Human Immunodeficiency Virus Status, Tenofovir Exposure, and the Risk of Poor Coronavirus Disease 19 Outcomes: Real-World Analysis From 6 United States Cohorts Before Vaccine Rollout

BACKGROUND: People with human immunodeficiency virus (HIV) (PWH) may be at increased risk for severe coronavirus disease 2019 (COVID-19) outcomes. We examined HIV status and COVID-19 severity, and whether tenofovir, used by PWH for HIV treatment and people without HIV (PWoH) for HIV prevention, was associated with protection. METHODS: Within 6 cohorts of PWH and PWoH in the United States, we compared the 90-day risk of any hospitalization, COVID-19 hospitalization, and mechanical ventilation or death by HIV status and by prior exposure to tenofovir, among those with severe acute respiratory syndrome coronavirus 2 infection between 1 March and 30 November 2020. Adjusted risk ratios (aRRs) were estimated by targeted maximum likelihood estimation, with adjustment for demographics, cohort, smoking, body mass index, Charlson comorbidity index, calendar period of first infection, and CD4 cell counts and HIV RNA levels (in PWH only). RESULTS: Among PWH (n = 1785), 15% were hospitalized for COVID-19 and 5% received mechanical ventilation or died, compared with 6% and 2%, respectively, for PWoH (n = 189 351). Outcome prevalence was lower for PWH and PWoH with prior tenofovir use. In adjusted analyses, PWH were at increased risk compared with PWoH for any hospitalization (aRR, 1.31 [95% confidence interval, 1.20-1.44]), COVID-19 hospitalizations (1.29 [1.15-1.45]), and mechanical ventilation or death (1.51 [1.19-1.92]). Prior tenofovir use was associated with reduced hospitalizations among PWH (aRR, 0.85 [95% confidence interval, .73-.99]) and PWoH (0.71 [.62-.81]). CONCLUSIONS: Before COVID-19 vaccine availability, PWH were at greater risk for severe outcomes than PWoH. Tenofovir was associated with a significant reduction in clinical events for both PWH and PWoH

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

No abstract available

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

The Economic Impact of Sea Level Rise on Port of Savannah's Garden City Terminal & City of Darien

The Garden City Terminal at the Port of Savannah is one of the largest and fastest growing container ports in the country, making it an economic engine locally and nationally. The Terminal is an integral economic component on several scales: locally, it supports many households in and around Chatham County; regionally, the port supports wider distribution networks and regional agriculture and manufacturing; and nationally, the port serves as a gateway to access markets across the globe. Therefore rising sea levels projected over the next 100 years make port disruptions an important economic threat on a variety of scales. This report describes the economic threat that sea level rise poses to port and port-related operations through permanent inundation, worsening storm surge, and other environmental changes at local, regional and statewide scales. The team drew on research by Keating and Habeeb (2012) and created new tools for assessing the potential impacts on jobs, property, transportation links, and other businesses. The intent is to provide actionable projections for business leaders, policy makers, and individuals in areas that may eventually have to respond to the effects of sea level rise

SAFER: Standardizing Admissions for Elderly Residents

The goal of this project is to improve health outcomes for elderly patients transferred between care facilities. Research shows that care transitions between nursing facilities (NF), emergency medical services (EMS) and critical access hospitals (CAH) carry significant risk for elderly patients stemming from such factors as missing or inaccurate information, infections, poor communication between staff and delayed treatment. This project will provide training and implement processes designed to improve the safety of care transitions and result in better patient outcomes. The demonstration project, sponsored by the Maine Critical Access Hospital Patient Safety Collaborative, will involve 14 small, rural hospitals, EMS systems, and nursing facilities that have committed to implement three specific interventions designed to improve communications, information flow, and patient safety in the transition of care for elderly NF residents to the hospital Emergency Department (ED). The interventions will include process mapping and appreciative inquiry of current handoffs, training in communication skills, and the development and implementation of transfer tools such as checklists and universal forms. In addition, the project will assist stakeholders in aligning interests, evaluate feasibility of implementation, avoid duplication of efforts, and increase wide-spread adoption of the safe practices

Safety of Rural Nursing Home-to-emergency Department Transfers: Improving Communication and Patient Information Sharing Across Settings

This article was published in the January/February 2015 issue of the Journal for Healthcare Quality, and reports on the evaluation of a demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments by forming interprofessional teams of hospital, emergency medical service, and NF staff to develop and implement tools and protocols for standardizing critical interfacility communication pathways and information sharing. The research team at the USM Muskie School worked with each of the 10 interprofessional teams to document current communication processes and information sharing tools and to design, implement and evaluate strategies/tools to increase effective communication and sharing of patient information across settings