When the coronavirus disease 2019 (COVID-19) wreaked an unprecedented havoc of an escalating number of deaths and hospitalization in the United States, clinicians were faced with a myriad of unanswered questions, one of the them being the implication of the renin-angiotensin-aldosterone system in patients with COVID-19. Animal data and human studies have shown that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) increase the expression of ACE2. ACE2 is an enzyme found in the heart, kidney, gastrointestinal tract, and lung and is a coreceptor for severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV2), the virus responsible for COVID-19. https://www.selleckchem.com/products/r428.html Therefore, one can speculate that discontinuing ACE inhibitor or ARB therapy may lead to decreased ACE2 expression, thereby attenuating the infectivity of SARS-CoV-2, and mitigating the disease progression of COVID-19. However, several studies have also shown that ACE2 exhibits reno- and cardioprotection and preserves lung function in acute respiratory distress syndrome, which would favor ACE inhibitor or ARB therapy. This article is to examine and summarize the 2 opposing viewpoints and provide guideline recommendations to support the use or discontinuation of ACE inhibitors and ARBs in patients with COVID-19.Background Consider a theoretical situation in which 2 patients with similar baseline characteristics receive a kidney transplant on the same day 1 from a standard criteria deceased donor, the other from a living donor. Which kidney transplant will last longer? Methods We conducted a population-based cohort study using linked administrative healthcare databases from Ontario, Canada from January 1, 2005 to March 31, 2014 to evaluate several posttransplant outcomes in individuals who received a kidney transplant from a standard criteria deceased donor (n=1523) or from a living donor (n=1373). We used propensity-score weighting using overlap weights, a novel weighting method that emphasizes the population of recipients with the most overlap in baseline characteristics. Results Compared to recipients of a living donor, the rate of all-cause graft failure was not statistically higher for recipients of a standard criteria deceased donor (hazard ratio 1.1, 95% confidence interval [CI] 0.8, 1.6). Recipients of a standard criteria deceased donor, compared to recipients of a living donor had a higher rate of delayed graft function (23.6% vs. link2 18.7%, odds ratio 1.3, 95% CI 1.0, 1.6) and a longer length of stay for the kidney transplant surgery (mean difference 1.7 days, 95% CI 0.5, 3.0). Conclusion After accounting for many important donor and recipient factors, we failed to observe a large difference in the risk of all-cause graft failure for recipients of a standard criteria deceased versus living donor. Some estimates were imprecise which meant we could not rule out the presence of smaller clinically important effects.Background The novel coronavirus SARS-CoV-2 (COVID-19) poses unique challenges for immunosuppressed patients. Solid organ transplant recipients (SOT) comprise a large proportion of this group, yet there is limited knowledge about the presentation, clinical course and immunosuppression management of this novel infection among heart, lung, liver, pancreas and kidney transplant recipients. Methods We present 21 SOT diagnosed with COVID-19 between January 1, 2020 - April 22, 2020 at a US high-volume transplant center. Diagnostic workup, clinical course, immunosuppression/antiviral management and immediate outcomes are described. Results Twenty-one (15.9%) of 132 symptomatic patients tested were positive. Mean age at diagnosis was 54.8 ± 10.9 years. Median time from transplant was 5.58 years (IQR 2.25, 7.33). Median follow-up was 18 days (IQR 13, 30). Fourteen patients required inpatient management, with 7 (50%) placed in the intensive care unit (ICU). All transplant types were represented. Nearly 43% exhibited GI symptoms. Over half (56.2%) presented with elevated serum creatinine suggestive of acute kidney injury. The majority of patients (5/7) with concomitant infections at baseline required the ICU. Eighty-percent received hydroxychloroquine ± azithromycin. Ten received toclizumab and/or ribavirin; 1 received remdesivir. Antimetabolites ± calcineurin inhibitors were held or reduced. Over half of hospitalized patients (8/14) were discharged home. Only 1 mortality (4.8%) to date, in a critically-ill heart/kidney patient who had been in the ICU prior to diagnosis. Conclusion COVID-19 positive SOT at our institution had favorable short-term outcomes. Those with concomitant infections had more severe illness. More data will be available to evaluate long-term outcomes and disease impact on graft function.Background Mycophenolic acid (MPA) is a standard immunosuppressant in organ transplantation. A simple monitoring biomarker for MPA treatment has not been established so far. Here, we describe inosine 5'-monophosphate dehydrogenase (IMPDH) monitoring in erythrocytes and its application to kidney allograft recipients. Methods IMPDH activity measurements were performed using a high-performance liquid chromatography assay. Based on 4203 IMPDH measurements from 1021 patients we retrospectively explored the dynamics early after treatment start. In addition, we analyzed the influence of clinically relevant variables on IMPDH activity in a multivariate model using data from 711 stable patients. Associations between IMPDH activity and clinical events were evaluated in hospitalized patients. Results We found that IMPDH activity reflects MPA exposure after 8 weeks of constant dosing. In addition to dosage, body mass index, renal function and coimmunosuppression affected IMPDH activity. Significantly lower IMPDH activities were found in patients with biopsy-proven acute rejection as compared to patients without rejection (median [IQR] 696 [358-1484] versus 1265 [867-1618] pmol XMP/h/mg haemoglobin, P less then 0.001). The highest IMPDH activities were observed in hospitalized patients with clinically evident MPA toxicity as compared to patients with hospitalization not related to MPA treatment (1548 [1021-2270] vs. 1072 [707-1439] pmol XMP/h/mg haemoglobin; P less then 0.001). Receiver operating characteristic curve analyses underlined the usefulness of IMPDH to predict rejection episodes (area 0.662; CI 0.584-0.740; P less then 0.001) and MPA-associated adverse events (area 0.632; CI 0.581-0.683; P less then 0.001), respectively. link3 Conclusion IMPDH measurement in erythrocytes is a novel and useful strategy for the longitudinal monitoring of MPA treatment.Purpose Being swamped is defined as "when you are so overwhelmed with what is occurring that you are unable to focus on the most important thing." The purpose of this study was to explore the experience of being swamped in the clinical setting among nurses who are members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the relationship of the level of being swamped to adherence to the AWHONN (2010) nurse staffing guidelines. Study design and methods A 25-item survey was sent to ~21,000 AWHONN members by email in the Fall of 2018. It was completed by 1,198 members, representing 49 states and the District of Columbia. Questions explored timing and causes of being swamped, its effect on health care team members and patients, what helps when a nurse feels swamped, and nurses' reports of their hospital following the AWHONN nurse staffing guidelines. Results Twenty-eight percent of nurses reported being swamped daily or multiple times per day. Situations that contribute to being swamped include assignments that are too heavy, interruptions, critical patient situations, and mistakes made by others that nurses are expected to catch and fix. Teamwork and someone stepping in to help without being asked were identified as most helpful when a nurse feels swamped. Nu rses practicing in hospitals following the AWHONN nurse staffing guidelines always or most of the time reported less frequency of being swamped as compared with those in hospitals that followed the guidelines some of the time, or rarely (p less then 0.001). Clinical implications Being swamped is a common phenomenon among AWHONN members responding to the survey. The reported incidence of being swamped daily is significantly associated with the extent to which hospitals follow the AWHONN nurse staffing guidelines. Nurse leaders, hospital administrators, and staff nurses must work together to identify and initiate timely, feasible nurse staffing solutions that support the safety of patients and nurses.Introduction Missed nursing care is required care that is delayed, incomplete, or left undone during a nurse's working shift. Missed nursing care is most often studied in adult populations; however, it may have significant consequences in pediatric and neonatal care settings. The purpose of this integrative review is to describe missed nursing care in pediatric and neonatal nursing care settings. Methods SCOPUS and PubMed were used in the literature search. Multiple combinations of the keywords and phrases "missed nursing care," "pediatric," "neonatal," "care left undone," or "nursing care rationing" were used for the literature search. Missed nursing care is a relatively new topic as the first article on the subject was published in 2006; therefore, inclusion criteria were set to English articles published between January 1, 2006 and October 11, 2019 that reported on missed nursing care in pediatric and neonatal inpatient care settings. Results Fourteen articles met inclusion criteria. Missed nursing care in pediatric and neonatal nursing care settings is associated with workload, patient acuity, work environment, and nurse characteristics, and is related to prolonged hospitalization of preterm infants. Clinical implications Providing nurses with an adequate amount of resources and tools to avoid missed nursing care will continue to improve care delivery. Missed nursing care and related patient and nurse outcomes in diverse pediatric and neonatal samples remains an area for future research.Purpose The purpose of this study was to determine associations between missed nursing care and nurse staffing during labor and birth, and exclusive breast milk feeding at hospital discharge. Study design and methods Labor and birth nurses in three states were surveyed about missed nursing care and their maternity units' adherence to the AWHONN (2010) nurse staffing guidelines for care during labor and birth, using the Perinatal Misscare Survey. Nursing responses were aggregated to the hospital level and estimated associations between missed nursing care, nurse staffing, and hospitals' exclusive breast milk feeding rates were measured using The Joint Commission's Perinatal Care Measure (PC-05). Results Surveys from 512 labor nurses in 36 hospitals were included in the analysis. The mean exclusive breast milk feeding rate was 53% (range 13%-76%). Skin-to-skin care, breastfeeding within 1 hour of birth, and appropriate recovery care were on average occasionally missed (2.33 to 2.46 out of 4; 1 = rarely, 2 = occasionally, 3 = frequently, or 4 = always) and were associated with PC-05 [B(CI) -17.1(-29, -6.3), -17.9(-30.5, -6.2), and -15.4(-28.7, -2.1), respectively]. Adherence with overall staffing guidelines was associated with PC-05 [12.9(3.4, 24.3)]. Missed nursing care was an independent predictor of PC-05 [-14.6(-26.4, -2.7)] in a multilevel model adjusting for staffing guideline adherence, perceived quality, mean age of respondents, and nurse burnout. Clinical implications Exclusive breast milk feeding is a national quality indicator of inpatient maternity care. Nurses have substantial responsibility for direct support of infant feeding during the childbirth hospitalization. These results support exclusive breast milk feeding (PC-05) as a nurse-sensitive quality indicator.