Lung Protective Ventilation during Pregnancy: An Observational Cohort Study.

Objectives We sought to describe characteristics of mechanically ventilated pregnant patients, evaluate utilization of low-tidal-volume ventilation (LTVV) and high-tidal-volume ventilation (HTVV) by trimester, and describe maternal and fetal outcomes by ventilation strategy. Study Design This is a retrospective cohort study of pregnant women with mechanical ventilation for greater than 24 hours between July 2012 and August 2020 at a tertiary care academic medical center. We defined LTVV as average daily tidal volume 8 mL/kg of less of predicted body weight, and HTVV as greater than 8 mL/kg. We examined demographic characteristics, maternal and fetal characteristics, and outcomes by ventilation strategy. Results We identified 52 ventilated pregnant women, 43 had LTVV, and 9 had HTVV. Acute respiratory distress syndrome occurred in 73% ( N = 38) of patients, and infection was a common indication for ventilation ( N = 33, 63%). Patients had LTVV more often than HTVV in all trimesters. Obstetric complications occurred frequently, 21% ( N = 11) experienced preeclampsia or eclampsia, and among 43 patients with available delivery data, 60% delivered preterm ( N = 26) and 16% had fetal demise ( N = 7). Conclusion LTVV was utilized more often than HTVV among pregnant women in all trimesters. There was a high prevalence of maternal and fetal morbidity and fetal mortality among our cohort. Key Points Our center utilized low tidal more often than high-tidal-volume ventilation during all trimesters of pregnancy.Prone positioning can be performed at advanced gestations.Infection is a common cause of antepartum ventilation.

Pre-exposure and post-exposure prophylaxis access in rural versus urban pharmacies in Georgia and Pennsylvania.

BACKGROUND: Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) prevent HIV among individuals at high risk for acquisition. Pre-existing structural barriers to PrEP/PEP access among rural patients may be exacerbated further if pharmacies do not keep PrEP/PEP in stock, constituting a significant barrier to mitigating the HIV epidemic. OBJECTIVES: To compare PrEP/PEP availability for same-day pickup in rural vs urban Georgia and Pennsylvania pharmacies. METHODS: We conducted a cross-sectional simulated patient caller study, calling pharmacists in Georgia and Pennsylvania to see whether PrEP/PEP was available for same-day pickup. We identified retail pharmacies through state pharmacy boards and categorized rurality using state-based definitions. We used multivariable logistic regression to assess PrEP availability by rurality and Ending the HIV Epidemic (EHE) designation, accounting for chain pharmacy status and county-level racial composition. RESULTS: Among 481 pharmacies contacted (304 in Pennsylvania and 177 in Georgia), only 30.77% had PrEP for same-day pickup and only 10.55% had PEP for same-day pickup. PrEP availability did not differ significantly by state. Urban pharmacies had 2.02 (95% CI: 1.32-3.09) greater odds of PrEP same-day availability compared to rural pharmacies. Pharmacies in EHE counties had 3.45 (95% CI: 1.9-6.23) times higher odds of carrying PrEP compared to non-EHE counties. CONCLUSIONS: Pharmacies were unlikely to carry PrEP or PEP. Pharmacies in rural compared to urban, and non-EHE compared to EHE locations were less likely to carry PrEP. Addressing pharmacy barriers to PrEP/PEP may enhance access to HIV prevention for those living at high risk of HIV.

HIV awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study.

BACKGROUND: People who exchange sex for money, favors, goods or services, combat higher risk of acquiring sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Understanding barriers to STD and HIV related healthcare from the perspective of this stigmatized and marginalized community may improve access to sexual health services including pre-exposure prophylaxis (PrEP).  METHODS: We used community-partnered participatory and qualitative methods to conduct anonymous one-on-one interviews with people who exchange sex to understand their perspectives and experiences related to pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. We conducted twenty-two interviews and coded them to perform thematic analysis.  RESULTS: We identified five themes: (1) Appreciation of HIV risk and prevention strategies grew from information accumulated over time. (2) PrEP information came from a variety of sources with mixed messages and uncertain credibility. (3) Decision-making about use of PrEP was relative to other behavioral decisions regarding exchange sex. (4) The multi-step process of obtaining PrEP presented multiple potential barriers. (5) Healthcare providers were seen as powerful facilitators to PrEP utilization. CONCLUSIONS: Our findings suggest that PrEP education and care needs to be made more relevant and accessible to individuals who exchange sex.

Getting To Implementation (GTI)-Teach: A seven-step approach for teaching the fundamentals of implementation science.

Introduction: Implementation Science (IS) is a complex and rapidly evolving discipline, posing challenges for educators. We developed, implemented, and evaluated a novel, pragmatic approach to teach IS. Methods: Getting To Implementation (GTI)-Teach was developed as a seven-step educational model to guide students through the process of developing, conducting, and sustaining an IS research project. During the four-week online course, students applied the steps to self-selected implementation problems. Students were invited to complete two online post-course surveys to assess course satisfaction and self-reported changes in IS knowledge and relevance of GTI-Teach Steps to their work. Results were summarized using descriptive statistics; self-reported post-course changes in IS knowledge were compared using paired t-tests. Results: GTI-Teach was developed to include seven Steps: 1. Define the implementation problem; 2. Conceptualize the problem; 3. Prioritize implementation barriers and facilitators; 4. Select and tailor implementation strategies; 5. Design an implementation study; 6. Evaluate implementation; 7. Sustain implementation. Thirteen students, ranging in experience from medical students to full professors, enrolled in and completed the first GTI-Teach course. Of the seven students (54%) completing an end-of course survey, six (86%) were very satisfied with the course. Ten students (77%) responded to the tailored, 6-month post-course follow-up survey. They retrospectively reported a significant increase in their knowledge across all steps of GTI-Teach (1.3-1.8 points on a 5-point Likert scale) and rated each of the Steps as highly relevant to their work. Conclusions: GTI-Teach is a seven-step model for teaching IS fundamentals that students reported increased their knowledge and was relevant to their work.

Implementing pre-exposure prophylaxis for HIV prevention in women: the role of the obstetrician-gynecologist.

Pre-exposure prophylaxis is a powerful HIV prevention tool that can reduce the risk of acquiring HIV by >90% from unprotected sex and >70% from injection drug use. The peripartum period is a time of heightened HIV risk, which underscores the need for HIV prevention counseling and the provision of biomedical interventions in all stages of a woman's reproductive life. It is important that women receive nonjudgmental care, have access to discussions of HIV risk, and are provided with pre-exposure prophylaxis counseling from their women's health practitioners. Obstetrician-gynecologists and other women's health providers are uniquely positioned to identify women who would benefit from pre-exposure prophylaxis and provide it in trusted clinical settings.

Experiences and Perspectives From Women Taking Investigational Therapy for Hepatitis C Virus During Pregnancy.

OBJECTIVE: Describe the experiences and perspectives among pregnant people with chronic HCV infection receiving ledipasvir/sofosbuvir (LDV/SOF) therapy during pregnancy. METHODS: We conducted semi-structured, in-depth interviews within an open-label, phase 1 study of LDV/SOF therapy among pregnant people with chronic HCV infection. Participants took 12 weeks of LDV/SOF and were interviewed at enrollment and again at the end of treatment. We transcribed the interviews verbatim and coded them with NVivo software for subsequent inductive thematic analysis. RESULTS: Nine pregnant people completed the study, leading to 18 interview transcripts. All participants identified as women. Eight women acquired HCV through injection drug use, and 1 through perinatal transmission. We identified 3 themes. (1) Treatment for HCV during pregnancy with LDV/SOF was tolerable and convenient. (2) Women described that taking investigational LDV/SOF increased their self-esteem and sense of well-being due to possible cure from HCV, and they felt that the experience of working hard to achieve cure may potentially prevent return to drug abuse in the future. (3) Women appreciated researchers and providers that gave non-judgmental care and communicated honestly, and preferred person-centered care that acknowledges women's individual needs. CONCLUSIONS: Women stated that cure from HCV would be "life-changing," and described antepartum treatment for HCV with LDV/SOF as tolerable and desired, when provided by non-judgmental providers. Antepartum treatment was found to be acceptable by study participants and should be further evaluated to combat the increasing HCV epidemic among young persons, including pregnant people.