Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial.

BACKGROUND: Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model. METHODS: Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout. DISCUSSION: This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 .

Dietary Total Isoflavone Intake Is Associated With Lower Systolic Blood Pressure: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

The effect of dietary isoflavone intake on systolic blood pressure (SBP) has not been studied in a large community-based cohort inclusive of African Americans. The authors analyzed data from the year 20 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study, including medical history, physical examination, and dietary intake surveys for 3142 participants. Multivariable linear regression models controlled for age, sex, body mass index, smoking, physical activity, and intakes of alcohol and total energy. Effect modification by race was tested. Overall, patients with hypertension had a lower daily intake of total dietary isoflavones (2.2±5.2 mg/d vs 4.1±11.7 mg/d; P<.001). In fully adjusted models, the highest quartile of dietary isoflavone intake was associated with a 4.4 mm Hg lower SBP on average compared with SBP for the lowest quartile. The relationship between dietary isoflavone intake and SBP was more pronounced among African Americans compared with Caucasians (P for interaction <.001). Greater dietary intake of isoflavones was independently associated with a lower SBP.

Relationship between premature ventricular complexes and depressive symptoms in non-ST-elevation acute coronary syndrome.

AIMS: Depression is a recognized risk marker for mortality among acute coronary syndrome (ACS) patients. We hypothesized that ventricular arrhythmia detected by inpatient telemetry monitoring is more frequent among ACS patients with elevated depressive symptoms compared to those without depressive symptoms. METHODS AND RESULTS: We analysed data from patients enrolled in a prospective observational study of depression in ACS. Telemetry recordings during the index admission (average recording 21.3±3.0 hours) were analysed for frequent premature ventricular complexes (PVCs), defined as ≥10 per hour. The self-report Beck Depression Inventory (BDI) was used to assess depressive symptoms. Among 200 ACS patients, frequent PVCs were observed in 29% of patients with moderate depressive symptoms (BDI ≥10), 27% of those with mild symptoms (BDI 5-9), and only 11% of those with no/minimal symptoms (p=0.02). Log-transformed PVCs per hour were associated with depressive symptom category (p=0.008). In a multivariable logistic regression model that included age, gender, left ventricular ejection fraction, cardiovascular risk score, heart rate, and QT interval, mild symptoms (OR 3.02, 95% 0.97-9.43, p=0.058) and moderate-severe symptoms (OR 3.94, 95% CI 1.27-12.22, p=0.018) were associated with frequent PVCs. CONCLUSIONS: In this sample of ACS patients, depressive symptoms were independently associated with frequent PVCs during inpatient telemetry monitoring.

Salt sensitivity: a review with a focus on non-Hispanic blacks and Hispanics.

The purpose of this review is to summarize the available information regarding salt sensitivity particularly as it relates to non-Hispanic blacks and Hispanics and to clarify possible etiologies, especially those that might shed light on potential treatment options. In non-Hispanic blacks, there is evidence that endothelial dysfunction, reduced potassium intake, decreased urinary kallikrein excretion, upregulation of sodium channel activity, dysfunction in atrial natriuretic peptide (ANP) production, and APOL1 gene nephropathy risk variants may cause or contribute to salt sensitivity. Supported treatment avenues include diets high in potassium and soybean protein, the components of which stimulate nitric oxide production. Racial heterogeneity complicates the study of salt sensitivity in Hispanic populations. Caribbean Hispanics, who have a higher proportion of African ancestry, may respond to commonly prescribed anti-hypertensive agents in a way that is characteristic of non-Hispanic black hypertensives. The low-renin hypertensive phenotype commonly seen in non-Hispanic blacks has been linked to salt sensitivity and may indicate an increased risk for salt sensitivity in a portion of the Hispanic population. In conclusion, increased morbidity and mortality associated with salt sensitivity mandates further studies evaluating the efficacy of tailored dietary and pharmacologic treatment in non-Hispanic blacks and determining the prevalence of low renin hypertension and salt sensitivity within the various subgroups of Hispanic Americans.