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Objectives. This research describes the prevalence and covariates associated with opioid-induced constipation (OIC) in an observational cohort study utilizing a national veteran cohort and integrated data from the Center for Medicare and Medicaid Services (CMS). Methods. A cohort of 152,904 veterans with encounters between 1 January 2008 and 30 November 2010, an exposure to opioids of 30 days or more, and no exposure in the prior year was developed to establish existing conditions and medications at the start of the opioid exposure and determining outcomes through the end of exposure. OIC was identified through additions/changes in laxative prescriptions, all-cause constipation identification through diagnosis, or constipation related procedures in the presence of opioid exposure. The association of time to constipation with opioid use was analyzed using Cox proportional hazard regression adjusted for patient characteristics, concomitant medications, laboratory tests, and comorbidities. Results. The prevalence of OIC was 12.6%. Twelve positively associated covariates were identified with the largest associations for prior constipation and prevalent laxative (any laxative that continued into the first day of opioid exposure). Among the 17 negatively associated covariates, the largest associations were for erythromycins, androgens/anabolics, and unknown race. Conclusions. There were several novel covariates found that are seen in the all-cause chronic constipation literature but have not been reported for opioid-induced constipation. Some are modifiable covariates, particularly medication coadministration, which may assist clinicians and researchers in risk stratification efforts when initiating opioid medications. The integration of CMS data supports the robustness of the analysis and may be of interest in the elderly population warranting future examination.

ObjectiveTo evaluate whether early initiation of prophylactic anticoagulation compared with no anticoagulation was associated with decreased risk of death among patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United States.DesignObservational cohort study.SettingNationwide cohort of patients receiving care in the Department of Veterans Affairs, a large integrated national healthcare system.ParticipantsAll 4297 patients admitted to hospital from 1 March to 31 July 2020 with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and without a history of anticoagulation.Main outcome measuresThe main outcome was 30 day mortality. Secondary outcomes were inpatient mortality, initiating therapeutic anticoagulation (a proxy for clinical deterioration, including thromboembolic events), and bleeding that required transfusion.ResultsOf 4297 patients admitted to hospital with covid-19, 3627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3600) of treated patients received subcutaneous heparin or enoxaparin. 622 deaths occurred within 30 days of hospital admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospital stay. Using inverse probability of treatment weighted analyses, the cumulative incidence of mortality at 30 days was 14.3% (95% confidence interval 13.1% to 15.5%) among those who received prophylactic anticoagulation and 18.7% (15.1% to 22.9%) among those who did not. Compared with patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30 day mortality (hazard ratio 0.73, 95% confidence interval 0.66 to 0.81). Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation. Receipt of prophylactic anticoagulation was not associated with increased risk of bleeding that required transfusion (hazard ratio 0.87, 0.71 to 1.05). Quantitative bias analysis showed that results were robust to unmeasured confounding (e-value lower 95% confidence interval 1.77 for 30 day mortality). Results persisted in several sensitivity analyses.ConclusionsEarly initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with covid-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events. These findings provide strong real world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial treatment for patients with covid-19 on hospital admission.

Recurrent AKI is common among patients after hospitalized AKI and is associated with progressive CKD. In this study, we identified clinical risk factors for recurrent AKI present during index AKI hospitalizations that occurred between 2003 and 2010 using a regional Veterans Administration database in the United States. AKI was defined as a 0.3 mg/dl or 50% increase from a baseline creatinine measure. The primary outcome was hospitalization with recurrent AKI within 12 months of discharge from the index hospitalization. Time to recurrent AKI was examined using Cox regression analysis, and sensitivity analyses were performed using a competing risk approach. Among 11,683 qualifying AKI hospitalizations, 2954 patients (25%) were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI within 12 months was 64 (interquartile range 19-167) days. In addition to known demographic and comorbid risk factors for AKI, patients with longer AKI duration and those whose discharge diagnosis at index AKI hospitalization included congestive heart failure (primary diagnosis), decompensated advanced liver disease, cancer with or without chemotherapy, acute coronary syndrome, or volume depletion, were at highest risk for being hospitalized with recurrent AKI. Risk factors identified were similar when a competing risk model for death was applied. In conclusion, several inpatient conditions associated with AKI may increase the risk for recurrent AKI. These findings should facilitate risk stratification, guide appropriate patient referral after AKI, and help generate potential risk reduction strategies. Efforts to identify modifiable factors to prevent recurrent AKI in these patients are warranted.

Background Systemic aspergillosis is a manifestation of Aspergillus sp. infection that can result in central nervous system (CNS) involvement with marked alterations in CNS function. Information regarding the clinical presentation and magnetic resonance imaging (MRI) findings in cases of aspergillosis with CNS involvement is lacking, resulting in a need for better understanding of this disease. Hypothesis/Objectives The primary objectives were to describe the clinical features and MRI findings in dogs with CNS aspergillosis. The secondary objectives were to describe clinicopathologic findings and case outcome. Animals Seven dogs with CNS aspergillosis. Methods Archived records from 6 institutions were reviewed to identify cases with MRI of CNS aspergillosis confirmed with serum galactomannan enzyme immunoassay (EIA) testing, culture, or supported by histopathology. Signalment, clinical, MRI, clinicopathologic, histopathologic, and microbiologic findings were recorded and evaluated. Results Aspergillosis of the CNS was identified in 7 dogs from 3 institutions. The median age was 3 years and six were German Shepherd dogs. Five dogs had signs of vestibular dysfunction as a component of multifocal neurological abnormalities. The MRI findings ranged from normal to abnormal, including hemorrhagic infarction and mass lesions. Conclusions and Clinical Importance Until now, all reported MRI findings in dogs with CNS aspergillosis have been abnormal. We document that CNS aspergillosis in dogs, particularly German Shepherd dogs, can be suspected based on neurologic signs, whether MRI findings are normal or abnormal. Confirmatory testing with galactomannan EIA, urine, cerebrospinal fluid (CSF) or tissue culture should be performed in cases where aspergillosis is a differential diagnosis.

Individuals with tuberous sclerosis complex (TSC) are at increased risk of developing self-injurious behaviour. The persistence of this deleterious behaviour over years is reported in aetiologically heterogeneous samples to be between 60% and 80% but is unknown for TSC.In this study, we determined the 3-year persistence of self-injury in a sample (n = 52) of children (with and without ID) and adults (with ID) with TSC and examined characteristics associated with persistence.Findings for self-injury were contrasted to those for aggression and property destruction to examine the specificity of results to this behaviour. Self-injury was persistent in 84.6% of those with TSC who showed this behaviour, in contrast to 66.7% both for aggression and destruction. Persistent self-injury was associated with poor self-help skills, greater overactivity/impulsivity and more behavioural indicators of pain. These latter two characteristics were also associated with persistent aggression. No characteristics were associated with persistence of property destruction.These findings suggest that self-injurious behaviours in individuals with TSC, together with aggressive and destructive behaviours, are highly persistent and would benefit from targeted intervention. Poor adaptive skills, overactivity/impulsivity and painful health conditions may differentiate those at most risk for persistent self-injury or aggression.

Background Limited research exists on physician-delivered education interventions. We examined the feasibility and impact of an educational tool on facilitating physician-patient kidney disease communication. Study Design Pilot feasibility clinical trial with a historical control to examine effect size on patient knowledge and structured questions to elicit physician and patient feedback. Setting & Participants Adults with chronic kidney disease (CKD) stages 1-5, seen in nephrology clinic. Intervention 1-page educational worksheet, reviewed by physicians with patients. Outcomes Kidney knowledge between patient groups and provider/patient feedback. Measurements Patient kidney knowledge was measured using a previously validated questionnaire compared between patients receiving the intervention (April to October 2010) and a historical cohort (April to October 2009). Provider input was obtained using structured interviews. Patient input was obtained through survey questions. Patient characteristics were abstracted from the medical record. Results 556 patients were included, with 401 patients in the historical cohort and 155 receiving the intervention. Mean age was 57 ± 16 (SD) years, with 53% men, 81% whites, and 78% with CKD stages 3-5. Compared with the historical cohort, patients receiving the intervention had higher adjusted odds of knowing they had CKD (adjusted OR, 2.20; 95% CI, 1.16-4.17; P = 0.02), knowing their kidney function (adjusted OR, 2.25; 95% CI, 1.27-3.97; P = 0.005), and knowing their stage of CKD (adjusted OR, 3.22; 95% CI, 1.49-6.92; P = 0.003). Physicians found the intervention tool easy and feasible to integrate into practice and 98% of patients who received the intervention recommended it for future use. Limitations Study design did not randomly assign patients for comparison and enrollment was performed in clinics at one center. Conclusions In this pilot study, a physician-delivered education intervention was feasible to use in practice and was associated with higher patient kidney disease knowledge. Further examination of physician-delivered education interventions for increasing patient disease understanding should be tested through randomized trials.

Background Acute kidney injury (AKI) is common and associated with poor outcomes. Heart failure is a leading cause of cardiovascular disease among patients with chronic kidney disease. The relationship between AKI and heart failure remains unknown and may identify a novel mechanistic link between kidney and cardiovascular disease. Study Design Observational study. Setting & Participants We studied a national cohort of 300,868 hospitalized US veterans (2004-2011) without a history of heart failure. Predictor AKI was the predictor and was defined as a 0.3-mg/dL or 50% increase in serum creatinine concentration from baseline to the peak hospital value. Patients with and without AKI were matched (1:1) on 28 in- and outpatient covariates using optimal Mahalanobis distance matching. Outcomes Incident heart failure was defined as 1 or more hospitalization or 2 or more outpatient visits with a diagnosis of heart failure within 2 years through 2013. Results There were 150,434 matched pairs in the study. Patients with and without AKI during the index hospitalization were well matched, with a median preadmission estimated glomerular filtration rate of 69mL/min/1.73m2. The overall incidence rate of heart failure was 27.8 (95% CI, 19.3-39.9) per 1,000 person-years. The incidence rate was higher in those with compared with those without AKI: 30.8 (95% CI, 21.8-43.5) and 24.9 (95% CI, 16.9-36.5) per 1,000 person-years, respectively. In multivariable models, AKI was associated with 23% increased risk for incident heart failure (HR, 1.23; 95% CI, 1.19-1.27). Limitations Study population was primarily men, reflecting patients seen at Veterans Affairs hospitals. Conclusions AKI is an independent risk factor for incident heart failure. Future studies to identify underlying mechanisms and modifiable risk factors are needed.

To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S).We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months.At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls.CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

It is likely that patients with chronic kidney disease (CKD) have a limited understanding of their illness. Here we studied the relationships between objective and perceived knowledge in CKD using the Kidney Disease Knowledge Survey and the Perceived Kidney Disease Knowledge Survey. We quantified perceived and objective knowledge in 399 patients at all stages of non-dialysis-dependent CKD. Demographically, the patient median age was 58 years, 47% were women, 77% had stages 3–5 CKD, and 83% were Caucasians. The overall median score of the perceived knowledge survey was 2.56 (range: 1–4), and this new measure exhibited excellent reliability and construct validity. In unadjusted analysis, perceived knowledge was associated with patient characteristics defined a priori , including objective knowledge and patient satisfaction with physician communication. In adjusted analysis, older age, male gender, and limited health literacy were associated with lower perceived knowledge. Additional analysis revealed that perceived knowledge was associated with significantly higher odds (2.13), and objective knowledge with lower odds (0.91), of patient satisfaction with physician communication. Thus, our results present a mechanism to evaluate distinct forms of patient kidney knowledge and identify specific opportunities for education tailored to patients with CKD.

Patients' ability to accurately report their preadmission medications is a vital aspect of medication reconciliation, and may affect subsequent medication adherence and safety. Little is known about predictors of preadmission medication understanding.We conducted a cross-sectional evaluation of patients at 2 hospitals using a novel Medication Understanding Questionnaire (MUQ). MUQ scores range from 0 to 3 and test knowledge of the medication purpose, dose, and frequency. We used multivariable ordinal regression to determine predictors of higher MUQ scores.Among the 790 eligible patients, the median age was 61 (interquartile range [IQR] 52, 71), 21% had marginal or inadequate health literacy, and the median number of medications was 8 (IQR 5, 11). Median MUQ score was 2.5 (IQR 2.2, 2.8). Patients with marginal or inadequate health literacy had a lower odds of understanding their medications (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.34 to 0.84; P = 0.0001; and OR = 0.49; 95% CI, 0.31 to 0.78; P = 0.0001; respectively), compared to patients with adequate health literacy. Higher number of prescription medications was associated with lower MUQ scores (OR = 0.52; 95% CI, 0.36 to 0.75; for those using 6 medications vs 1; P = 0.0019), as was impaired cognitive function (OR = 0.57; 95% CI, 0.38 to 0.86; P = 0.001).Lower health literacy, lower cognitive function, and higher number of medications each were independently associated with less understanding of the preadmission medication regimen. Clinicians should be aware of these factors when considering the accuracy of patient-reported medication regimens, and counseling patients about safe and effective medication use.

To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements.A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center.A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009.None.Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria.A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0).The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients.Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations.Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p0.05), higher treatment satisfaction (OR 1.76-1.96, all p0.01), portion size reduction (OR 1.43, p0.05), diabetes self-efficacy (OR 1.41, p0.05), and lower A1C (β=-0.06, p0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p0.001).Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction.Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations.

Unintentional injury is a leading cause of infant mortality.To examine the role of caregiver health literacy in infant injury prevention behaviors.A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety.Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9).Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

Fluoroquinolone exposure before tuberculosis (TB) diagnosis is common. We anticipated that exposure to older-generation fluoroquinolones is associated with greater fluoroquinolone MICs in Mycobacterium tuberculosis than exposure to newer agents. A nested case–control study was performed among newly diagnosed TB patients reported to the Tennessee Department of Health (January 2002–December 2009). Each fluoroquinolone-resistant case ( n = 25) was matched to two fluoroquinolone-susceptible controls ( n = 50). Ciprofloxacin and ofloxacin were classified as older-generation fluoroquinolones; levofloxacin, moxifloxacin and gatifloxacin were considered newer agents. There was no difference between median ofloxacin MIC for isolates from 9 patients exposed only to older fluoroquinolones, 25 exposed only to newer fluoroquinolones, 6 exposed to both and 35 fluoroquinolone-unexposed patients (Kruskal–Wallis, P = 0.35). Using multivariate proportional odds logistic regression adjusting for age and sex, duration of exposure to newer fluoroquinolones was independently associated with higher MIC (OR = 1.79, 95% CI 1.22–2.64), but duration of exposure to older fluoroquinolones was not (OR = 0.94, 95% CI 0.50–1.78). Isolates from patients exposed only to newer fluoroquinolones tended to have mutations at gyrA codons 90, 91 or 94 more frequently than those exposed only to older fluoroquinolones (44% vs. 11%). We were surprised to find that duration of exposure to newer fluoroquinolones, but not older ones, was independently associated with higher ofloxacin MIC. This suggests that the mutant selection window lower boundary is likely to have clinical relevance; caution is warranted when newer fluoroquinolones are prescribed to patients with TB risk factors.

To examine the relationship between parent health literacy and "obesogenic" infant care behaviors.Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate ≥ 23; low23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site.Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (30 min/d), (aOR = 3.0 [1.5-5.8]).Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

Delirium is a neurobehavioral condition, which the Diagnostic and Statistical Manual-IV (DSM-IV) defines as a disturbance in consciousness accompanied by a change in cognition or a perceptual disturbance that is not better accounted for by dementia (American Psychiatric Association, 2000). The DSM-IV also specifies that the disturbance in consciousness develops over a short period and tends to fluctuate in course and that the diagnosis hinges on the presence of inattention (the hallmark of delirium) and not the presence of hallucinations or delusions. Delirium is a common occurrence among hospitalized individuals, with rates ranging from 15% to 50% (Francis, Martin, & Kapoor, 1990; Inouye et al., 1999; Levkoff et al., 1992; Peterson et al., 2006) or as high as 60% to 80% in intensive care units (ICUs). Delirium is a particular concern among hospitalized elders, given the increased risk of delirium conferred by advanced age (Ely et al., 2004; Levkoff et al., 1992; Peterson et al., 2006) and its association with increased morbidity and mortality (Bellelli et al., 2007; Elie et al., 2009; Fong et al., 2012; Inouye, Rushing, Foreman, Palmer, & Pompei, 1998; Rockwood et al., 1999). Recent research suggests that individuals who experience delirium while in ICU may also experience long-term cognitive deficits (Fong et al., 2009; Girard et al., 2010; Leslie, Marcantonio, Zhang, Leo-Summers, & Inouye, 2008; O’Keeffe and Lavan, 1997) with significant medical and public health costs (Marcantonio, Bergmann, Liely, Orav, & Jones, 2010; Milbrandt et al., 2004). There have been reports from postacute care (PAC) rehabilitation settings in nursing homes that 16% of patients are admitted with delirium and that 12% demonstrate delirium at 1 week when evaluated by research staff with the Confusion Assessment Method (CAM; Ely et al., 2001). Although brief screening instruments have been shown to detect delirium, there has been little research into the methods of diagnosing delirium in the setting of postacute geriatric inpatient units. The CAM-ICU is a brief structured delirium assessment instrument. It has previously been validated among ventilated patients in the ICU (Ely et al., 2004) and has been modified for use in settings that require very brief methods to screen such as the emergency department (Han et al., 2009). Although the CAM-ICU has been demonstrated to have good sensitivity and specificity in multiple studies for detecting delirium in ICU populations (Gusmao-Flores, Salluh, Chalhub, & Quarantini, 2012), it has not been widely used with patients with dementia or in postacute settings. This study sought to determine how frequently delirium was detected by the CAM-ICU in a Veteran’s Affairs (VA) postacute setting as compared with standard-of-care treatment team’s clinical assessment based on DSM-IV criteria.

Baseline creatinine (BCr) is frequently missing in AKI studies. Common surrogate estimates can misclassify AKI and adversely affect the study of related outcomes. This study examined whether multiple imputation improved accuracy of estimating missing BCr beyond current recommendations to apply assumed estimated GFR (eGFR) of 75 ml/min per 1.73 m(2) (eGFR 75).From 41,114 unique adult admissions (13,003 with and 28,111 without BCr data) at Vanderbilt University Hospital between 2006 and 2008, a propensity score model was developed to predict likelihood of missing BCr. Propensity scoring identified 6502 patients with highest likelihood of missing BCr among 13,003 patients with known BCr to simulate a "missing" data scenario while preserving actual reference BCr. Within this cohort (n=6502), the ability of various multiple-imputation approaches to estimate BCr and classify AKI were compared with that of eGFR 75.All multiple-imputation methods except the basic one more closely approximated actual BCr than did eGFR 75. Total AKI misclassification was lower with multiple imputation (full multiple imputation + serum creatinine) (9.0%) than with eGFR 75 (12.3%; P0.001). Improvements in misclassification were greater in patients with impaired kidney function (full multiple imputation + serum creatinine) (15.3%) versus eGFR 75 (40.5%; P0.001). Multiple imputation improved specificity and positive predictive value for detecting AKI at the expense of modestly decreasing sensitivity relative to eGFR 75.Multiple imputation can improve accuracy in estimating missing BCr and reduce misclassification of AKI beyond currently proposed methods.

Fluoroquinolone resistance in Mycobacterium tuberculosis can be conferred by mutations in gyrA or gyrB . The prevalence of resistance mutations outside the quinolone resistance-determining region (QRDR) of gyrA or gyrB is unclear, since such regions are rarely sequenced. M. tuberculosis isolates from 1,111 patients with newly diagnosed culture-confirmed tuberculosis diagnosed in Tennessee from 2002 to 2009 were screened for phenotypic ofloxacin resistance (>2 μg/ml). For each resistant isolate, two ofloxacin-susceptible isolates were selected: one with antecedent fluoroquinolone exposure and one without. The complete gyrA and gyrB genes were sequenced and compared with M. tuberculosis H37Rv. Of 25 ofloxacin-resistant isolates, 11 (44%) did not have previously reported resistance mutations. Of these, 10 had novel polymorphisms: 3 in the QRDR of gyrA , 1 in the QRDR of gyrB , and 6 outside the QRDR of gyrA or gyrB ; 1 did not have any gyrase polymorphisms. Polymorphisms in gyrA codons 1 to 73 were more common in fluoroquinolone-susceptible than in fluoroquinolone-resistant strains (20% versus 0%; P = 0.016). In summary, almost half of fluoroquinolone-resistant M. tuberculosis isolates did not have previously described resistance mutations, which has implications for genotypic diagnostic tests.

Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs).To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge.Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021)Two tertiary care academic hospitals.Adults hospitalized with acute coronary syndromes or acute decompensated heart failure.Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge.The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs.Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]).The characteristics of the study hospitals and participants may limit generalizability.Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention.National Heart, Lung, and Blood Institute.

Nucleoside analogue reverse transcriptase inhibitors are an integral component of combination antiretroviral treatment regimens. However, their ability to inhibit polymerase-γ has been associated with several mitochondrial toxicities, including potentially life-threatening lactic acidosis. A total of 650 antiretroviral-naive adults (69% female) initiated combination antiretroviral therapy (cART) and were intensively screened for toxicities including lactic acidosis as part of a 3-year clinical trial in Botswana. Patients were categorized as no lactic acidosis symptoms, minor symptoms but lactate

AKI associates with an increased risk for the development and progression of CKD and mortality. Processes of care after an episode of AKI are not well described. Here, we examined the likelihood of nephrology referral among survivors of AKI at risk for subsequent decline in kidney function in a US Department of Veterans Affairs database. We identified 3929 survivors of AKI hospitalized between January 2003 and December 2008 who had an estimated GFR (eGFR)

Limited health literacy is common in the United States and associates with poor clinical outcomes. Little is known about the effect of health literacy in patients with advanced kidney disease. In this prospective cohort study we describe the prevalence of limited health literacy and examine its association with the risk for mortality in hemodialysis patients. We enrolled 480 incident chronic hemodialysis patients from 77 dialysis clinics between 2005 and 2007 and followed them until April 2008. Measured using the Rapid Estimate of Adult Literacy in Medicine, 32% of patients had limited (

Study objective Delirium's adverse effect on long-term mortality in older hospitalized patients is well documented, whereas its effect in older emergency department (ED) patients remains unclear. Similarly, the consequences of delirium on nursing home patients treated in the ED are also unknown. As a result, we seek to determine whether delirium in the ED is independently associated with 6-month mortality in older patients and whether this relationship is modified by nursing home status. Methods Our prospective cohort study was conducted at a tertiary care, academic ED, using convenience sampling, and included English-speaking patients who were aged 65 years and older and were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or had incomplete data. The Confusion Assessment Method for the Intensive Care Unit was used to determine delirium and was administered by trained research assistants. Cox proportional hazard regression was performed to determine whether delirium in the ED was independently associated with 6-month mortality after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. To test whether the effect of delirium in the ED on 6-month mortality was modified by nursing home residence, an interaction term (delirium*nursing home) was incorporated into the multivariable model. Hazard ratios with their 95% confidence intervals were reported. Results Of the 628 patients enrolled, 108 (17.2%) were delirious in the ED and 58 (9.2%) were from the nursing home. For the entire cohort, the 6-month mortality rate was higher in the delirious group compared with the nondelirious group (37.0% versus 14.3%). Delirium was an independent predictor of increased 6-month mortality (hazard ratio=1.72; 95% confidence interval 1.04 to 2.86) after adjusting for age, comorbidity burden, severity of illness, dementia, functional dependence, and nursing home residence. The "delirium*nursing home" interaction was nonsignificant (P=.86), indicating that place of residence had no effect on the relationship between delirium in the ED and 6-month mortality. Conclusion Delirium in older ED patients is an independent predictor of increased 6-month mortality, and this relationship appears to be present regardless of nursing home status.

Background Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort. Methods We acquired clinical data from the Electronic health record (EHR) of 5 Veterans Affairs (VA) hospitals to identify patients hospitalized with AKI from January 1st, 2002 to December 31st, 2009, and followed these patients for 1 year or until death, enrollment in palliative care, or improvement in renal function to estimated GFR (eGFR) ≥60 L/min/1.73 m2. Using demographic data, administrative codes, and laboratory test data, we evaluated the receipt and timing of outpatient testing for serum concentrations of creatinine and any as well as quantitative proteinuria recommended for CKD risk stratification. Additionally, we reported the rate of phosphorus and parathyroid hormone (PTH) monitoring recommended for chronic kidney disease (CKD) patients. Results A total of 10,955 patients admitted with AKI were discharged with an eGFR