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Introduction: Despite availability of effective and inexpensive pharmacologic therapies for hypercholesterolemia and hypertension, many patients at high risk for atherosclerotic cardiovascular disease (ASCVD) do not achieve optimal low-density lipoprotein (LDL) and systolic blood pressure (SBP) levels. We hypothesized that risk factor control could be improved by using nurse practitioners and a guideline-directed protocol in a Medicare Advantage (MA) population. Methods: We designed and implemented an ongoing 18 site, multistate (FL, TX, NV), ASCVD risk assessment and management program (Healthy Heart) in a large national MA primary care clinic (Cano Health). The cardiometabolic risk assessment and management program was designed by a team of preventive cardiologists, with the plan of being Nurse Practitioner (NP)-led, with remote support by a cardiologist. Protocols provided details on initiation and titration of drug therapy to achieve LDL-C and SBP goals. Patients with organ transplants, advanced cancer, an ejection fraction Results: From October 2021-October 2022, 5430 patients were enrolled in the program. A total of 1858 (34.2%) had established ASCVD, 1033 (19.0%) had diabetes mellitus (DM). A total of 713 (13.1%) had both ASCVD and DM. In patients who had ASCVD and diabetes together, high intensity statin use increased from 39.4% to 68.3% after enrollment; 52.66% achieved an LDL-C Conclusions: Implementing a novel cardiovascular prevention program in a population of mostly Hispanic MA patients at high risk for ASCVD, using NPs, with strict adherence to a step-by-step evidence-based protocol supervised by cardiologists, is associated with reduction in LDL levels and SBP and with improvement in reaching LDL and SBP targets.

OBJECTIVES: To determine (1) factors linked to hospitalizations among managed care patients (MCPs), (2) outcome improvement with use of outpatient off-label treatment, and (3) outcome comparison between MCPs and a mirror group. STUDY DESIGN: Retrospective cohort study comparing MCPs with an age- and gender-matched mirror group in Florida from April 1, 2020, to May 31, 2020. METHODS: A total of 38,193 MCPs in a Florida primary care group were monitored for COVID-19 incidence, hospitalization, and mortality. The highest-risk patients were managed by the medical group's COVID-19 Task Force. As part of a population health program, the COVID-19 Task Force contacted patients, conducted medical encounters, and tracked data including comorbidities and medical outcomes. The MCPs enrolled in the medical group were compared with a mirror group from the state of Florida. RESULTS: The mean (SD) age among the MCPs was 67.9 (15.2) years, and 60% were female. Older age and hypertension were the most important factors in predicting COVID-19. Obesity, chronic kidney disease (CKD), and congestive heart failure (CHF) were linked to higher rates of hospitalizations. Patients prescribed off-label outpatient medications had 73% lower likelihood of hospitalization (P < .05). Compared with the mirror group, MCPs had 60% lower COVID-19 mortality (P < .05). CONCLUSIONS: MCPs have risk factors similar to the general population for COVID-19 incidence and progression, including older age, hypertension, obesity, CHF, and CKD. Outpatient treatment with off-label medicines decreased hospitalizations. A comprehensive population health program decreased COVID-19 mortality.

ImportanceCurrently, there is no unified framework linking disease progression to established viral levels, clinical tests, inflammatory markers, and investigational treatment options.ObjectiveIt may take many weeks or months to establish a standard treatment approach. Given the growing morbidity and mortality with respect to COVID-19, we present a treatment approach based on a thorough review of scholarly articles and clinical reports. Our focus is on staged progression, clinical algorithms, and individualized treatment.Evidence ReviewWe followed the protocol for a quality review article proposed by Heyn et. al.1 A literature search was conducted to find all relevant studies related to COVID-19. The search was conducted between April 1, 2020 and April 13, 2020 using the following electronic databases: PubMed (1809 to present), Google Scholar (1900 to present), MEDLINE (1946 to present), CINAHL (1937 to present), and Embase (1980 to present). Keywords used included COVID-19, 2019-nCov, SARS-CoV-2, SARS-CoV, and MERS-CoV, with terms such as efficacy, seroconversion, microbiology, pathophysiology, viral levels, inflammation, survivability, and treatment and pharmacology. No language restriction was placed on the search. Reference lists were manually scanned for additional studies.FindingsOf the articles found in the literature search, 70 were selected for inclusion in this study (67 cited in the body of the manuscript and 3 additional unique references in the Figures).The articles represent work from China, Japan, Taiwan, Vietnam, Rwanda, Israel, France, the United Kingdom, the Netherlands, Canada, and the United States. Most of the articles were cohort or case studies, but we also drew upon information found in guidelines from hospitals and clinics instructing their staff on procedures to follow. In addition, we based some decisions on data collected by agencies such as the CDC, FDA, IHME, ISDA, and Worldometer. None of the case studies or cohort studies used a large number of participants. The largest group of participants numbered less than 500 and some case studies had fewer than 30 patients. However, the review of the literature revealed the need for individualized treatment protocols due to the variability of patient clinical presentation and survivability. A number of factors appear to influence mortality: the stage at which the patient first presented for care, pre-existing health conditions, age, and the viral load the patient carried.Conclusion and RelevanceCOVID-19 can be divided into three distinct Stages, beginning at the time of infection (Stage I), sometimes progressing to pulmonary involvement (Stage II, with or without hypoxemia) and less frequently to systemic inflammation (Stage III). In addition to modeling the stages of disease progression, we have also created a treatment algorithm which considers age, comorbidities, clinical presentation, and disease progression to suggest drug classes or treatment modalities. This paper presents the first evidence-based recommendations for individualized treatment for COVID-19.Key PointsQuestionWhat are the most effective treatment recommendations for COVID-19?FindingsCOVID-19 can be divided into three distinct Stages, beginning at the time of infection (Stage I), sometimes progressing to pulmonary involvement (Stage II, with or without hypoxemia) and less frequently to systemic inflammation (Stage III). In addition to modeling the stages of disease progression, we also created a treatment algorithm which considers age, comorbidities, clinical presentation, and disease progression to suggest drug classes or treatment modalities.MeaningThis paper presents the first evidence-based recommendations for individualized treatment for COVID-19.

Four million individuals under the age of 21 admit to consuming alcohol in any given month. This is a significant statistic considering alcohol is responsible for most health problems related to drugs among adolescents. Research has shown that the high influence of alcohol advertising may encourage adolescents to emulate the behaviors seen in alcohol commercials. Further, those who begin drinking before age 13 are seven times more likely to consume 4+ drinks at least 6 times a month. The authors sought to show causality between the positive social perception of alcohol and the ability to influence drinking behavior. Survey findings of the study suggest that adolescents are more likely to be influenced by those who drink than those who do not. Therefore, measures to change this perception (in order to avert addiction and disease) must be put in place at an early age, much as they are (at both the academic and professional level) for combating tobacco.

In most health professions institutions, curricular evaluation is conducted in the absence of psychological tools. Yet, student health is correlated with stress and depression. This study used latent class analysis to describe student groups and their levels of stress, depression, and medical symptoms. Data from 386 health professions students (including medical, physician assistant, nursing, and audiology students) at Nova Southeastern University were analyzed. The results showed that nursing students are most likely to be classified as “healthy-adjusted” (latent class 1). Medical students were most likely to be classified as “severely depressed” (latent class 3). The findings demonstrate a need for the use of psychological tools in addition to conventional metrics to evaluate and improve curricula.

BACKGROUND: Heart failure (HF) is the leading cause of hospitalizations and readmissions in the United States. Approximately one‐third of patients admitted for HF are readmitted within 3 months; however, there are few markers that can identify those at highest risk for readmission. The purpose of this study was to identify clinical and laboratory markers associated with hospital readmission in decompensated HF. HYPOTHESIS: Clinical and laboratory markers are associated with readmission rates in decompensated HF. METHODS: Clinical and laboratory data from 412 patients admitted with HF were analyzed using a multivariable logistic regression analysis to find predictors of HF readmission by 30 days. RESULTS: HF readmission rates at 30 days were lowest in those with at least 2 of the following discharge criteria: net fluid reduction >1.3 L (odds ratio [OR]: 0.27, P = 0.019), serum sodium level >135 (OR: 0.46, P = 0.034), and N‐terminal brain natriuretic peptide level reduction >23% (OR: 0.11, P = 0.048). In multivariate analysis, those patients meeting ≥2 criteria had a very low risk of 30‐day readmission (OR: 0.10, 95% confidence interval: 0.01‐0.68, P = 0.019) compared to patients who failed to meet 2 criteria. CONCLUSIONS: A negative fluid balance, normal serum sodium, and net reduction in N‐terminal brain natriuretic peptide level during hospitalization may be important indices to target to help reduce the likelihood of HF readmission within 30 days.

The utilization of SPECT imaging has increased significantly over the last 2 decades. Appropriateness Criteria (AC) has been created to improve quality of care by guiding appropriate use since 2005. Although many studies have demonstrated that AC can improve appropriate use in clinical settings, the impact of AC on clinical outcomes has not been well studied. The objective of this study is to assess the AC and clinical outcomes. Methods. Consecutive outpatients in Cardiology and Internal Medicine over 12 months were included in the study. New SPECT AC (2009) was used as the standard to assess appropriateness. Outpatient visit notes, SPECT imaging results and cardiac events (Hospitalization, PCI, CABG, MI and death) were analyzed. Inferential statistics were applied to evaluate each specific AC indications and their associations with cardiac events. Results. Out of 32,961 consecutive pts, 327 (1%) pts had events. Seventy-nine of the pts (24%) were excluded due to uncertain or non-categorized. Pts met Appropriate Indications (A-I) had significantly higher event rates than those pts with Inappropriate Indications (I-I) (63% v. 29%; OR 2.17, p < 0.001), and 10 fold between the most predictive and least predictive indications (60% versus 6.4%). The most predictive A-I were criterions #5 (detection of CAD in patient with high pre-test probability of CAD) and #30 (known CAD with new/worsening symptoms). However, I-I #13 (intermediate CHD risk by ATP-III), and #27 (known CAD on coronary angiography or prior abnormal stress imaging study) were equivalent to A-I in predicting cardiac events(63 % v. 59%, p=NS). Conclusion: Some inappropriate indications of AC need to be reevaluated and might be considered for reclassified to reflect outcomes. Further research on the AC use is warranted before widely applied to clinical settings in the US from 1/1/2011 as a mandate for lab accreditation and reimbursement. Risk of Cardiovascular Event within the Study Period Performed Not-Performed Appropriate Indications 9/34(26.5%) 40/44(90.9%) Inappropriate Indications 8/102(7.8%) 39/60(65.0%) *Rate of events within any particular group vs. all other groups (p < 0.05)