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

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–critically 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 = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free 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–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (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–free 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

Hepatitis C viral clearance in an intravenous drug-using cohort in the Dublin area.

The rate of spontaneous HCV viral clearance is reported as 20—25% but recent data indicate a higher frequency in some cohorts. The rate of spontaneous clearance in intravenous drug users has not been reported in an Irish setting. The aim of this study was to determine the rate of spontaneous hepatitis C viral clearance and genotype in an Irish intravenous drug-using cohort. Drug users attending five drug treatment clinics in the Dublin area were investigated. Data were prospectively recorded from January 1997 to June 2001 and follow-up testing completed in 2003. There were 496 HCV antibody-positive patients identified and assessed for HCV RNA clearance. All were HIV and hepatitis B negative, 68.8% were male. HCV RNA negativity (viral clearance) was documented in 38% of patients. Viral clearance was 47.4% in females and 34.5% in males (p = 000.6). Clearance was independent of age or duration of intravenous drug use. Viral clearance, defined as two negative consecutive HCV RNA tests, a minimum of one year apart, was sustained in 82.2% at two-year follow-up, giving an overall viral clearance of 31.1%. HCV genotype 1 and 3 were most commonly identified at 48.8% and 48.5% respectively in those with chronic infection. The study concluded that spontaneous HCV viral clearance occurs at a higher frequency than previously reported. Genotype 1 and 3 are commonest in the patient cohort

Work-Based Learning Curricula in Nursing : A Literature Review

The goal of undergraduate nursing education is to prepare nurses for practice in a demanding and dynamic health care environment. Among other factors, the increased demand for nurses, the rapid growth in nursing knowledge, increased use of technology and the changing demographics of Australia's population have all resulted in significant challenges to educational institutions that are preparing nurses for practice. This report explores how some of these challenges can be met using curricular models that emphasise work-based learning and strong articulation between programs preparing division 2 and division 1 nurses

Putting Learning into the Learning Commons : A Literature Review

For decades academic libraries have been seen as portals to information, print resources and more recently digital resources, but, as Demas states, 'we have reawakened to the fact that libraries are fundamentally about people:-how they learn, how they use information, and how they participate in the life of a learning community' (Demas 2005, p. 25). As a result 'Libraries today are in transition both as institutions and as a building type' (Hartman 2000, p. 112)

An audit of violent incidents in a drug treatment centre.

The aim of this study was to examine the prevalence of, and factors associated with violence in a drug treatment centre. This study is a retrospective audit of all incident forms completed at an urban drug treatment centre between December 1991 and July 1996 with reference to case notes for additional clinical information on individuals involved in violent incidents. Participants included all patients attending the centre in the aforementioned time period who were involved in violent incidents. Information was obtained about the prevalence and severity of violent incidents and patient details including main drug of abuse, route of use, reason for attendance, comorbid axis 1 diagnosis, history of previous incidents and HIV status at the time of the incident. One per cent of all patients were involved in violent incidents. Less than one quarter of incidents involved serious injury or assault. Most perpetrators were male intravenous heroin users on a methadone maintenance programme. Nurses and doctors were most frequently the victims of incidents. Ten per cent of patients had a history of previous incidents and almost half the perpetrators were HIV positive. A comorbid axis 1 diagnosis was found in 9% of perpetrators (n = 6), mainly alcohol dependence syndrome. Those on methadone maintenance programmes were most likely to be violent. Almost half the perpetrators involved in violent incidents were HIV positive. Acute psychiatric problems did not account for violence in this setting. The presence of on site security staff probably accounted for the low levels of violence when compared to general psychiatric settings