Clostridium difficile infection among veterans health administration patients

OBJECTIVETo report on the prevalence and incidence of Clostridium difficile infection (CDI) from 2009 to 2013 among Veterans Healthcare Administration patientsDESIGNA retrospective descriptive analysis of data extracted from a large electronic medical record (EMR) databaseSETTINGData were acquired from VHA healthcare records from 2009 to 2013 that included outpatient clinical visits, long-term care, and hospitalized care as well as pharmacy and laboratory information.RESULTSIn 2009, there were 10,207 CDI episodes, and in 2013, there were 12,143 CDI episodes, an increase of 19.0%. The overall CDI rate increased by 8.4% from 193 episodes per 100,000 patient years in 2009 to 209 episodes per 100,000 patient years in 2013. Of the CDI episodes identified in 2009, 58% were identified during a hospitalization, and 42% were identified in an outpatient setting. In 2013, 44% of the CDI episodes were identified in an outpatient setting.CONCLUSIONThis is one of the largest studies that has utilized timely EMR data to describe the current CDI epidemiology at the VHA. Despite an aging population with greater burden of comorbidity than the general US population, our data show that VHA CDI rates stabilized between 2011 and 2013 following increases likely attributable to the introduction of the more sensitive nucleic acid amplification tests (NAATs). The findings in this report will help establish an accurate benchmark against which both current and future VA CDI prevention initiatives can be measured.Infect. Control Hosp. Epidemiol. 2015;36(9):1038–1045</jats:sec

Ror receptor tyrosine kinases: orphans no more

Receptor tyrosine kinase-like orphan receptor (Ror) proteins are a conserved family of tyrosine kinase receptors that function in developmental processes including skeletal and neuronal development, cell movement and cell polarity. Although Ror proteins were originally named because the associated ligand and signaling pathway were unknown, recent studies in multiple species have now established that Ror proteins are Wnt receptors. Depending on the cellular context, Ror proteins can either activate or repress transcription of Wnt target genes and can modulate Wnt signaling by sequestering Wnt ligands. New evidence implicates Ror proteins in planar cell polarity, an alternative Wnt pathway. Here, we review the progress made in understanding these mysterious proteins and, in particular, we focus on their function as Wnt receptors

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decision-making for clinicians interested in providing patient-centered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of non-adherence to medications for chronic conditions

Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings

Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior

Incidence of and risk factors for community-associated <it>Clostridium difficile </it>infection: A nested case-control study

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.</p

Bisphosphonate Drug Holiday and Fracture Risk

Background/Aims: Among women with ≥ 3 years exposure to bisphosphonates (BPs), we compared the incidence of fragility fractures in those who discontinued BPs for ≥ 12 months (drug holiday) to those who continued to use BPs (persistent use). Methods: This retrospective cohort study included women aged ≥ 45 years who initiated BP use from four Kaiser Permanente regions between January 1, 1998, and December 31, 2009. Drug holiday was defined as ≥ 12 months with BP use at 0% adherence. Persistent use status required ongoing use at ≥ 50% adherence. The primary outcome of interest was the first occurrence of an incident clinical osteoporosis-related fragility fracture, identified from the electronic medical record (EMR) via ICD-9-CM codes. All subjects were followed until fracture, disenrollment from the health plan, death, or December 31, 2012. From the EMR, we collected information on the following potential confounders and effect modifiers: race/ethnicity, age, body mass index, comorbidities, history of previous fragility fracture, lowest T-score prior to cohort entry, fall risk, 10-year fracture risk, and prior/concomitant use of bone-active medications. Persistent users and drug holiday subjects were compared with regard to several demographic and clinical characteristics. Time-varying Cox proportional hazards models were used to compare osteoporosis-related fracture incidence between the two groups. Results: The cohort of 28,620 women, observed for 111,997 person-years, included 17,123 (59.8%) persistent BP users and 11,497 (40.2%) drug holiday subjects. The drug holiday group had fewer comorbidities, higher baseline T-scores, and lower fracture and fall risk scores. A total of 3,571 osteoporosis-related fractures were observed. The unadjusted rate ratio (RR) for any osteoporosis-related fractures for drug holiday compared to persistent use was 0.87 (95% confidence interval [CI]: 0.81–0.94), but was 1.0 (95% CI: 0.9–1.2) for hip fractures only. The time-varying models suggested no differences in fracture risk (hazard ratio [HR]: 0.90, 95% CI: 0.80–1.00) after adjustment for baseline fall and fracture risk, comorbidities and other bone-active medication use. Similarly, no difference in hip fracture risk was observed (HR: 0.84, 95% CI: 0.68–1.03). Discussion: Women who undertake a holiday from BP use are not at greater risk of osteoporosis-related fragility fractures, nor hip fractures specifically, than are women who continue to use BPs persistently