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

Wearing someone else's shoes

This paper recounts a journey of discovery by a scientist who inadvertently takes on coordination of an ArtsHealth programme. The dynamics of role change are explored showcasing the vulnerabilities and fears that often accompany these career adjustments. The associated ArtsHealth programme (Gomeroi gaaynggal) works with Aboriginal and Torres Strait Islander women in Australia throughout their pregnancy to improve understanding of issues that impact the health of themselves and their developing baby. By wearing someone else shoes, the scientist is immersed in the project and must confront issues including skill mix, learning and cultural diversity

Fragile forgotten families: Parenting a premature infant in a rural area, where is the evidence?

Background and aims Families in rural Australia are at higher risk of preterm birth and have poorer access to health services. This paper reviews the literature on parenting premature infants and asks why so few studies examine the experiences of rurally residing parents. Methods CINAHL, Medline, Embase and the Maternity and Infant Care databases were searched and articles were analysed using qualitative content analysis. Results The literature search returned 17,237 articles, of which 23 met the inclusion criteria. One article examined experiences of rurally residing parents and no articles included Indigenous Australians. The following four themes emerged: The NICU environment, detailed parents' need to adjust to the NICU environment before they focus on their child. Connectedness, described connections parents develop to cope. Fragility refers to parents' perception of their premature infant as fragile and their fragile confidence in their parenting ability. Touch described the importance of touch and the distress caused by restriction of touch. Conclusions The evidence describing parenting a premature infant lacks accounts of different socio-economic and cultural groups, particularly rural families and Indigenous Australians. Implications for clinical practice Despite facing additional challenges accessing specialist care and local follow-up services, little is known about the experiences of rural parents

Is it me or is there something in the water?: client decision making in nursing

Objective: This paper aims to retrospectively explore client decision making via two case studies prompting us as nurses to reflect on the factors that lead to this. Clients do not always act in ‘their own best interests’ as ‘defined by health professionals’. Our response and understanding of this is key if we are to support and devise strategies encouraging more appropriate decisions and improved outcomes. Setting: Sole nurse practitioner in community health practice in isolated rural Australia. Primary Argument: In the rush of daily chronic care caseload management, factors affecting client decision making are often overlooked. Client decisions around care often result in poor outcomes for isolated rural clients. Improved client outcomes can be gained if nurses, (aware of these decision making factors), are able to assist clients to overcome their decision making barriers. Conclusion: In rural nursing practice client decision making is multifactorial. By reflecting on clients decisions and addressing barriers in this context, short term and long term strategies can be implemented to improve the decision making process resulting in improved outcomes for isolated rural clients

Physical activity of rurally residing children with a disability: a survey of parents and carers

Background: Children residing in rural areas face unique barriers to physical activity participation. Further, while children with a disability who reside in metropolitan areas face barriers hindering physical activity, rurally residing children with a disability may face the augmented combination of these barriers that could have negative health implications. Parents are often the key advocates for children with disabilities and are likely to have valuable insight into the opportunities and barriers to physical activity for their child.Objective: The aim of this study was to investigate parents' perceptions of physical activity opportunities for their child with a disability in a rural area. Methods: A mixed method survey examining parent's perceptions of their child's physical activity and possible barriers to participation was mailed to rurally residing parents of children with a disability. Quantitative data were analyzed descriptively using frequencies and proportions. Qualitative data were analyzed using qualitative content analysis.Results: There were 34 completed surveys, a response rate of 37%. Participants' responses indicated 74% of children were not meeting daily recommendations of physical activity. Participation barriers including emotional, physical and environmental issues. Three main themes emerged from qualitative data; segregation, access to facilities and resources and barriers specific to the child.Conclusion: The children in this study were from rural areas and face similar barriers to children in metropolitan areas. However, they are also confronted with the same barriers children without a disability in rural areas face, participating in physical activity. This may have detrimental effects on their health and development. (C) 2017 Elsevier Inc. All rights reserved

Personalised medicine: a new approach to improving health in Indigenous Australian populations

Personalised medicine is a newly emerging field with much to offer to all populations in improved clinical treatment options. Since the 1970s, clinicians and researchers have all been working towards improving the health of Indigenous Australians. However, there has been little research on the impact of genetics on Indigenous health, how genetic and environmental factors interact to contribute to poor health in Indigenous people, and how genetic factors specific to Indigenous people affect their responses to particular treatments. This short review highlights the urgent need for more genetic studies specific to Indigenous people in order to provide more appropriate care and to improve health outcomes. This paper explores why genetic work with Indigenous communities has been limited, how personalised medicine could benefit Indigenous communities, and highlights a number of specific instances in which personalised medicine has been critical for improving morbidity and mortality in other high-risk groups. In order to take the next step in advancing the health of Indigenous peoples, targeted research into the genetic factors behind chronic diseases is critically needed. This research may allow clinicians a better understanding of how genetic factors interact with environmental factors to influence an Indigenous Australian's individual risk of disease, prognosis, and response to therapies. It is hoped that this knowledge will produce clinical interventions that will help deliver clearly targeted, more appropriate care to this at-risk population. (C) 2017 S. Karger AG, Base

Surviving, not thriving: a qualitative analysis of parents' perceptions of physical activity participation for rurally residing children with a disability

Introduction: Preliminary research suggests that rurally residing children with a disability seldom participate in the recommended 60 minutes of moderate-to-vigorous physical activity per day and face multiple barriers to participation. The purpose of this study was to explore parents' perceptions of physical activity participation of rurally residing children with a disability, including barriers and any factors that may facilitate their participation.Methods: Participants were parents or carers of a school-aged child with a disability residing in a rural or remote area of the state of New South Wales, Australia. Data were collected using semi-structured focus group interviews, which were audio-recorded and transcribed. Qualitative data were analysed inductively using qualitative content analysis.Results: Focus group interviews were conducted with 10 parents. Thematic analysis yielded the overarching description of the study, surviving, not thriving, which described the participants' limited success in augmenting the health of their child with a disability, despite their desire to do so. Within this description, three main themes emerged. (1) A parent's predicament described the parents' struggle to support their child's participation in physical activity, despite understanding its numerous benefits. (2) Barriers to participation described the various barriers to physical activity participation that were perceived to be hampering their child's potential to thrive. Some of these barriers were related to the child's disability, while others were specific to the rural context. (3) Facilitators to participation described the factors that served to motivate and enable children with a disability to participate in physical activity.Conclusions: This investigation of parents' perceptions suggests that the physical activity participation of rurally residing children with a disability is currently insufficient to adequately support the health of this population. It appears service providers need to address the factors that impede participation, including issues surrounding access, ability and isolation, but should also support the parents' behaviours, community opportunities and the child's own drive to participate. Existing support structures aimed at promoting physical activity should be enhanced and more inclusive, and accessible strategies should be developed

The birth of Gomeroi Gaaynggal

In response to the "Closing the Gap" campaign, a collaboration was established between the University Department of Rural Health (Tamworth) and the Mothers and Babies Research Centre (Newcastle) in 2007 that aimed to improve outcomes for Aboriginal mothers and their infants. Through community consultation surrounding a program of scientific research, community members shared the need for a supportive place for pregnancy issues to be discussed for expectant Aboriginal mothers. It was suggested that in addition to working with mothers in a research program, that we, the scientists, need to be putting something back into the community. This story is about the beginnings of the Gomeroi gaaynggal program. When first discussed, staff at Aboriginal health services talked about how Aboriginal mums are often younger and easily intimidated by health services generally. Community members talked extensively of the need for a place and a function where mums could go to meet with other expectant mums to talk about their pregnancy. A group of health staff suggested we run a program that used the local love of the arts to create a non-threatening environment for Aboriginal mothers. As a scientist, this idea seemed quite frightening. However, everywhere it was discussed, the eyes of local people lit up. It seemed that the scientist was about to learn a whole new way of doing business

Cultural experiences of student and new-graduate dietitians in the Gomeroi gaaynggal ArtsHealth program: a quality assurance project

Issue addressed Undergraduate dietetic students are required to demonstrate cultural awareness and culturally respectful communication to meet national competencies, but exposure to practical experiences may be limited. The Gomeroi gaaynggal ArtsHealth Centre was established in 2009 after community consultation with the Indigenous community in Tamworth, New South Wales. The Centre provides a safe and welcoming space where women can create art while discussing health issues with visiting health professionals and students. The present study aimed to evaluate the cultural experiences of student and new-graduate dietitians visiting an Aboriginal ArtsHealth centre through a quality assurance project.Methods Six student and new-graduate dietitians were invited to provide feedback on their experiences for this report. A generic inductive approach was used for qualitative data analysis.Results Key qualitative themes of building rapport' and developing cultural understanding' were identified. Four of the participants interviewed felt they gained a deeper understanding of the context around health disparity for Indigenous Australians through their experiences. Key ways to build rapport with community members were identified.Conclusions Results suggest that first-hand experiences working in an Aboriginal ArtsHealth centre are effective in building cultural competency skills for student and new-graduate dietitians. These experiences could be better supported through improved preparation for the cultural setting, and ongoing monitoring of participant experiences is recommended.So what? The authors encourage undergraduate dietetic programs and students to seek out opportunities for further development of cultural awareness through increased practical experiences working with Indigenous communities