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Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PR agmatic Trial O f Messaging to P roviders about T reatment of A cute H eart F ailure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PR agmatic Trial O f Messaging to P roviders about T reatment of A cute H eart F ailureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm. [ABSTRACT FROM AUTHOR]

Digital health tools may improve quality of life (QOL) in patients with heart failure (HF) by promoting self-care, continuous education, and engagement with their condition. We sought to evaluate the effect on QOL of three digital health tools as compared to usual care in a randomized controlled trial. One hundred eighty-two patients across 11 HF clinics in the Yale New Haven Health System were randomized to receive one of three digital technologies - Bodyport (smart scale, N=46), Conversa™ (conversational platform, N=46), Noom® (smartphone application, N=46) - or usual care (control group, N=44). These technologies were designed to promote self-care and provide alerts to clinicians based on vital signs and other parameters (i.e., weight, impedance, and symptoms). The primary outcome was change in QOL at 90 days as assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score (OSS). Secondary outcomes included the evaluation of clinical outcomes and usage metrics at 90 days of follow-up. One hundred fifty-one (83%) participants completed their 90-day surveys. Median age of participants was 61 (IQR 53-69) years, 38% were women, and 34% were non-Hispanic black. Most participants had HF with reduced ejection fraction (70%). The baseline and 90-day results in KCCQ OSS by randomization group are shown in the Figure. The OSS did not significantly change within any treatment group and no group was significantly improved relative to usual care (Bodyport +2.1 [IQR -7.8 to +14.6], Conversa +2.1 [IQR -9.1 to +6.8], Noom +3.4 [IQR -2.8 to +15.1]). However, symptoms at 90 days, as assessed by the Total Symptom Score, were significantly improved in the Noom group relative to usual care (+4.2 points [IQR -1 to +16.7] vs -1 points [IQR -13.5 to +7.8], respectively; P=0.006). The Clinical Summary Score was also improved in the Noom group relative to usual care (+2.8 points [IQR -1 to +14.6] vs -3.1 points [IQR -10.2 to +3], respectively; P=0.002). During the 90 days of follow-up, 43 (93.5%) participants in the Bodyport group used the technology at least once, 33 (71.7%) engaged at least once with Conversa and 24 (52.2%) engaged at least once with Noom during their follow-up. There was no difference in emergency visits or hospitalization rates across the study arms. Overall, 23% of participants had a finding from their device that prompted a provider alert and 6% of the alerts led to changes in management. This randomized, pilot study of three digital interventions showed no effect on QOL as assessed by the KCCQ OSS. However, participants randomized to Noom technology demonstrated improved KCCQ Total Symptom Score and Clinical Summary Score relative to usual care group. Larger studies may better elucidate these effects. [ABSTRACT FROM AUTHOR]

BACKGROUND: We conducted a national survey of general surgeons to address the association be-tween surgeon characteristics and the tendency to recommend surgery. METHODS: We used a web-based survey with 25 hypothetical clinical scenarios with clinical equi-poise regarding the decision to operate. The respondent-level tendency to operate (TTO) score was cal-culated as the average score over the 25 scenarios. Surgical volume was based on self-report. Linear regression models were used to evaluate the associations between TTO, other covariates of interest, and surgical volume. RESULTS: There were 907 respondents. The mean surgical TTO was 3.05 ± .43. Surgeons had sig-nificantly lower TTO scores when responding to questions within their area of practice (P < .0001). There was no association between TTO and malpractice concerns, financial incentives, or compensa-tion structure. CONCLUSIONS: Surgeons recommend intervention far less frequently within their area of speciali-zation. Malpractice concerns, volume, and financial compensation do not significantly affect surgical decision making. [ABSTRACT FROM AUTHOR]

Proton pump inhibitors (PPIs) are widely prescribed and have effects on gut ion absorption and urinary ion concentrations. PPIs might therefore protect against or contribute to development of kidney stones. We investigated the association between PPI use and kidney stones. We performed a retrospective study using data from the Women's Veteran's Cohort Study, which comprised men and women, from October 1, 1999 through September 30, 2017. We collected data from 465,891 patients on PPI usage over time, demographics, laboratory results, comorbidities, and medication usage. Time-varying Cox proportional hazards and propensity matching analyses determined risk of PPI use and incident development of kidney stones. Use of histamine-2 receptor antagonists (H2RAs) was measured and levothyroxine use was a negative control exposure. PPI use was associated with kidney stones in the unadjusted analysis, with PPI use as a time-varying variable (hazard ratio [HR], 1.74; 95% CI, 1.67–1.82), and persisted in the adjusted analysis (HR, 1.46; CI, 1.38–1.55). The association was maintained in a propensity score-matched subset of PPI users and nonusers (adjusted HR, 1.25; CI 1.19–1.33). Increased dosage of PPI was associated with increased risk of kidney stones (HR, 1.11; CI, 1.09–1.14 for each increase in 30 defined daily doses over a 3-month period). H2RAs were also associated with increased risk (adjusted HR, 1.47; CI 1.31–1.64). We found no association, in adjusted analysis, of levothyroxine use with kidney stones (adjusted HR, 1.06; CI 0.94–1.21). In a large cohort study of veterans, we found PPI use to be associated with a dose-dependent increase in risk of kidney stones. H2RA use also has an association with risk of kidney stones, so acid suppression might be an involved mechanism. The effect is small and should not change prescribing for most patients. [ABSTRACT FROM AUTHOR]

Abstract: The novel iminosugar (1R,2S,3R,5R,8aR)-3-(hydroxymethyl)-5-methyloctahydroindolizine-1,2-diol (steviamine) was isolated from leaf material of Stevia rebaudiana and leaves and bulbs of Veltheimia capensis. This is the first report of an indolizidine iminosugar alkaloid from the Asteraceae and Hyacinthaceae. Steviamine may occur in some Stevia products and influence taste. [Copyright &y& Elsevier]