Nutrition and Healthy Aging.

Diet is a key determinant of health and is vital to the prevention and management of chronic disease. The predictors of an individual's dietary health are complex and influenced by multiple socioeconomic, environmental, and behavioral domains. Dietary behavior change in late life requires an in-depth understanding of internal and external factors influencing the individual and knowledge of community resources available. Dietary patterns-the combination of foods and beverages consumed-may be related to quality of life and health in older adults. Dietary patterns may also be easier for individuals to adopt and understand than dietary planning based on single nutrients.

Development of a Tailored Behavioral Weight Loss Program for Veterans With PTSD (MOVE!+UP): A Mixed-Methods Uncontrolled Iterative Pilot Study.

PURPOSE: Veterans with post-traumatic stress disorder (PTSD) lose less weight in the Veterans Affairs (VA) weight management program (MOVE!), so we developed MOVE!+UP. DESIGN: Single-arm pre-post pilot to iteratively develop MOVE!+UP (2015-2018). SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Overweight Veterans with PTSD (5 cohorts of n = 5-11 [N = 44]; n = 39 received ≥1 MOVE+UP session, with cohorts 1-4 [n = 31] = "Development" and cohort 5 [n = 8] = "Final" MOVE!+UP). INTERVENTION: MOVE!+UP weight management for Veterans with PTSD modified after each cohort. Final MOVE!+UP was coled by a licensed clinical psychologist and Veteran peer counselor in 16 two-hour in-person group sessions and 2 individual dietician visits. Sessions included general weight loss support (eg, behavioral monitoring with facilitator feedback, weekly weighing), cognitive-behavioral skills to address PTSD-specific barriers, and a 30-minute walk to a nearby park. MEASURES: To inform post-cohort modifications, we assessed weight, PTSD, and treatment targets (eg, physical activity, diet), and conducted qualitative interviews. ANALYSIS: Baseline to 16-week paired t tests and template analysis. RESULTS: Development cohorts suggested improvements (eg, additional sessions and weight loss information, professional involvement) and did not lose weight (mean [M] = 1.8 lbs (standard deviation [SD] = 8.2); P = .29. Conversely, the final cohort reported high satisfaction and showed meaningful weight (M = -14 pounds [SD = 3.7] and 71% lost ≥5% baseline weight) and PTSD (M = -17.9 [SD = 12.2]) improvements, P < .05. CONCLUSIONS: The comprehensive, 16-week, in-person, cofacilitated Final MOVE!+UP was acceptable and may improve the health of people with PTSD. Iterative development likely produced a patient-centered intervention, needing further testing.

How to Ensure That Teaching Kitchens Are Age-Friendly.

Health systems and community organizations have increasingly offered nutrition education through teaching kitchens. With an increasing number of older adults (>65 years) accessing these programs, teaching kitchens may consider age-friendly adaptations to their standard curriculum. Based on experiences with implementing Healthy Teaching Kitchens Across Veteran Affairs Health Care System, and by applying the 5M Geriatric Care Framework (Mind, Multicomplexity, Medications, Mobility, What Matters Most), several steps are proposed for teaching kitchens to be able to better accommodate older adults.

Healthy Teaching Kitchen Programs: Experiential Nutrition Education Across Veterans Health Administration, 2018.

Traditional clinical interventions yield few positive effects on diet. The Healthy Teaching Kitchen (HTK) program implemented by the Veterans Health Administration at sites across the United States delivers interactive nutrition and culinary education, guided instruction, and social opportunities for patients and caregivers. We report HTK outcomes of veterans' self-reported acceptability, self-efficacy for dietary change, and dietary and cooking habits. The HTK program is acceptable and feasible and may empower participants to improve health.

Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients.

Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices. OBJECTIVE: We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP. DESIGN AND PARTICIPANTS: We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA. KEY RESULTS: We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation. CONCLUSIONS: We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

Identifying and categorizing spurious weight data in electronic medical records.

Background: Spurious weights compromise the validity of summary measures, such as averages and trends. Even rare errors in weight records can undermine the utility of electronic medical record (EMR) data. Objective: We sought to estimate the prevalence of spurious weight values in a large EMR, to ascertain the likely causes, and to develop and test straightforward algorithms for identifying spurious weight data. Design: Using EMR data from 10,000 randomly selected patients aged ≥65 y in the VA system, we examined the percentage of weight change across various time intervals, from 1 to 3000 d. We examined descriptive results and developed 3 algorithms to categorize degree of weight change over time. On the basis of distributions, we identified cases that were most likely spurious. We manually reviewed these and categorized the type of error. Results: The data followed the expected distributions. The algorithms reliably identified spurious weight. Approximately 0.8% of all weights in the record appeared to be spurious and ∼1 in 5 patient charts included ≥1 spurious weight value. The most common type of error involved the misentry of a single digit (e.g., 148 for 178). Conclusions: Spurious weights are common in EMRs. Straightforward algorithms can identify and remove them, and thus enhance the reliability of EMR data.

Hitting the target: Lyme or STARI?

Erythema migrans (EM) is a characteristic rash most commonly associated with Lyme disease (LD) in the northeastern and north central United States. EM rash found in the southeastern United States is usually classified as Southern Tick-Associated Rash Illness (STARI). Here we describe an EM rash in a 3-year-old female from central Louisiana, whose laboratory and clinical findings were suspicious for LD. This case report highlights the importance of distinguishing STARI from LD, as LD left untreated can lead to long-term complications.

Simultaneous acute appendicitis and pseudomembranous colitis in a pediatric patient.

Acute appendicitis is a common cause for pediatric surgery, with an increasing incidence as this population ages. Pseudomembranous colitis (PMC) from Clostridum difficle is being seen more frequently in pediatric patients, especially after treatment with antibiotics and in those with Hirschsprung's disease. Only three prior cases of appendicitis associated with PMC have been described in the literature, and all of them occurred in adult patients. Here, we describe the first documented pediatric case: a 16-year-old female who developed acute appendicitis while concomitantly being treated for suspected pseudomembranous colitis. We concur with previous authors that there may be an association between these two pathologies; furthermore, this association may not always be clinically apparent and may be both under-diagnosed and under-reported.

Analysis of 23 million US hospitalizations: uninsured children have higher all-cause in-hospital mortality.

BACKGROUND: The number of uninsured children in the USA is increasing while the impact on children's health of being uninsured remains largely uncharacterized. We analyzed data from more than 23 million US children to evaluate the effect of insurance status on the outcome of US pediatric hospitalization. METHODS: In our analysis of two well-known large inpatient databases, we classified patients less than 18 years old as uninsured (self-pay) or insured (including Medicaid or private insurance). We adjusted for gender, race, age, geographic region, hospital type, admission source using regression models. In-hospital death was the primary outcome and secondary outcomes were hospital length of stay and total hospital charges adjusted to 2007 dollars. RESULTS: The crude in-hospital mortality was 0.75% for uninsured versus 0.47% for insured children, with adjusted mortality rates of 0.74 and 0.46%, respectively. On multivariate analysis, uninsured compared with insured patients had an increased mortality risk (odds ratio: 1.60, 95% CI: 1.45-1.76). The excess mortality in uninsured children in the US was 37.8%, or 16,787, of the 38,649 deaths over the 18 period of the study. CONCLUSION: Children who were hospitalized without insurance have significantly increased all-cause in-hospital mortality as compared with children who present with insurance.