Nephrotoxic Risk Associated With Combination Therapy of Vancomycin and Piperacillin-Tazobactam in Critically Ill Patients With Chronic Kidney Disease.

Background: The combination of vancomycin and piperacillin-tazobactam (VPT) has been associated with acute kidney injury (AKI) in hospitalized patients when compared to similar combinations. Additional studies examining this nephrotoxic risk in critically ill patients have not consistently demonstrated the aforementioned association. Furthermore, patients with baseline renal dysfunction have been excluded from almost all of these studies, creating a need to examine the risk in this patient population. Methods: This was a retrospective cohort analysis of critically ill adults with baseline chronic kidney disease (CKD) who received vancomycin plus an anti-pseudomonal beta-lactam at Emory University Hospital. The primary outcome was incidence of AKI. Secondary outcomes included stage of AKI, time to development of AKI, time to return to baseline renal function, new requirement for renal replacement therapy, intensive care unit and hospital length of stay, and in-hospital mortality. Results: A total of 109 patients were included. There was no difference observed in the primary outcome between the VPT (50%) and comparator (58%) group (P = .4), stage 2 or 3 AKI (15.9% vs 6%; P = .98), time to AKI development (1.7 vs 2 days; P = .5), time to return to baseline renal function (4 vs 3 days; P = .2), new requirement for RRT (4.5% vs 1.5%; P = .3), ICU length of stay (7.3 vs 7.4 days; P = .9), hospital length of stay (19.3 vs 20.1 days; P = .87), or in-hospital mortality (15.9% vs 10.8%; P = .4). A significant difference was observed in the duration of antibiotic exposure (3.32 vs 2.62 days; P = .045 days). Conclusion: VPT was not associated with an increased risk of AKI or adverse renal outcomes. Our findings suggest that the use of this antibiotic combination should not be avoided in this patient population. More robust prospective studies are warranted to confirm these findings.

Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial.

Importance: Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. Objective: To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. Design, Setting, and Participants: Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. Interventions: Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. Main Outcomes and Measures: The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. Results: Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. Conclusions and Relevance: Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. Trial Registration: ClinicalTrials.gov Identifier: NCT03509350.

The impact of Hurricane Katrina upon older adult nurses: an assessment of quality of life and psychological distress in the aftermath.

The primary purpose of the current study was to evaluate the impact of Hurricane Katrina upon older nurses using cross sectional data from 291 respondents. Collected data served as the numerical predicate for the evaluation of quality of life and psychological distress among nurses who were affected by Hurricane Katrina. While the focus for the present study was upon older nurses, cross sectional data was reflected for the plenary sample as well. Predictors of Katrina's impact upon older nurses were identified through multinomial regression analyses and included the physical function subscale (OR=0.954), the fatigue subscale (OR=0.961), the arousal subscale (OR=4.190), average to poor health (OR=2.040), married (OR=2.769) and the MSPSS (OR = 0.780). Significant associations between age and storm impact (F=10.707, ñ=.001), depression (F=15.782, ñ< .001), social support (F=5.869, ñ=.016), health status (F=29.004, ñ<.001), anxiety (F=5.583, ñ=.019) and posttraumatic distress disorder (F .032, fñ= .46) remained after adjustment for other risk factors. These associations, as reflected in their respective mean scores, indicated that older nurses experienced greater storm impact (2.880 vs. 2.511), depressive symptoms (11.250 vs. 9.080), anxiety (77.800 vs. 75.430), posttraumatic distress (72.830 vs. 70.860) and lower health status (68.891 vs. 73.569). Accordingly, a more robust public policy paradigm for addressing the growing labor shortages in the medical community is needed. Heightened Congressional interest and increased resourcing is required in order to affect necessary programmatic, educational and institutional remediation. Furthermore, given the increasing role of older nurses in the work place, extensive studies are needed to evaluate their status and independent risk factors for sustaining quality of life and psychological well being among these contributors of health care.

The use of discriminant function analysis to predict student success on the NCLEX-RN.

Predicting whether a student will be successful on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) has been an important endeavor for faculty in schools of nursing for the past 2 decades. Extensive documentation exists in the literature concerning research aimed at exploring the academic and nonacademic predictors of success on the NCLEX-RN. Reviews of the findings of these studies indicate that various factors emerge as academic predictors of success. The results of this study suggest that first-time success on the NCLEX-RN can be predicted with a high level of accuracy using existing student data. The findings also support the belief that it is possible to identify students who may be at risk for unsuccessful first time performance on the NCLEX-RN. Early identification of at-risk students will promote timely intervention strategies to optimize the students' potential for success.

Retention of African-American students in baccalaureate nursing programs: are we doing enough?

With the increasing minority population in the United States, much attention has been given to the lack of diversity among health care professionals, specifically nursing. Since the 1960s, the federal government has provided financial resources to institutions of higher education whose purpose was to diversify the health care profession. Historically, these resources have supported initiatives that primarily focused on the recruitment of minority students into higher education. These efforts temporarily increased the enrollment of students from varying racial and ethnic backgrounds. However, without established retention initiatives in place, the attrition rates for students from diverse backgrounds far exceeded the enrollment rates. Consequently, the nursing workforce continues to be a predominantly White female profession. In order for schools of nursing to create a workforce reflective of its patient population, both nursing education and institutions of higher education must be committed to implementing initiatives to increase the retention and graduation rates of minority students.

Shifting paradigms. Teaching gerontological nursing from a new perspective.

Gerontological health care is undergoing a revolution, much like that of the feminist movement of the 1960s. Fundamental changes in health care require revisions in nursing education to ensure appropriate care of older adults in the least restrictive environment. The purpose of this study is to promote the preparation of future nurses who have the knowledge and the skills necessary to provide nursing care for the growing cohorts of older adults. A theoretical rationale for a new perspective in nursing education is discussed. An experiential clinical learning activity based on the functional model of gerontological health care is examined. This home visit clinical learning activity provides nursing students with the opportunity to practice nursing reflective of the health care needs of older adults. Strategies for replication of this clinical learning activity are provided.

Said another way. Call to action: the need to increase diversity in the nursing workforce.

Nursing is multidimensional, interactive, interdisciplinary, and complex. Almost anything that can be said about nursing can be said another way. Some things worth being said and heard will not follow the norms of journal presentation. A forum accommodates the emerging voice, the new format, the innovative approach. Nursing Forum, in an effort to honor the independent voice in nursing, presents here the voice who elects to enter the dialogue, but who does so in another way.

A United States perspective on the challenges in nursing education.

Nursing education in the US today is at crossroads. The profession has made great strides in gaining public respect and recognition for the work that nurses do. Nurses' voices are being heard in important political debates about revolutionary changes in the problematic US health care system. Advanced practice nurses are becoming valued providers of primary care to US citizens. It is innovative educational programs and educators that have provided the foundation to help nursing use its voice and to propel the profession forward. However, nurse educators are finding that they face major challenges in keeping nursing on track to be in the forefront of health care in the future. Some of these challenges include confronting nursing and faculty shortages, eliminating inconsistent and confusing educational choices, taking responsibility for mandates to stay on the cutting edge of quality initiatives, providing excellent clinical experiences for students and being willing to step out of old comfort zones to engage in designing imaginative and innovative ways to educate nurses in the future. Nurse educators must be successful in turning these challenges into opportunities if nursing is to command a key role in an evolving US health care system.