Search

The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with COVID-19 ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings.To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS.We conducted a qualitative study using semi-structured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews.ICU clinicians reported that during the COVID-19 pandemic proning is viewed as standard early therapy for COVID-19 ARDS, rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk high-benefit intervention. Within ICUs, adequate numbers of trained staff, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure-injuries), facilitated greater proning use. Hospitals level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care.The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support, and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.

ImportanceEarly observations suggested that COVID-19 pneumonia had a higher mortality rate than other causes of pneumonia.ObjectiveTo compare outcomes between mechanically ventilated patients with pneumonia due to COVID-19 (March 2020 to June 2021) and other etiologies (July 2016 to December 2019).Design, Setting, and ParticipantsThis retrospective cohort study was conducted at the Johns Hopkins Healthcare System among adult patients (aged ≥18 years) with pneumonia who required mechanical ventilation in the first 2 weeks of hospitalization. Clinical, laboratory, and mechanical ventilation data were extracted from admission to hospital discharge or death.ExposuresPneumonia due to COVID-19.Main Outcomes and MeasuresThe primary outcome was 90-day in-hospital mortality. Secondary outcomes were time to liberation from mechanical ventilation, hospital length of stay, static respiratory system compliance, and ventilatory ratio. Unadjusted and multivariable-adjusted logistic regression, proportional hazards regression, and doubly robust regression were used in propensity score–matched sets to compare clinical outcomes.ResultsOverall, 719 patients (mean [SD] age, 61.8 [15.3] years; 442 [61.5%] were male; 460 [64.0%] belonged to a minoritized racial group and 253 [35.2%] were White) with severe COVID-19 pneumonia and 1127 patients (mean [SD] age, 60.9 [15.8] years; 586 [52.0%] were male; 459 [40.7%] belonged to a minoritized racial group and 655 [58.1%] were White) with severe non–COVID-19 pneumonia. In unadjusted analyses, patients with COVID-19 pneumonia had higher 90-day mortality (odds ratio, 1.21, 95% CI 1.04-1.41), longer time on mechanical ventilation (subdistribution hazard ratio 0.72, 95% CI 0.63-0.81), and lower compliance (32.0 vs 28.4 mL/kg PBW/cm H2O; P P = .85), had similar respiratory system compliance (mean difference, 1.82 mL/cm H2O; 95% CI, −1.53 to 5.17 mL/cm H2O; P = .28) and ventilatory ratio (mean difference, −0.05; 95% CI, −0.22 to 0.11; P = .52), but had lower rates of liberation from mechanical ventilation (subdistribution hazard ratio, 0.81; 95% CI, 0.65 to 1.00) when compared with those with non–COVID-19 pneumonia. Patients with COVID-19 pneumonia had somewhat lower rates of being discharged from the hospital alive at 90 days (subdistribution hazard ratio, 0.83; 95% CI, 0.68 to 1.01) than those with non–COVID-19 pneumonia; however, this was not statistically significant.Conclusions and RelevanceIn this study, mechanically ventilated patients with severe COVID-19 pneumonia had similar mortality rates as patients with other causes of severe pneumonia but longer times to liberation from mechanical ventilation. Mechanical ventilation use in COVID-19 pneumonia should follow the same evidence-based guidelines as for any pneumonia.

Partner notification is a widely accepted method whose intent is to limit onwards HIV transmission. With acceleration in the use of new technologies such as text-messaging, e-mail and social network sites, there has been growing interest in utilizing these techniques for “next-generation” HIV partner services (PS). We conducted a systematic review to assess the utilization and effectiveness of these technologies in HIV PS. Our literature search resulted in 1,343 citations, and 8 met our inclusion criteria. We found efforts focused in 3 domains: 1) patient-led anonymous referral online (n=3); 2) provider-led efforts to augment traditional partner notification techniques at public health departments (n=4); 3) a hybrid approach utilizing a website for e-notification available to those with confirmed STI through an STI clinic (n=1). For the provider-led efforts a modest increase in HIV case-finding was noted despite a generally lower rate of successful notification in comparison to traditional PS. The public websites had a high total number of e-notifications sent, but less than 10% of cards were sent for HIV. Furthermore, low awareness of these services was found in surveys amongat-risk target populations. When given a choice, the majority of clients chose to send an e-notification via text versus e-mail. Although successful notification may be lower overall, use of next-generation services provides an avenue to contact those that would previously have been untraceable. Additional research is needed to determine to what extent technology enhanced partner services improves identification of newly infected persons as well as initiating new prevention for HIV negative clients within high-risk networks.

Objectives Herpes simplex virus-2 (HSV-2) and syphilis are associated with increased risk of HIV, highlighting the importance of understanding their transmission dynamics. In India, most studies of HSV-2 and syphilis incidence are in high-risk populations and may not accurately reflect infectious activity. In this study, we aim to define HSV-2/syphilis incidence and risk factors in a population sample. Methods We conducted a longitudinal population-based survey in Andhra Pradesh, India, in two rounds: 2004–2005 and 2010–2011. Sociodemographic and behavioural data were collected, and dried blood spots tested for HSV-2 and Treponema pallidum IgG. After calculating sexually transmitted infection (STI) incidence, associated factors were assessed using modified Poisson regression and within-couple transmission rates modelled using seroconcordance/discordance data. Results 12 617 adults participated at baseline with 8494 at follow-up. Incidence of HSV-2 and syphilis per 1000 person-years was 25.6 (95% CI 24.1 to 27.2) and 3.00 (95% CI 2.52 to 3.54). Incidence of HSV-2 was higher in women vs men (31.1 vs 20.2) and in rural vs urban residents (31.1 vs 19.0) (p

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by airflow obstruction from small airway remodeling and alveolar airspace destruction. As a disease primarily related to cigarette smoke and environmental exposure, the role of the respiratory epithelium, as a defensive barrier, is crucial. In COPD, there is a chronic breakdown of epithelial barrier properties including physical, chemical, and immunologic dysfunction. In the airways, this results in a leaky barrier with metaplastic changes leading to mucous hypersecretion, small airway fibrosis, and narrowing. In the alveolar airspaces, emphysema develops and is characterized by a tissue-destructive process. Both airway and airspace changes occur in the setting of chronic inflammation and may involve accelerated cell aging. As we will outline in this chapter, the epithelium is critical in the pathogenesis of COPD and may serve as an important target for future COPD therapy.