Efficacy of Tocilizumab in Patients Hospitalized with Covid-19.

BACKGROUND: The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS: We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).

HIV testing in a large community health center serving a multi-cultural patient population: A qualitative study of providers.

In the United States, 15% of HIV-positive individuals do not know their HIV serostatus. While CDC guidelines recommend HIV testing for individuals age 13-64 years, racial and ethnic minorities continue to experience delays in HIV diagnosis. We assessed providers' perspectives on HIV testing at an urban community health center serving racial/ethnic minority populations of low socioeconomic status. We conducted five focus groups from January 2017 to November 2017 with 74 health center staff: 20 adult medicine/primary care providers, 34 community health workers (CHWs) and community health administrators, six urgent care physicians, and fourteen behavioral health providers. Study staff analyzed transcripts using a grounded theory approach and used open coding to develop themes. We identified five themes affecting HIV testing: 1) provider perception of patients' preferences for HIV testing; 2) competing medical and social issues; 3) inter-professional communication; 4) knowledge of clinical indicators for HIV testing; and 5) knowledge of frequency of HIV testing. Primary care physicians desired mechanisms to easily identify patients for HIV testing and assistance with testing for non-English speakers. Training to improve comfort with HIV testing, integrating CHWs into routine practice, and focusing on patients' cultural beliefs may increase HIV testing in diverse community health centers..

Atrophy, focal spinal cord lesions and alterations of diffusion tensor imaging (DTI) parameters in asymptomatic virus carriers and patients suffering from human T-lymphotrophic virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP).

In tropical spastic paraparesis, spinal cord atrophy is a well-known finding in magnetic resonance imaging. But in contrast to histological reports, focal lesions of the spinal cord have only been described in imaging reports in exceptional acute cases. Here, we looked for such focal lesions and for alterations of diffusion tensor imaging parameters of the long fibre tracts in the usual case of a long-standing and slowly progressive disease. We examined 10 symptomatic patients, 11 seropositive, but asymptomatic human T-lymphotrophic virus type 1 carriers and 18 seronegative volunteers as controls. Sagittal and transversal T2-weighted images were visually assessed for atrophy and focal cord lesions. The spinal cord cross-sectional areas and the segmental cord volumes were measured at all levels. High-resolution diffusion tensor imaging was performed in sagittal planes from the bregma down to the cervical spine. For tractography and calculation of fractional anisotropy and mean diffusivity, we used manufacturer-provided software. Two-thirds of patients showed focal lesions affecting the antero-lateral columns and in two cases also the dorsal columns. Compared to carriers and volunteers, patients presented a significant spinal cord atrophy and a reduction of fractional anisotropy (p < 0.05), correlating more to duration of symptoms than to clinical impairment. Because our carriers did not show a significant atrophy, focal lesions or a change of diffusion tensor imaging parameters, we need further long-term studies to see if these parameters at some stage may be used as early indicators of spinal cord affection in virus carriers.

Effect of Palliative Care Curriculum on Serious Illness Conversation Preparedness.

BACKGROUND: A shortage of palliative pare (PC) specialists underscores the necessity that all clinicians feel comfortable with serious illness conversations (SICs). OBJECTIVE: To assess the effect of an intensive PC curriculum with multiple teaching modalities on Internal Medicine residents' confidence with SICs and advance care planning documentation. METHODS: Twelve PC modules consisting of didactic lectures, role-playing, and online interactive modules were integrated as continuing education during academic year 2018-2019. Surveys were administered precurriculum and at 3 and 6 months postcurriculum to measure the primary outcome of increasing resident preparedness for SICs. A retrospective chart review was used to analyze secondary outcomes of advance care planning documentation for patients cared for by residents exposed to the curriculum versus residents from the previous year who received monthly didactic PC lectures. RESULTS: Postintervention surveys demonstrated statistically significant improvement in resident confidence. An increase in patient code status confirmation rates (odds ratio, 1.81; 95% confidence interval, 1.12-2.94; P = 0.02) and a decrease in PC consultation (odds ratio, 0.56; 95% confidence interval, 0.33-0.97; P = 0.04) was observed when compared with the previous year. CONCLUSION: Among residents, the incorporation of an intensive PC curriculum that uses multiple teaching modalities improves confidence in SICs, which we believe is integral to the practice of goal-concordant patient care.

Strategies for Managing the Costs of Chronic Illness in the Context of Limited Financial Resources: A Qualitative Study in Dominican Persons With Arthritis.

OBJECTIVE: Persons who reside in low- and middle-income countries often have insufficient resources to pay for treatments prescribed for their medical conditions. The aim of this study was to determine, using qualitative methods, how patients with arthritis in the Dominican Republic manage the costs associated with chronic illnesses. METHODS: We conducted individual interviews with 17 Dominican adults with advanced arthritis who were undergoing total knee replacement or total hip replacement at a hospital in Santo Domingo, Dominican Republic. Interviewers followed a moderator's guide with questions pertaining to the financial demands of arthritis treatment and the strategies participants used to pay for treatments. Interviews were audio recorded, transcribed verbatim, and translated into English. We used thematic analysis to identify salient themes. RESULTS: The thematic analysis suggested that health system factors (such as the extent of reimbursement for medications available in the public health care system) along with personal factors (such as disposable income) shaped individuals' experiences of managing chronic illness. These systemic and personal factors contributed to a sizeable gap between the cost of care and the amount most participants were able to pay. Participants managed this resource gap using a spectrum of strategies ranging from acceptance (or, "making do with less") to resourcefulness (or, "finding more"). Participants were aided by strong community bonds and religiously oriented resilience. CONCLUSION: This qualitative study illuminates the range of strategies Dominican individuals with limited resources use to obtain health care and manage chronic illness. The findings raise hypotheses that warrant further study and could help guide provider-patient conversations regarding treatment adherence.