35 research outputs found

    Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

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    IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non‚Äďcritically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n‚ÄČ=‚ÄČ257), ARB (n‚ÄČ=‚ÄČ248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n‚ÄČ=‚ÄČ10), or no RAS inhibitor (control; n‚ÄČ=‚ÄČ264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support‚Äďfree days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support‚Äďfree days among critically ill patients was 10 (‚Äď1 to 16) in the ACE inhibitor group (n‚ÄČ=‚ÄČ231), 8 (‚Äď1 to 17) in the ARB group (n‚ÄČ=‚ÄČ217), and 12 (0 to 17) in the control group (n‚ÄČ=‚ÄČ231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support‚Äďfree days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

    Getting to Yes: The Makings of Paid Leave in Massachusetts

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    Considered one of the strongest paid family and medical leave laws in the nation, the paid leave law adopted in Massachusetts in 2018 was notable for the depth and range of robust caregiving supports and protections for workers. But just as notable is how the law came to be. After all, paid leave bills had been filed for years in Massachusetts. Decades in fact. Yet until 2018, there had been limited movement in the legislature to establish a statewide program. What led to the passage of paid leave legislation in Massachusetts with approval from a Republican Governor? What factors influenced not only the scope and parameters of the paid leave program but how it was developed and by whom? This case study tells the story of the Massachusetts paid leave law primarily through the eyes of those closely involved in the negotiation process. Drawing on in-depth interviews with legislators, legislative aides, paid leave advocates, business leaders, and individuals from the academic and political consulting arenas, the following analysis incorporates legislative documents, including testimony, as well as reports issued by academic institutions, think tanks, and nonprofit organizations, press releases, news items, and other documents focused primarily on the process of securing paid leave. Therefore, this case study emphasizes the paid leave negotiation process that took place between November 2017 and June 2018. In addition, available information about the law’s implementation is integrated to shed light on implementation to date

    Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study