Nutrition, Obesity, and Cachexia in Patients With Heart Failure: A Consensus Statement from the Heart Failure Society of America Scientific Statements Committee.

Dietary guidance for patients with heart failure (HF) has traditionally focused on sodium and fluid intake restriction, but dietary quality is frequently poor in patients with HF and may contribute to morbidity and mortality. Restrictive diets can lead to inadequate intake of macronutrients and micronutrients by patients with HF, with the potential for deficiencies of calcium, magnesium, zinc, iron, thiamine, vitamins D, E, and K, and folate. Although inadequate intake and low plasma levels of micronutrients have been associated with adverse clinical outcomes, evidence supporting therapeutic repletion is limited. Intravenous iron, thiamine, and coenzyme Q10 have the most clinical trial data for supplementation. There is also limited evidence supporting protein intake goals. Obesity is a risk factor for incident HF, and weight loss is an established approach for preventing HF, with a role for bariatric surgery in patients with severe obesity. However weight loss for patients with existing HF and obesity is a more controversial topic owing to an obesity survival paradox. Dietary interventions and pharmacologic weight loss therapies are understudied in HF populations. There are also limited data for optimal strategies to identify and address cachexia and sarcopenia in patients with HF, with at least 10%-20% of patients with ambulatory systolic HF developing clinically significant wasting. Gaps in our knowledge about nutrition status in patients with HF are outlined in this Statement, and strategies to address the most clinically relevant questions are proposed.

Impact of video technology on efficiency of pharmacist-provided anticoagulation counseling and patient comprehension.

BACKGROUND: Discharge anticoagulation counseling is important for ensuring patient comprehension and optimizing clinical outcomes. As pharmacy resources become increasingly limited, the impact of informational videos on the counseling process becomes more relevant. OBJECTIVE: To evaluate differences in pharmacist time spent counseling and patient comprehension (measured by the Oral Anticoagulation Knowledge [OAK] test) between informational videos and traditional face-to-face (oral) counseling. METHODS: This prospective, open, parallel-group study at an academic medical center randomized 40 individuals-17 warfarin-naïve ("New Start") and 23 with prior warfarin use ("Restart")-to receive warfarin discharge education by video or face-to-face counseling. "Teach-back" questions were used in both groups. RESULTS: Although overall pharmacist time was reduced in the video counseling group (P < 0.001), an interaction between prior warfarin use and counseling method (P = 0.012) suggests the difference between counseling methods was smaller in New Start participants. Following adjustment, mean total time was reduced 8.71 (95% CI = 5.15-12.26) minutes (adjusted P < 0.001) in Restart participants and 2.31 (-2.19 to 6.81) minutes (adjusted P = 0.472) in New Start participants receiving video counseling. Postcounseling OAK test scores did not differ. Age, gender, socioeconomic status, and years of education were not predictive of total time or OAK test score. CONCLUSION: Use of informational videos coupled with teach-back questions significantly reduced pharmacist time spent on anticoagulation counseling without compromising short-term patient comprehension, primarily in patients with prior warfarin use. Study results demonstrate that video technology provides an efficient method of anticoagulation counseling while achieving similar comprehension.

Student experiences across multiple flipped courses in a single curriculum.

CONTEXT: The flipped classroom approach has garnered significant attention in health professions education, which has resulted in calls for curriculum-wide implementations of the model. However, research to support the development of evidence-based guidelines for large-scale flipped classroom implementations is lacking. OBJECTIVES: This study was designed to examine how students experience the flipped classroom model of learning in multiple courses within a single curriculum, as well as to identify specific elements of flipped learning that students perceive as beneficial or challenging. METHODS: A qualitative analysis of students' comments (n = 6010) from mid-course and end-of-course evaluations of 10 flipped courses (in 2012-2014) was conducted. Common and recurring themes were identified through systematic iterative coding and sorting using the constant comparison method. Multiple coders, agreement through consensus and member checking were utilised to ensure the trustworthiness of findings. RESULTS: Several themes emerged from the analysis: (i) the perceived advantages of flipped learning coupled with concerns about implementation; (ii) the benefits of pre-class learning and factors that negatively affect these benefits, such as quality and quantity of learning materials, as well as overall increase in workload, especially in the context of multiple concurrent flipped courses; (iii) the role of the instructor in the flipped learning environment, particularly in engaging students in active learning and ensuring instructional alignment, and (iv) the need for assessments that emphasise the application of knowledge and critical thinking skills. CONCLUSIONS: Analysis of data from 10 flipped courses provided insight into common patterns of student learning experiences specific to the flipped learning model within a single curriculum. The study points to the challenges associated with scaling the implementation of the flipped classroom across multiple courses. Several core elements critical to the effective design and implementation of the flipped classroom model are identified.

Student Pharmacists Provide Similar Quality Clinical Reasoning Feedback as Resident Teaching Assistants.

OBJECTIVE: Pharmacists utilize clinical reasoning (CR) to improve patient outcomes via medication optimization. It is critical to develop these skills in student pharmacists, yet optimal pedagogies to teach and assess CR are unknown. Peer feedback may be used to develop CR in student pharmacists, but a certain feedback quality must be reached to be effective. This study sought to evaluate if student pharmacists could provide similar quality peer feedback compared to pharmacy resident teaching assistant (TA) feedback. METHODS: This was a retrospective, mixed-methods pedagogical analysis comparing the quality of first-year student pharmacist peer feedback to resident TA CR feedback. The CR comments were defined using the intellectual standards of CR. Quality was assessed for task specification, gap identification, actionability, and process orientation by 2 independent investigators. Student performance and perceptions were also assessed. Mann-Whitney U, t tests, and descriptive statistics were used to analyze data where appropriate. RESULTS: Clinical reasoning feedback from peers (N = 805) and TAs (N = 206) were analyzed. Interrater reliability for feedback quality was moderate to substantial. Overall, peer CR feedback was of higher quality regarding task specification and process orientation while TA CR feedback was of higher quality regarding gap identification and actionability. Students receiving peer feedback performed better on a final patient case than those receiving TA feedback (95.2% vs 92.3%). Overall, the peer feedback process was well received by students. CONCLUSION: Student pharmacists can provide similar quality feedback as resident TAs. Peer feedback offers an alternative to resident TA feedback and has the potential to contribute to improved CR skills.

Accuracy of the electronic health record's problem list in describing multimorbidity in patients with heart failure in the emergency department.

Patients with heart failure (HF) often suffer from multimorbidity. Rapid assessment of multimorbidity is important for minimizing the risk of harmful drug-disease and drug-drug interactions. We assessed the accuracy of using the electronic health record (EHR) problem list to identify comorbid conditions among patients with chronic HF in the emergency department (ED). A retrospective chart review study was performed on a random sample of 200 patients age ≥65 years with a diagnosis of HF presenting to an academic ED in 2019. We assessed participant chronic conditions using: (1) structured chart review (gold standard) and (2) an EHR-based algorithm using the problem list. Chronic conditions were classified into 37 disease domains using the Agency for Healthcare Research Quality's Elixhauser Comorbidity Software. For each disease domain, we report the sensitivity, specificity, positive predictive value, and negative predictive of using an EHR-based algorithm. We calculated the intra-class correlation coefficient (ICC) to assess overall agreement on Elixhauser domain count between chart review and problem list. Patients with HF had a mean of 5.4 chronic conditions (SD 2.1) in the chart review and a mean of 4.1 chronic conditions (SD 2.1) in the EHR-based problem list. The five most prevalent domains were uncomplicated hypertension (90%), obesity (42%), chronic pulmonary disease (38%), deficiency anemias (33%), and diabetes with chronic complications (30.5%). The positive predictive value and negative predictive value of using the EHR-based problem list was greater than 90% for 24/37 and 32/37 disease domains, respectively. The EHR-based problem list correctly identified 3.7 domains per patient and misclassified 2.0 domains per patient. Overall, the ICC in comparing Elixhauser domain count was 0.77 (95% CI: 0.71-0.82). The EHR-based problem list captures multimorbidity with moderate-to-good accuracy in patient with HF in the ED.

Underutilization of evidence-based therapies in heart failure: the pharmacist's role.

Utilization of evidence-based therapy in the heart failure population includes implementation of heart failure treatment guidelines, interventions to improve prescribing, and inclusion of pharmacists on the multidisciplinary team. Use of treatment guidelines eases the challenge of selecting the appropriate drug and dosage; quality interventions by pharmacists can ensure optimal prescribing of therapy; and provision of care by a multidisciplinary team can improve outcomes in patients with heart failure. Evidence-based therapy, however, remains underutilized in the heart failure population. Barriers to utilization include misperceptions that various heart failure subpopulations do not need certain medical therapies, a fear of polypharmacy, inappropriate assumptions about adverse effects and contraindications, and cost. In fact, optimal prescribing of evidence-based therapy can actually reduce costs. Clearly documented processes and systems are needed to ensure that evidence-based therapy and education are available to every patient.

Nesiritide: harmful or harmless?

Nesiritide is the recombinant form of human B-type (brain) natriuretic peptide (BNP), and its amino acid sequence is identical to that of endogenous human BNP. Administration of nesiritide results in venous and arterial vasodilation, as well as enhanced diuresis. Given the many limitations of therapies previously available for the treatment of acute decompensated heart failure, the anticipation was that nesiritide would offer a safer and more effective therapeutic option. Recently, two meta-analyses raised the question of safety with nesiritide therapy, specifically an increased risk of renal dysfunction and mortality. Although several studies generated information regarding the potential role of nesiritide in various settings, the questions raised by the meta-analyses are concerning. Our hope is that future clinical trials will address the concerns raised and provide a better understanding of the role of nesiritide in the management of acute decompensated heart failure. Until these data are available, nesiritide use should be limited.

A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients.

OBJECTIVE: To compare duration of mechanical ventilation for patients randomized to receive lorazepam by intermittent bolus administration vs. continuous infusions of propofol using protocols that include scheduled daily interruption of sedation. DESIGN: A randomized open-label trial enrolling patients from October 2001 to March 2004. SETTING: Medical intensive care units of two tertiary care medical centers. PATIENTS: Adult patients expected to require mechanical ventilation for >48 hrs and who required > or =10 mg of lorazepam or a continuous infusion of a sedative to achieve adequate sedation. INTERVENTIONS: Patients were randomized to receive lorazepam by intermittent bolus administration or propofol by continuous infusion to maintain a Ramsay score of 2-3. Sedation was interrupted on a daily basis for both groups. MEASUREMENTS AND MAIN RESULTS: The primary outcome was median ventilator days. Secondary outcomes included 28-day ventilator-free survival, intensive care unit and hospital length of stay, and hospital mortality. Median ventilator days were significantly lower in the daily interruption propofol group compared with the intermittent bolus lorazepam group (5.8 vs. 8.4, p = .04). The difference was largest for hospital survivors (4.4 vs. 9.0, p = .006). There was a trend toward greater ventilator-free survival for patients in the daily interruption propofol group (median 18.5 days for propofol vs. 10.2 for lorazepam, p = .06). Hospital mortality was not different. CONCLUSIONS: For medical patients requiring >48 hrs of mechanical ventilation, sedation with propofol results in significantly fewer ventilator days compared with intermittent lorazepam when sedatives are interrupted daily.