genus Anaplasma. This study aimed to evaluate the potential of S. calcitrans to act as a mechanical vector of A. phagocytophilum under laboratory conditions. Two experimental models were employed: one mimicking immediate transmission, and the other delayed transmission. In both models, A. phagocytophilum DNA and RNA were detected in S. calcitrans for the first time, but no traces of the bacterium's DNA or RNA were found in the glass feeder's blood. Further research is needed to confirm these findings through field studies investigating the presence of the bacterium in flies under natural conditions. This study also describes two original infection models of stable flies designed to reproduce their ex vivo blood-feeding, promoting alternative experimental approaches in accordance with animal welfare regulations and 4R principles. Stomoxys calcitrans comme vecteur mécanique potentiel d'Anaplasma phagocytophilum : évaluation à l'aide de modèles d'alimentation ex vivo originaux. L’anaplasmose granulocytaire est une maladie zoonotique pouvant toucher divers mammifères domestiques (chiens, chevaux et plus rarement le chat). Chez les ruminants, cette maladie plus connue sous le nom de Tick-Borne Fever (TBF), est responsable d’importantes pertes économiques dans les élevages européens en raison notamment de chutes de production laitière, d’avortements et d’immunodépressions pouvant conduire à des infections secondaires. Cette maladie est causée par Anaplasma phagocytophilum, bactérie intracellulaire stricte dont les vecteurs biologiques sont les tiques du genre Ixodes. D’autres arthropodes hématophages pourraient être impliqués dans la transmission de cette bactérie, notamment Stomoxys calcitrans, ectoparasite important des bovins incriminé dans la transmission d’agents pathogènes, dont des bactéries du genre Anaplasma. L’objectif de cette étude a été d’évaluer le rôle de S. calcitrans en tant que vecteur mécanique potentiel d’A. phagocytophilum en conditions de laboratoire. Deux modèles expérimentaux ont été utilisés, l’un mimant une transmission immédiate et l’autre mimant une transmission retardée. Dans ces deux modèles, la présence d’ADN et d’ARN d’A. phagocytophilum a été détectée pour la première fois dans S. calcitrans, cependant aucune trace d’ADN ou d’ARN de la bactérie n’a été détectée dans le sang du receveur. Il serait intéressant de confirmer ces données par des études de terrain en recherchant la présence de la bactérie dans les mouches en conditions naturelles. Cette étude présente également deux modèles originaux d’infection des stomoxes permettant de reproduire leur prise de repas sanguins ex vivo, et promeut ainsi des approches expérimentales alternatives respectueuses de l’éthique animale, conformément à la règle des 4R.

Research has explored health care providers' perceptions of shared medical decision-making, but to our knowledge, no study in France has examined their use of decision aids. The objective of this study was to explore how nephrology professionals use and perceive the tools designed to support patients with chronic kidney disease and their families when choosing a treatment. Semi-structured interviews were conducted with 17 professionals involved in treatment decisions for chronic kidney disease. The data were processed using inductive thematic content analysis. Seven themes emerged from the analyses, highlighting both the wide variety of tools used and the central role played by professional stance in how they are used. The technical sophistication of these tools should not replace interaction between patients and health care professionals. According to the participants, the ideal tool should facilitate learning, empower patients, and strengthen the relationship between health care professionals and patients, or even between health care professionals and family members . The role accorded to family members varied greatly among respondents, with some expressing a degree of ambivalence regarding whether and how they should be involved in using these decision-making support tools. This study documents the existence of a wide variety of tools used by health care professionals. Beyond their informational role, these tools fulfil many other functions. On the basis of these results, a survey of a broad panel of professionals would provide a more detailed picture of practices in France. Des recherches ont exploré la perception des soignants sur la décision médicale partagée mais, à notre connaissance, aucune étude en France ne questionne leur utilisation des outils d’aide à la décision. L’objectif de cette étude était d’explorer l’utilisation et l’avis des professionnels en néphrologie sur les supports autour de l’accompagnement des patients atteints de maladie rénale chronique et de leurs proches au moment du choix de traitement. Des entretiens semi-directifs ont été menés auprès de 17 professionnels impliqués dans le choix du traitement dans la maladie rénale chronique. Les données ont été traitées par analyse thématique de contenu inductive. Sept thèmes ressortent des analyses et soulignent la diversité des supports utilisés, mais également la centralité de la posture professionnelle dans leur usage. La technicité des outils ne devrait pas venir remplacer l’interaction entre les patients et leurs professionnels de santé. Selon les participants, le support idéal doit amener une forme d’apprentissage, d’autonomisation des patients et un renforcement de la relation soignant-soigné, voire proche-soignant. La place accordée aux proches est très variable selon les personnes interrogées, soulignant parfois une forme d’ambivalence vis-à-vis de leur inclusion dans l’usage de ces outils d’aide à la décision. Cette étude fait état de l’existence d’une grande diversité d’outils utilisés par les professionnels. Au-delà de leur rôle informationnel, ces outils remplissent de nombreuses autres fonctions. Sur la base de ces résultats, une enquête auprès d’un large panel de professionnels permettrait d’obtenir une représentation plus fine des pratiques en France.

Chronic bacterial respiratory infections by Staphylococcus aureus are a hallmark of cystic fibrosis (CF) lung disease, affecting up to 80% of all people with CF by their mid-teens. S. aureus is able to survive and persist in the CF lung despite robust neutrophilic inflammation. As neutrophils are the immune system's front line of defense against bacteria, the persistent nature of S. aureus infections in CF indicates both a defect in the ability of neutrophils to kill S. aureus and an enhanced ability of the bacteria to survive. S. aureus persistence in the CF lung is driven by both microbial and host, genetic and microenvironmental, factors. There doesn't seem to be one unifying feature that makes S. aureus more virulent in the CF lung as several factors have been proposed to aide its survival. These include increased resistance to antibiotics, the ability to form small colony variants, biofilm formation, co-infection with Pseudomonas aeruginosa, and several virulence factors such as the accessory gene regulatory system, leukocidins, and staphylococcal protein A. A variety of host factors also affect the ability of neutrophils to kill S. aureus in the CF lung. Defects in the function of the cystic fibrosis transmembrane conductance regulator, the genetic cause of CF, affect phagolysosomal killing and lead to increased formation of neutrophil extracellular traps, which are less effective at killing S. aureus. Additionally, data suggest that factors within the CF lung microenvironment also affect neutrophilic killing of S. aureus. However, more research is needed to clearly identify what these environmental factors may be. This review article summarizes the current knowledge on the clinical relevance of S. aureus lung infections in CF, on microbial and host mechanisms promoting S. aureus survival in the CF lung, and on details of neutrophil-S. aureus interactions in CF. By understanding how S. aureus is able to survive in the CF lung and why neutrophils are unable to kill this bacterium, it could be possible to identify potential therapeutic targets to alleviate the consequences of S. aureus respiratory infection in CF.

Emergency medical services (EMS) are critical for patient outcomes during emergencies. Organised EMS systems that can promptly locate patients, deliver on-scene care, and transport patients to appropriate facilities are lacking in low- and middle-income countries. Through a long-standing partnership with Rwanda's Service d'Aide M&#xe9;dicale d'Urgence (SAMU), we developed and implemented an electronic application to capture prehospital times in Kigali, Rwanda. This study validates the accuracy of electronically captured data and establishes baseline response times for emergencies in Kigali. Prospective data on prehospital transport times in Kigali collected from July 2022 to December 2023 were captured using a novel electronic application custom-built by Rwanda Build program (RWB), a local software accelerator in Kigali. RWB data were compared to SAMU's manually collected data to validate the accuracy of the electronically captured data. Datasets were deterministically linked using patient identifications (ID). Cases with missing patient ID were probabilistically linked using RWB deploy time compared to the paper dataset's leave time. The primary outcome was total prehospital time, from ambulance deployment to healthcare facility arrival. Secondary outcomes included time intervals of deployment to scene, on scene, scene to healthcare facility, and handoff times. Additional analyses compared response times of subgroups captured by RWB, including emergency type, severity, and prehospital delays. After SAMU and RWB data linkage, 6209 patients were included. The primary outcome, total time of ambulance deployment to hospital arrival, took an average of 54.5&#xa0;min (standard deviation (SD)&#x2009;=&#x2009;22.2) with a 0.53-min difference between paper records and the electronically captured dataset. The 30-s difference suggests the newly implemented electronic collection system is consistent with data recorded manually on EMS run reports. Trauma represented the most common emergency (65.2%), with an average prehospital time of 52.2&#xa0;min (SD&#x2009;=&#x2009;21.4). "Severe" emergencies took an average of 20&#xa0;min longer to reach hospitals than "mild" cases (p&#x2009;<&#x2009;0.001). Transit delays and districts with fewer transports were also associated with longer prehospital times. EMS is critical to healthcare systems. This study validated an electronic data-collection system to improve EMS services in Rwanda. This is one of the first studies to document EMS quality benchmarks in a sub-Saharan African country.

Validation of Magnetic Resonance Elastography (MRE) often relies on simple geometric phantoms which lack the complexity and heterogeneity of biological tissues. This limitation creates a methodological gap when assessing reconstruction algorithms intended for heterogeneous clinical environments. The aims were to demonstrate the feasibility of fabricating advanced polyphasic plastisol phantoms using a welding method and to evaluate reconstruction performance for phantoms with increasing geometric complexity specifically at material interfaces. Four plastisol phantoms (32 mm diameter, 17 mm height) were developed: homogeneous, inclusions, sectorial divisions, and a 3 &#xd7; 3 checkerboard grid. Acquisitions were performed at 9.4T using a fast spin-echo sequence with sinusoidal motion-encoding gradients (6 G/cm) and eight temporal phase offsets, an isotropic 0.8 mm resolution, a 64 &#xd7; 64 matrix, and T2 mapping. Shear stiffness (&#x3bc;) and damping ratio (&#x3be;) were reconstructed using Algebraic Inversion of the Differential Equation (AIDE) and Non-Linear Inversion (NLI). Performance was evaluated comparing welded samples to non-welded controls and analyzing property deviations from the homogeneous case. Polyphasic samples demonstrated mechanical properties identical to homogeneous (&#x3bc;=9.9&#xb1;0.5 vs. 10.1&#xb1;0.5kPa), confirming that the thermal process preserves the material's intrinsic properties. The resulting interfaces exhibit full mechanical continuity, acting as a single block. While both algorithms successfully captured structural heterogeneities, increasing geometric complexity induced systematic biases, particularly the underestimation of stiff regions and the overestimation of damping ratios near boundaries. Plastisol thermal fusion assembly enables the fabrication of stable, complex phantoms with precise mechanical control. Although the heterogeneities in this study were primarily 2D due to the ratio between shear wavelength and sample dimensions, the process is inherently compatible with 3D voxel-wise assembly. While formal tensile testing was not performed, basic stress tests confirmed that the interfacial cohesion is largely sufficient for the low-amplitude strains involved in MRE. These phantoms provide a versatile experimental framework for identifying algorithmic limitations at tissue interfaces and benchmarking advanced reconstruction methods in biologically relevant models.

Given the long-term care (LTC) staffing "crisis," it is important to understand factors associated with upward career mobility in residential LTC settings. The study aimed to understand the individual and organizational factors associated with upward career mobility among direct care workers (DCWs) in residential LTC settings. Cross-sectional analysis using data from the 2024 National Dementia Workforce Study, a nationally representative survey of LTC facilities and staff in the United States. US nursing homes and assisted living communities, where registered nurses (RNs), licensed practical nurses (LPNs), and unlicensed DCWs (ie, certified nursing assistants, home health, personal care, and medication aides) were employed. We used a generalized linear mixed model with facility random effects to examine individual (eg, sex, age, foreign born) and organizational (eg, ownership, benefit, staffing) characteristics associated with upward career mobility among unlicensed DCWs. In assisted living communities (n = 396 staff), 9% of staff were LPNs/RNs, of whom 23% had previously worked as unlicensed DCWs. Among current unlicensed DCWs, 33% reported enrollment in a certification, licensure, or health care degree program. In nursing homes (n = 370 staff), 34% were LPNs/RNs, of whom 47% had formerly worked as DCWs. Among current DCWs, one-third reported seeking professional advancement. After adjusting for covariates and facility random effects, DCWs' professional advancement was significantly associated with younger age (adjusted odds ratio [AOR], 0.93; P < .001), being foreign born (AOR, 3.23; P < .001), and working in not-for-profit (AOR, 0.49; P = .013), larger (AOR, 1.01; P = .009), chain-affiliated facilities (AOR, 2.55; P = .007), with a lack of paid time off (AOR, 0.49; P = .007), and higher direct care staffing levels (AOR, 1.25; P = .041). One-third of current LTC DCWs are actively pursuing healthcare credentials, indicating strong potential for workforce advancement from within LTC settings. Additional research is needed to identify the practice and policy interventions that facilitate upward career mobility and address workforce shortages in LTC.

Medical assistance in dying (MAiD) became a legal end-of-life option on December 10, 2015, in Qu&#xe9;bec, and on June 17, 2016, in the rest of Canada. Since its legalization, there has been a steady increase in the number of MAiD requests and provisions. Across permissive jurisdictions, Qu&#xe9;bec now has the highest rate of assisted death. Despite the growing use of MAiD, research examining the factors driving this increase remains limited and fragmented. Existing studies offer partial and sometimes contradictory explanations, with little integration of legal, institutional, societal, and individual dimensions. Further research is needed to better understand the determinants of MAiD requests and practices, particularly in the Canadian and Qu&#xe9;bec contexts. This research aims to understand the factors influencing changes in MAiD requests and administrations in Qu&#xe9;bec by examining laws, practices, societal perspectives, organization of care and services, and individual characteristics of those requesting MAiD, as well as their interrelationships. We present the protocol developed by the Consortium interdisciplinaire de recherche sur l'aide m&#xe9;dicale &#xe0; mourir, an interdisciplinary research consortium, including an international advisory committee, set up for this research. The design of this protocol is multimethods and convergent mixed methods, including (1) an international cross-thematical approach with 4 main research methods (a scoping review, key informant interviews, focus groups with health care professionals, and a population-based survey) chosen to partially answer research questions across the entire study and to compare with other jurisdictions and (2) 11 theme-specific methods (including community forums, media coverage analysis, comparative legal analyses, case studies of triads, individual interviews, and system mapping) to enrich and complement findings from the cross-thematical approach. When this 3-year funded study started in July 2024, several research methods not requiring ethics committee approval (because no human participants were involved) were initiated, including scoping and systematic reviews, media coverage analysis, and comparative legal analyses. By August 2025, interviews with key informants were completed, and analyses took place in September. Concurrently, other subteams started data collection (focus groups December 2025) or are getting ready to seek ethics approval for their protocols and data collection processes involving human participants: case studies of triads, individual interviews, and community forums. Findings from the international cross-thematical approach and theme-specific methods will provide a comprehensive understanding of the factors influencing the use of MAiD in Qu&#xe9;bec. This study has strengths, including the use of a specific theoretical framework, a variety of complementary methods, and an integrated knowledge mobilization strategy. As for its limitations, we foresee challenges with the comparison of jurisdictions in terms of language, culture, and legal systems, as well as access to data about MAiD cases, since reporting systems may differ between jurisdictions. DERR1-10.2196/83549.

Medicare-funded home health (HH) provides short-term nursing, physical therapy, and other services to over 3.5 million older adults each year. Currently, half of HH episodes are "community-entry," meaning the patient was referred without an immediately preceding hospitalization. The 2020 implementation of a new payment system-the Patient-Driven Groupings Model (PDGM)-reduced traditional Medicare reimbursement for community-entry HH (CEHH). We investigated shifts in CEHH care delivery following PDGM implementation. Cross-sectional study of national 2019 and 2021 linked HH claims, assessment, HH agency, and geographic data. Traditional Medicare beneficiaries receiving a CEHH episode in 2019 or 2021 (n = 577,602). HH is provided through clinician visits to the patient's home; therefore, visits are the primary unit of care delivery. We modeled the number of visits overall and by service type (eg, nursing, physical therapy) using national data for CEHH patients pre-PDGM (ie, 2019) and post-PDGM (ie, 2021). Models adjust for relevant patient, HH agency, and geographic characteristics (including monthly county-level COVID-19 infection rates). Following PDGM, there was an 18% decrease in total visits received, with the largest decreases in the number of physical therapy (-13%), occupational therapy (-17%), and aide (-16%) visits. Reductions in visits were greatest at HH agencies with lower Medicare Advantage penetration (and thus, greater exposure to PDGM) and for-profit agencies. Findings raise questions about HH agencies' ongoing ability to meet the needs of patients with complex, overlapping clinical and social needs following PDGM implementation. Ongoing monitoring of how these care delivery changes impact outcomes for CEHH patients is essential to ensure that HH can continue to help high-need older adults safely age in place.

While risk factors for COVID-19 outbreaks in nursing homes were well characterized during the pandemic, the factors influencing outbreak severity in the postpandemic period remain poorly understood. We analyzed COVID-19 outbreaks in Illinois nursing homes from July 1, 2023 to June 30, 2024. A facility's average COVID-19 prevalence was calculated as confirmed resident cases per occupied beds, with outbreak severity classified as mild (>0% to &#x2264;10%), moderate (>10% to &#x2264;20%), or severe (>20%). Multivariate ordinal logistic regression assessed associations among outbreak severity and facility characteristics, staffing measures, and vaccination rates. Among 649 facilities, 32% experienced mild, 36% moderate, and 32% severe outbreaks. Higher odds of severe outbreaks were observed in facilities located in rural counties (odds ratio [OR]: 2.59, P < .001), those with above-median registered nurse turnover (OR: 1.41, P = .04), higher nurse aide hours per resident per day (OR: 1.75, P = .01), and lower resident vaccination rates (OR: 1.60, P = .003). Staffing quality was significantly associated with outbreak severity when staff vaccination rates were low (OR: 2.67, P = .02). These findings emphasize ongoing drivers of COVID-19 outbreak severity in nursing homes and highlight the importance of interventions that target vaccination uptake, staff retention, and infection prevention and control education.