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Abstract Background Clostridium difficile is the most common cause of nosocomial infectious diarrhea in the United States. However, recent reports have documented that C. difficile infections (CDIs) are occurring among patients without traditional risk factors. The purpose of this study was to examine the epidemiology of CA-CDI, by estimating the incidence of CA-CDI and HA-CDI, identifying patient-related risk factors for CA-CDI, and describing adverse health outcomes of CA-CDI. Methods We conducted a population-based, retrospective, nested, case-control study within the University of Iowa Wellmark Data Repository from January 2004 to December 2007. We identified persons with CDI, determined whether infection was community-associated (CA) or hospital-acquired (HA), and calculated incidence rates. We collected demographic, clinical, and pharmacologic information for CA-CDI cases and controls (i.e., persons without CDI). We used conditional logistic regression to estimate the odds ratios (ORs) for potential risk factors for CA-CDI. Results The incidence rates for CA-CDI and HA-CDI were 11.16 and 12.1 cases per 100,000 person-years, respectively. CA-CDI cases were more likely than controls to receive antimicrobials (adjusted OR, 6.09 [95% CI 4.59-8.08]) and gastric acid suppressants (adjusted OR, 2.30 [95% CI 1.56-3.39]) in the 180 days before diagnosis. Controlling for other covariates, increased risk for CA-CDI was associated with use of beta-lactam/beta-lactamase inhibitors, cephalosporins, clindamycin, fluoroquinolones, macrolides, and penicillins. However, 27% of CA-CDI cases did not receive antimicrobials in the 180 days before their diagnoses, and 17% did not have any traditional risk factors for CDI. Conclusions Our study documented that the epidemiology of CDI is changing, with CA-CDI occurring in populations not traditionally considered "high-risk" for the disease. Clinicians should consider this diagnosis and obtain appropriate diagnostic testing for outpatients with persistent or severe diarrhea who have even remote antimicrobial exposure.

Objective: Fear of Aversive Consequences (FOAC), such as choking or vomiting, is an important associated feature of Avoidant/Restrictive Food Intake Disorder (ARFID). However, the manifestation of FOAC in young children is poorly understood. This study aimed to describe the fears of children with ARFID symptoms and examine the concordance between parent and child ratings of fear., Method: Child-reported FOAC was assessed using an interview designed for children between 6 and 10 years old, the Gustatory Avoidance and Gastrointestinal Stress Symptoms (GAGSS). Parents were administered a semi-structured diagnostic interview regarding their child's symptoms, the Pica, ARFID, and Rumination Interview., Results: Among 68 children with ARFID diagnoses or symptoms (41.2% female, 85.3% White, mean age = 8.2 years, SD = 1.1 years; range 5.2-9.9 years), 91.2% of children endorsed at least one fear relative to 26.5% of parents. Among parent-child dyads, 36.8% disagreed about the child's fear of stomach pain (κ = 0.12) and 48.5% disagreed about the child's fear of vomiting, (κ = 0.08), both indicating low inter-rater reliability. On average, children endorsed 4.3 (SD = 2.3) fears out of 9 options. The most frequently endorsed fears were that food will "taste bad," (n = 43, 63.2%), "make you gag" (n = 37, 54.4%), and "look disgusting" (n = 36, 52.9%)., Discussion: Findings highlight ways in which fear may manifest in children with ARFID that are not easily discernable by adults. Greater precision in depicting childhood fears may facilitate the earlier detection of problematic eating behaviors., (© 2024 Wiley Periodicals LLC.)

Importance: Patient-directed educational materials are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks., Objective: To examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit (proton pump inhibitors) or high-risk medications (high-dose gabapentin, diabetes agents with hypoglycemia risks)., Design, Setting, and Participants: This pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct US Veterans Affairs (VA) medical centers from April 2021 to October 2022. The total study sample was composed of the intervention cohort and the historical control cohort cared for by 103 primary care practitioners (PCPs)., Intervention: The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to all eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same PCPs at the same sites 1 year prior to the study intervention served as controls., Main Outcome and Measures: The primary binary outcome variable was deprescribing 6 months after the intervention, defined as complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data., Results: The total study sample included 5071 patients. The overall rate of deprescribing among the intervention cohort (n = 2539) was 29.5% compared with 25.8% among the controls (n = 2532). In an unadjusted model, the intervention cohort was statistically significantly more likely to have deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = .02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = .008). The difference in deprescribing prevalence between the intervention and control cohorts (proton pump inhibitors: 29.4% vs 25.4%; gabapentin: 40.2% vs 36.2%; hypoglycemia risk: 27.3% vs 25.1%) did not statistically significantly differ by medication group (P = .90)., Conclusion and Relevance: This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups., Trial Registration: ClinicalTrials.gov Identifier: NCT0429490.

Rationale & Objective: Prescribing psychoactive medications for patients with kidney disease is common, but for patients receiving dialysis some medications may be inappropriate. We evaluated the association of coprescribing gabapentinoids and other psychoactive potentially inappropriate medications (PPIMs) (eg, sedatives or opioids) with altered mental status (AMS) and falls and whether the associations are modified by frailty., Study Design: Observational cohort study., Setting & Participants: Adults receiving dialysis represented in the US Renal Data System who had an active gabapentinoid prescription and no other PPIM prescriptions in the prior 6 months., Exposure: PPIM coprescribing, or the presence of overlapping prescriptions of a gabapentinoid and≥1 additional PPIM., Outcome: Acute care visits for AMS and injurious falls., Analytical Approach: Prentice-Williams-Petersen Gap Time models estimated the association between PPIM coprescribing and each outcome, adjusting for demographics, comorbidities, and frailty, as assessed by a validated frailty index (FI). Each model tested for interaction between PPIM coprescribing and frailty., Results: Overall, PPIM coprescribing was associated with increased hazard of AMS (HR, 1.66 [95% CI, 1.44-1.92]) and falls (HR, 1.55 [95% CI, 1.36-1.77]). Frailty significantly modified the effect of PPIM coprescribing on the hazard of AMS (interaction P=0.01) but not falls. Among individuals with low frailty (FI=0.15), the HR for AMS with PPIM coprescribing was 2.14 (95% CI, 1.69-2.71); for individuals with severe frailty (FI=0.34), the hazard ratio for AMS with PPIM coprescribing was 1.64 (95% CI, 1.42-1.89). Individuals with PPIM coprescribing and severe frailty (FI=0.34) had the highest hazard of AMS (HR, 3.22 [95% CI, 2.55-4.06]) and falls (HR, 2.77 [95% CI, 2.27-3.38]) compared with nonfrail individuals without PPIM coprescribing., Limitations: Outcome ascertainment bias; residual confounding., Conclusions: Compared with gabapentinoid prescriptions alone, PPIM coprescribing was associated with an increased risk of AMS and falls. Clinicians should consider these risks when coprescribing PPIMs to patients receiving dialysis., Plain-Language Summary: Among people on dialysis, gabapentinoids may lead to confusion and falls. Often they are prescribed with other sedatives drugs or opioids, which can increase these risks. This study of adults with kidney failure receiving maintenance dialysis in the United States found that those who were prescribed both gabapentinoids and other psychoactive drugs were more likely to have confusion and falls compared with those who only took gabapentinoids. These relationships were seen at all levels of frailty although the relative risk of confusion related to an additional psychoactive drug was somewhat lower in the setting of greater frailty. Clinicians should consider elevated risks of confusion and falls when prescribing psychoactive drugs to patients receiving dialysis who are also prescribed gabapentinoids., (Published by Elsevier Inc.)

Background/objective: Slowing the progression of diabetic kidney disease (DKD) is critical. We conducted a randomized controlled trial to target risk factors for DKD progression., Methods: We evaluated the effect of a pharmacist-led intervention focused on supporting healthy behaviors, medication management, and self-monitoring on decline in estimated glomerular filtration rate (eGFR) for 36 months compared with an educational control., Results: We randomized 138 individuals to the intervention group and 143 to control. At baseline, mean (SD) eGFR was 80.7 (21.7) mL/min/1.73m 2 , 56% of participants had chronic kidney disease and a history of uncontrolled hypertension with a baseline SBP of 134.3 mm Hg. The mean (SD) decline in eGFR by cystatin C from baseline to 36 months was 5.0 (19.6) and 5.9 (18.6) mL/min/1.73m 2 for the control and intervention groups, respectively, with no significant between-group difference ( P =0.75)., Conclusions: We did not observe a significant difference in clinical outcomes by study arm. However, we showed that individuals with DKD will engage in a pharmacist-led intervention. The potential explanations for a lack of change in DKD risk factors can be attributed to 5 broad issues, challenges: (1) associated with enrolling patients with low eGFR and poor BP control; (2) implementing the intervention; (3) limited duration during which to observe any clinical benefit from the intervention; (4) potential co-intervention or contamination; and (5) low statistical power., Competing Interests: This study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (1R01DK93938.). H.B. reports research grants from the PhRMA Foundation, Proteus Digital Health, Otsuka, Novo Nordisk, Sanofi, and Improved Patient Outcomes, as well as consulting from Sanofi, Novartis, Otsuka, Abbott, Preventric Diagnostics, and the Medicines Company. U.D.P. was supported by R01DK093938, R34DK102166, and P30DK096493 before joining Gilead Sciences in 2016. C.A.D. was partially supported by UL1TR002553, the NIH Clinical and Translational Science Award at Duke. J.P. was partially supported by P30AG02871615, the NIA Claude D. Pepper Older Americans Independence Center Award at Duke. H.B. was partially supported by U24-HL137907 and U24-DK065176. A.A.L. reports receiving funds from Otsuka and PhRMA Foundation, and is supported by VA HSR&D grant #18-234. M.J.C. reports funding from the National Institutes of Health (1R01NR019594-01), the Veterans Affairs Quality Enhancement Research Initiative (VA QUE 20-012), and the Veterans Affairs Office of Rural Health. The other authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Older age is linked with poorer self-care in the chronic kidney disease (CKD) setting. Informal health supporters (family members and friends) are critical sources of self-care support, but much remains unclear about the characteristics and implications of received support among this patient population. We examined how received self-care support (amount and type) related to positive (CKD management self-efficacy) and negative (depressive symptoms) psychosocial health correlates of self-care in 536 adults aged 65 years and older with non-dialysis-dependent CKD. Participants who received a greater amount of support reported less CKD management self-efficacy and more depressive symptoms. We did not observe associations between self-care support type and psychosocial health. Further research is needed to clarify our findings, especially studies that investigate causality and contextual influences., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this nursing continuing professional development (NCPD) activity., (Copyright© by the American Nephrology Nurses Association.)

Objectives: We identify factors associated with sustainment of an intervention (STAR-VA) to address distress behaviors in dementia (DBD), guided by the Organizational Memory Knowledge Reservoir (KR) framework, compared across 2 types of outcomes: (1) site performance improvement on a clinical outcome, the magnitude of change in levels of DBD, and (2) self-rated adherence to STAR-VA core components, a process outcome., Design: We used a cross-sectional sequential explanatory mixed methods design guided by the Organizational Memory Framework., Setting and Participants: We selected 20 of 79 sites that completed STAR-VA training and consultation based on rankings on 2 outcomes-change in an indicator of DBD and reported adherence to STAR-VA core components. We recruited key informants most knowledgeable about STAR-VA resulting in a sample of 43% behavioral coordinators, 36% nurse champions, and 21% nurse leaders., Methods: We collected data with key informants at each Community Living Center (CLC) from December 2018 to June 2019. We analyzed data using within-case and cross-case matrixes created from the coded transcripts for each a priori KR domain. We then assessed if there were any similarities or differences for CLCs in comparable DBD performance and STAR-VA adherence categories., Results: We found 4 KRs that differentiated sustainment factors based on CLC implementation process and clinical outcomes-3 KRs related to DBD performance (people, relationships, and routines) and 2 related to STAR-VA adherence (relationships and culture)., Conclusions and Implications: This evaluation found several knowledge retention mechanisms that differ in high and low performance/adherence sites. Our findings highlight knowledge retention/sustainment strategies based on site functioning to support sustainment strategies in the CLC. Understanding sustainment factors as they relate to clinical and process outcomes is innovative and can be used to support CLCs struggling with sustainment. More research is needed to inform tailored sustainment efforts based on site functioning in the nursing home setting., Competing Interests: Disclosure The authors declare no conflicts of interest., (Published by Elsevier Inc.)

Purpose: Understand how weekly monetary incentives for dietary tracking and/or weight loss impact 6-month weight loss behavioral adherence., Design: Secondary analysis of participants randomized to one of four conditions in a behavioral weight loss intervention: incentives for dietary tracking, incentives for weight loss, both, or none., Setting: Participants were asked to self-weigh at least twice weekly, log food and drink in a mobile application five days weekly, and attend bi-weekly, group-based classes., Sample: Data from (n = 91) adults with obesity who completed a 24-week behavioral weight loss intervention of whom 88% were female and 74% Non-Hispanic White, were analyzed., Measures: Non-adherence to weight and dietary self-monitoring was defined as the second week of not meeting criteria. Class attendance was also tracked., Analysis: Kaplan-Meier analyses were used to examine differences across the four conditions., Results: Participants incentivized for dietary self-monitoring had an average 15.8 weeks (SE:1.2) until the first non-adherent week compared to 5.9 weeks (SE:0.8) for those not incentivized for dietary self-monitoring ( P < .01). Those incentivized for weight loss had an average 18.0 weeks (SE:1.02) of self-weighing until the first non-adherent week compared to 13.5 weeks (SE:1.3) for those not incentivized for weight loss ( P = .02). No difference in class attendance was observed., Conclusions: Incentivizing behaviors associated with weight loss improved adherence to those behaviors and does not appear to spill over to non-incentivized behaviors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale & Objective: Optimal approaches to treat secondary hyperparathyroidism (SHPT) in patients on maintenance hemodialysis (HD) have yet to be established in randomized controlled trials (RCTs)., Study Design: Two observational clinical trial emulations., Setting & Participants: Both emulations included adults receiving in-center HD from a national dialysis organization. The patients who had SHPT in the period between 2009 and 2014, were insured for≥180 days by Medicare as primary payer, and did not have contraindications or poor health status limiting theoretical trial participation., Exposure: The parathyroid hormone (PTH) Target Trial emulation included patients with new-onset SHPT (first PTH 300-600pg/mL), with 2 arms defined as up-titration of either vitamin D sterols or cinacalcet within 30 days (lower target) or no up-titration (higher target). The Agent Trial emulation included patients with a PTH≥300 pg/mL while on≥6μg weekly of vitamin D sterol (paricalcitol equivalent dose) and no prior history of cinacalcet. The 2 arms were defined by the first dose or agent change within 30 days (vitamin D-favoring [vitamin-D was up-titrated] vs cinacalcet-favoring [cinacalcet was added] vs nondefined [neither applies]). Multiple trials per patient were allowed in trial 2., Outcome: The primary outcome was all-cause death over 24 months; secondary outcomes included cardiovascular (CV) hospitalization or the composite of CV hospitalization or death., Analytical Approach: Pooled logistic regression., Results: There were 1,152 patients in the PTH Target Trial (635 lower target and 517 higher target). There were 2,726 unique patients with 6,727 patient trials in the Agent Trial (6,268 vitamin D-favoring trials and 459 cinacalcet-favoring trials). The lower PTH target approach was associated with reduced adjusted hazard of death (HR, 0.71 [95% CI, 0.52-0.93]), CV hospitalization (HR, 0.78 [95% CI, 0.63-0.98]), and their composite (HR, 0.74 [95% CI, 0.61-0.89]). The cinacalcet-favoring approach demonstrated lower adjusted hazard of death compared to the vitamin D-favoring approach (HR, 0.79 [95% CI, 0.62-0.99]), but not of CV hospitalization or the composite outcome., Limitations: Potential for residual confounding; low use of cinacalcet with low power., Conclusions: SHPT management that is focused on lower PTH targets may lower mortality and CV disease in patients receiving HD. These findings should be confirmed in a pragmatic randomized trial., Plain-Language Summary: Optimal approaches to treat secondary hyperparathyroidism (SHPT) have not been established in randomized controlled trials. Data from a national dialysis organization was used to identify patients with SHPT in whom escalated treatment may be indicated. The approach to treatment was defined based on observed upward titration of SHPT-controlling medications: earlier titration (lower target) versus delayed titration (higher target); and the choice of medication (cinacalcet vs vitamin D sterols). In the first trial emulation, we estimated a 29% lower rate of death and 26% lower rate of cardiovascular disease or death for patients managed with a lower versus higher target approach. Cinacalcet versus vitamin D-favoring approaches were not consistently associated with outcomes in the second trial emulation. This observational study suggests the need for additional clinical trials of SHPT treatment intensity., (Copyright © 2023 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT)., Objective: To evaluate center-level factors and racial equity in LDKT during an 11-year time period., Design, Setting, and Participants: A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients., Main Outcomes and Measures: Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT., Results: The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients., Conclusions and Relevance: In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.

Background and Objectives: Sustained implementation of new programs in complex care systems like nursing homes is challenging. This prospective qualitative evaluation examined factors affecting the sustainability of the Staff Training in Assisted Living Residences in Veterans Health Administration (STAR-VA) program in Veterans Health Administration (VA) Community Living Centers (CLC, i.e., nursing homes). STAR-VA is an evidence-based interdisciplinary, resident-centered, behavioral approach for managing distress behaviors in dementia., Evaluation Design and Methods: In 2019, we conducted 39 semistructured phone interviews with STAR-VA key informants across 20 CLCs. We identified a priori themes based on the Organizational Memory Framework, which includes 7 Knowledge Reservoirs (KRs): people, routines, artifacts, relationships, organizational information space, culture, and structure. We conducted content-directed analysis of transcripts to identify factors to program sustainment., Results: We identified 9 sustainment facilitators across KRs: engaged site leaders and champions, regular meetings and trainings, written documentation and resources, regular and open communication, available educational tools (e.g., handouts and posters), adequate spaces, leadership support on many levels, staff buy-in across disciplines, and staff competencies and recognition. Ten barriers across KRs included: staffing concerns, inconsistent/inefficient routines, inconsistent documentation, lack of written policies, communication gaps, nonstandardized use of tools, constraints with meeting spaces and regulations on posting information, limited leadership support, division among staff, and missing performance expectations., Discussion and Implications: Findings inform tailored strategies for optimizing STAR-VA program sustainment in CLCs, including the development of a sustained implementation guide, implementation resources, regional communities of practice, and STAR-VA integration into national CLC quality improvement routines for team communication and problem-solving., (Published by Oxford University Press on behalf of The Gerontological Society of America 2022.)

The choice of deprivation index can influence conclusions drawn regarding the extent of deprivation within a community and the identification of the most deprived communities in the United States. This study aimed to determine the degree of correlation among deprivation indices commonly used to characterize transplant populations. We used a retrospective cohort consisting of adults listed for liver or kidney transplants between 2008 and 2018 to compare 4 deprivation indices: neighborhood deprivation index, social deprivation index (SDI), area deprivation index, and social vulnerability index. Pairwise correlation between deprivation indices by transplant referral regions was measured using Spearman correlations of population-weighted medians and upper quartiles. In total, 52 individual variables were used among the 4 deprivation indices with 25% overlap. For both organs, the correlation between the population-weighted 75th percentile of the deprivation indices by transplant referral region was highest between SDI and social vulnerability index (liver and kidney, 0.93) and lowest between area deprivation index and SDI (liver, 0.19 and kidney, 0.15). The choice of deprivation index affects the applicability of research findings across studies examining the relationship between social risk and clinical outcomes. Appropriate application of these measures to transplant populations requires careful index selection based on the intended use and included variable relevance., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)