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ObjectivesTo assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19.DesignMulticentre pragmatic randomised clinical trial.Setting15 hospitals in Canada and the United States from May 2020 until May 2021.ParticipantsEligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis.InterventionPatients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position).Main outcome measuresThe primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen.ResultsThe trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care.ConclusionAmong non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.Study registrationClinicalTrials.govNCT04383613.

ObjectivesTo assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients hospitalized with COVID-19DesignPragmatic randomized clinical trial of prone positioning of patients hospitalized with COVID-19 across 15 hospitals in Canada and the United States from May 2020 until May 2021.SettingsPatients were eligible is they had a laboratory-confirmed or a clinically highly suspected diagnosis of COVID-19, required supplemental oxygen (up to 50% fraction of inspired oxygen [FiO2]), and were able to independently prone with verbal instruction. (NCT04383613).Main Outcome MeasuresThe primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as requiring at least 60% FiO2 for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to FiO2 (S/F ratio).ResultsA total of 248 patients were included. The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomization was 1 day, the median age of patients was 56 years (interquartile range [IQR] 45,65), 36% were female, and 90% of patients were receiving oxygen via nasal prongs at the time of randomization. The median time spent prone in the first 72 hours was 6 hours total (IQR 1.5,12.8) for the prone arm compared to 0 hours (0,2) in the control arm. The risk of the primary outcome was similar between the prone group (18 [14.3%] events) and the standard care group (17 [13.9%] events), odds ratio 0.92 (95% CI 0.44 to 1.92). The change in the S/F ratio after 72 hours was similar for patients randomized to prone compared to standard of care.ConclusionAmong hypoxic but not critically patients with COVID-19 in hospital, a multifaceted intervention to increase prone positioning did not improve outcomes. Adherence to prone positioning was poor, despite multiple efforts. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.What is already known on this topicProne positioning is considered standard of care for mechanically ventilated patients who have severe acute respiratory distress syndrome. Recent data suggest prone positioning is beneficial for patients with COVID-19 who are requiring high flow oxygen. It is unknown of prone positioning is beneficial for patients not on high flow oxygen.What this study addsProne positioning is generally not well tolerated and innovative approaches are needed to improve adherence. Clinical and physiologic outcomes were not improved with prone positioning among hypoxic but not critically ill patients hospitalized with COVID-19.

Background. Despite the low and decreasing prevalence of tuberculosis (TB) in the United States, there remain certain high-risk groups with high incidence rates. The targeted screening and treatment of latent TB infection (LTBI) among these high-risk groups are needed to achieve TB elimination; however, by most accounts, LTBI treatment completion rates remain low. Methods. We retrospectively studied all patients accepting treatment for LTBI at the Fulton County Health Department TB clinic over 2 years. Medical chart abstraction was performed to collect information on sociodemographics, medical, and LTBI treatment history. Treatment completion was defined as finishing ≥88% of the prescribed regimen. Logistic regression analysis was performed to identify predictors of treatment completion. Results. Among 547 adults offered LTBI treatment, 424 (78%) accepted treatment and 298 of 424 (70%) completed treatment. The median age was 42 years, most patients were black (77%), and close to one third did not have stable housing. No significant difference in completion rates was found between the 3 regimens of 9 months isoniazid (65%), 4 months rifampin (71%), and 3 months of weekly rifapentine and isoniazid (79%). In multivariate analysis, having stable housing increased the odds of finishing treatment, whereas tobacco use and an adverse event decreased the odds. Conclusion. Utilizing comprehensive case management, we demonstrated high rates of LTBI treatment completion, including among those receiving a 3-month regimen. Completion rates were higher among persons with stable housing, and this finding highlights the need to develop strategies that will improve adherence among homeless persons.

Background: Technical improvements of inferior vena cava filters (IVCF) have led to a markedly increased use of this modality over the last two decades.While these devices may provide significant short-term protection from pulmonary embolism (PE) in patients for whom anticoagulation is contraindicated or ineffective, the risk-benefit ratio is unknown in a variety of indications not recommended by current guidelines. Serious long-term complications include an increased risk of deep vein thrombosis (DVT), IVCF malposition, fracture, migration and embolism. Methods: In this paper, we describe a case demonstrating multiple complications of IVCF placement. In addition, we attempted to review all available literature to identify data on the risk-benefit ratio of conventional versus liberal use of IVCF. Results: (i) Case Description: A 38-year-old woman with a history of recurrent VTE presented with severe abdominal pain. Her initial left popliteal vein thrombosis and PE had occurred in 2000 after a few months on oral contraceptives (OC). She was treated with warfarin for a year. A recurrent unprovoked episode of left iliofemoral DVT was diagnosed four years later, at which time she was off OC. Indefinite warfarin treatment was started, given her young age and recurrent VTE. She became pregnant two years later and was switched to enoxaparin until two months after delivery. However, she did not restart warfarin and experienced no complications until three years later, when a prophylactic temporary IVC filter was placed prior to partial hysterectomy for menorrhagia. The surgery was performed without complications, but six months later she developed a recurrent untriggered right femoral DVT and began to experience sharp pains and an abrupt change in her bowel habits. At presentation, a CT scan (below) determined that her IVC filter had migrated out of position with its wires protruding into her aorta and spine and perforating her duodenum. Major abdominal and vascular surgery was performed to remove the filter. A thrombophilia panel returned with normal results. The patient was started on rivaroxaban indefinitely with no further issues. (ii) Literature review: A PubMed search of all English language clinical trials with the key word "IVC filter" resulted in a total of 46 papers, 6 of which did not focus on outcomes of cava filters leaving 40 papers for review. These 40 papers were individually studied. We could identify no papers directly comparing standard versus liberal indications. Complication rates varied widely among the reviewed case series. Conclusion: While temporary IVC filters are an effective method of preventing PE when anticoagulation therapy is contraindicated or ineffective, there is no data in current medical literature comparing outcomes of standard versus liberal indications of IVCF use. Such studies are urgently needed to support or refute current medical practices in the United States and other developed countries. Furthermore, retrievable filters should be retrieved as soon as clinically feasible to avoid long-term complications, such as illustrated by our case. Axial contrast-enhanced CT showing migrated anterior arm of IVC filter protruding into the duodenum. Sagittal CT image showing posterior arm extending to the adjacent psoas muscle. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures No relevant conflicts of interest to declare.