The Impact of Dual-Tasks and Disease Severity on Posture, Gait, and Functional Mobility among People Living with Dementia in Residential Care Facilities: A Pilot Study.

Gait speed and timed-up-and-go (TUG) predict cognitive decline, falls, and mortality. Dual-tasks may be useful in cognitive screening among people living with dementia (PWD), but more evidence is needed. This cross-sectional study aimed to compare single- and dual-task performance and determine the influence of dementia severity on dual-task performance and interference. Thirty PWD in two residential care facilities (Age: 81.3 ± 7.1 years; Montreal Cognitive Assessment: 10.4 ± 6.0 points) completed two trials of single- (feet apart) and dual-task posture (feet apart while counting backward), single- (walk 4 m) and dual-task gait (walk 4m while naming words), and single- (timed-up-and-go (TUG)), and dual-task functional mobility (TUG while completing a category task) with APDM inertial sensors. Dual-tasks resulted in greater sway frequency, jerk, and sway area; slower gait speed; greater double limb support; shorter stride length; reduced mid-swing elevation; longer TUG duration; reduced turn angle; and slower turn velocity than single-tasks (ps < 0.05). Dual-task performance was impacted (reduced double limb support, greater mid-swing elevation), and dual-task interference (greater jerk, faster gait speed) was related to moderate-to-severe compared to mild PWD. Moderate-to-severe PWD had poorer dynamic stability and a reduced ability to appropriately select a cautious gait during dual-tasks than those with mild PWD, indicating the usefulness of dual-tasks for cognitive screening.

Atopic Dermatitis and the Risk of Infection in End-Stage Renal Disease.

Background and Objectives: Atopic dermatitis (AD), also known as eczema, is a common chronic inflammatory skin condition affecting 16.5 million adults in the United States. AD is characterized by an impaired epidermal barrier that can predispose individuals to infection. End-stage renal disease (ESRD) is also commonly complicated by infections due to chronic vascular access and immune-system dysfunction, possibly related to uremia. Multiple studies have reported that renal disease is a common comorbidity in adults with atopic dermatitis. The aim of this study was to determine whether AD is a risk factor for certain infections in patients with ESRD. Materials and Methods: Using the United States Renal Data System, a retrospective cohort analysis was conducted on adult ESRD patients initiating dialysis between 2004 and 2019 to investigate associations between infections and AD in this population. Results: Of 1,526,266 patients, 2290 were identified with AD (0.2%). Infectious outcomes of interest were bacteremia, septicemia, cellulitis, herpes zoster, and conjunctivitis. In all infectious outcomes except for conjunctivitis, patients with the infectious outcomes were more likely to carry a diagnosis of AD. After controlling for demographic and clinical covariates, AD was associated with an increased risk of cellulitis (adjusted relative risk (aRR) = 1.39, 95% confidence interval (CI) = 1.31-1.47) and herpes zoster (aRR = 1.67, CI = 1.44-1.94), but not with bacteremia (aRR = 0.96, CI = 0.89-1.05), septicemia (aRR = 1.02, CI = 0.98-1.08), or conjunctivitis (aRR = 0.97, CI = 0.740-1.34). Conclusions: Overall, after controlling for demographic and clinical covariates and adjusting for person-years-at-risk, AD was associated with an increased risk for some, but not all, infections within the population of patients with ESRD.

Role of prostaglandin D2 receptors in the pathogenesis of abdominal aortic aneurysm formation.

Prostaglandin D2 (PGD2) released from immune cells or other cell types activates its receptors, D prostanoid receptor (DP)1 and 2 (DP1 and DP2), to promote inflammatory responses in allergic and lung diseases. Prostaglandin-mediated inflammation may also contribute to vascular diseases such as abdominal aortic aneurysm (AAA). However, the role of DP receptors in the pathogenesis of AAA has not been systematically investigated. In the present study, DP1-deficient mice and pharmacological inhibitors of either DP1 or DP2 were tested in two distinct mouse models of AAA formation: angiotensin II (AngII) infusion and calcium chloride (CaCl2) application. DP1-deficient mice [both heterozygous (DP1+/-) and homozygous (DP1-/-)] were protected against CaCl2-induced AAA formation, in conjunction with decreased matrix metallopeptidase (MMP) activity and adventitial inflammatory cell infiltration. In the AngII infusion model, DP1+/- mice, but not DP1-/- mice, exhibited reduced AAA formation. Interestingly, compensatory up-regulation of the DP2 receptor was detected in DP1-/- mice in response to AngII infusion, suggesting a potential role for DP2 receptors in AAA. Treatment with selective antagonists of DP1 (laropiprant) or DP2 (fevipiprant) protected against AAA formation, in conjunction with reduced elastin degradation and aortic inflammatory responses. In conclusion, PGD2 signaling contributes to AAA formation in mice, suggesting that antagonists of DP receptors, which have been extensively tested in allergic and lung diseases, may be promising candidates to ameliorate AAA.

Dietary Protein Source and Phosphate Levels in Patients on Hemodialysis.

OBJECTIVE: To determine the sources of protein and phosphorus levels from the food consumed by patients on dialysis. DESIGN AND METHODS: This is a retrospective, secondary data analysis of the Comprehensive Dialysis Survey study participants who had a baseline food frequency questionnaire and baseline lab data (N = 358). We examined intake of protein, phosphorus, and 7 other key nutrients from a subcohort of the Comprehensive Dialysis Survey based on the published National Kidney Foundation Kidney Dialysis Outcome Quality Initiative's nutrition recommendations. We studied the relationship of dietary protein source (plant or animal) with phosphorus intake using self-reported data from food frequency questionnaires. Variables included in final analysis are demographic, lab variables (albumin and prealbumin, alpha-1 acid glycoprotein, and C-reactive protein), and nutrition variables (calorie density, protein density, total fat, saturated fat, cholesterol, carbohydrates, phosphorus, calcium, sodium, potassium, plant-based protein, animal-based protein, and daily protein intake). RESULTS: Most of the patients had a lower than recommended consumption of calories, protein, phosphorus, and potassium while sodium, total, and saturated fats were overconsumed. Patients intake of dietary protein and calories was proportional to the amount of food consumed for both plant- and animal-based food. The levels of dietary protein and phosphorus were significantly (P < .05) lower in patients who primarily consumed a plant-based diet than in those who mainly consumed an animal-based diet. CONCLUSIONS: Consuming more plant-based protein as part of a varied diet could be nutritionally adequate while limiting intake of absorbable dietary phosphorus. More research in plant-based protein diets and their impact on patients with end-stage renal disease is needed.

Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit.

BACKGROUND: Nonactionable alarms comprise over 70% of alarms and contribute a threat to patient safety. Few studies have reported approaches to translate and sustain these interventions in clinical settings. PURPOSE: This study tested whether an interprofessional team-based approach can translate and implement effective alarm reduction interventions in the adult intensive care unit. METHODS: The study was a prospective, cohort, pre- and postdesign with repeated measures at baseline (preintervention) and post-phase I and II intervention periods. The settings for the most prevalent nonactionable arrhythmia and bedside parameter alarms were adjusted during phases I and II, respectively. RESULTS: The number of total alarms was reduced by 40% over a 14-day period after both intervention phases were implemented. The most prevalent nonactionable parameter alarms decreased by 47% and arrhythmia alarms decreased by 46%. CONCLUSIONS: It is feasible to translate and sustain system-level alarm management interventions addressing alarm fatigue using an interprofessional team-based approach.

An Examination of Multilevel Factors Influencing Colorectal Cancer Screening in Primary Care Accountable Care Organization Settings: A Mixed-Methods Study.

OBJECTIVE: To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets. DESIGN: A concurrent mixed-methods design using electronic health records, provider survey, and provider interview. SETTING: Eight primary care accountable care organization clinics in Nebraska. MEASURES: Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system). ANALYSIS: Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding). RESULTS: At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors. CONCLUSIONS: This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.

The Impact of Self-management Knowledge and Support on the Relationships Among Self-efficacy, Patient Activation, and Self-management in Rural Patients With Heart Failure.

BACKGROUND: Self-management (SM) is an essential component of heart failure (HF) management. The mechanisms to improve SM behaviors are unclear. OBJECTIVE: The objective of this study is to examine whether patient activation mediates the effect of self-efficacy on SM behaviors in rural HF patients. METHODS: A secondary analysis was conducted using data collected from a randomized controlled trial aimed to improve SM behaviors. The main variables included were SM knowledge, self-efficacy, patient activation, and SM behaviors. RESULTS: Mediation analysis showed patient activation mediated the effect of self-efficacy on SM. Both self-efficacy and patient activation were significantly related to SM behaviors, respectively (r = 0.46, P < .001; ß = .48, P = .001). However, self-efficacy was no longer directly related to SM behaviors when patient activation was entered into the final model (ß = .17, P = .248). Self-management knowledge and support were significant moderators. In patients with high levels of SM knowledge, patient activation did not mediate the effect of self-efficacy on SM behaviors (ß = .15, P = .47). When SM support was entered in the path model, patient activation was not a significant mediator between self-efficacy and SM behavior at high (ß = .27, P = .27) or low (ß = .27, P = .25) levels of SM support. CONCLUSIONS: Study findings suggest that targeted SM support for high-risk HF patients with low SM knowledge and support may be useful. In addition, strategies to increase patient activation may improve HF patients' SM confidence.

Promoting colorectal cancer screening through a new model of delivering rural primary care in the USA: a qualitative study.

INTRODUCTION: Despite the known benefits of colorectal cancer (CRC) screening, rural areas have consistently reported lower screening rates than their urban counterparts. Alternative healthcare delivery models, such as accountable care organizations (ACOs), have the potential to increase CRC rates through collaboration among healthcare providers with the aim of improving quality and decreasing cost. However, researchers have not sufficiently explored how this innovative model could influence the promotion of cancer screening. The purpose of the study was to explore the mechanism of how CRC screening can be promoted in ACO-participating rural primary care clinics. METHODS: The study collected qualitative data from in-depth interviews with 21 healthcare professionals employed in ACO-participating primary care clinics in rural Nebraska. Participants were asked about their views on opportunities and challenges to promote CRC screening in an ACO context. Data were analyzed using a grounded theory approach. RESULTS: The study found that the new healthcare delivery model can offer opportunities to promote cancer screening in rural areas through enhanced electronic health record use, information sharing and collaborative learning within ACO networks, use of standardized quality measures and performance feedback, a shift to preventive/comprehensive care, adoption of team-based care, and empowered care coordinators. The perceived challenges were found in financial instability, increased staff workload, lack of provider training/education, and lack of resources in rural areas. CONCLUSIONS: This study found that the innovative care delivery model, ACO, could provide a well-designed platform for promoting CRC screening in rural areas, if sustainable resources (eg finance, health providers, and education) are provided. This study provides 'practical' information to identify effective and sustainable intervention programs to promote preventive screening. Further efforts are needed to facilitate delivery system reforms in rural primary care, such as improving performance evaluation measures and methods.

Effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the PATCH randomized controlled trial.

BACKGROUND: Heart failure (HF) patients discharged from rural hospitals have higher 30-day readmission rates. Self-management (SM) reduces readmissions, but adherence to SM guidelines is low in the rural HF population. We tested a home-based intervention to enhance patient activation and lead to improved SM adherence. METHODS: In this two-group, repeated measures randomized control trial, the main outcomes were patient reported and clinical outcomes associated with SM adherence, and all-cause readmission at 30, 90 and 180 days. RESULTS: The study included 100 HF patients discharged from a rural critical access hospital. The intervention group received a 12-week SM training and coaching program delivered by telephone and tailored on subjects' activation levels. At α = .10, the PATCH intervention showed significantly greater improvement compared to usual care in patient-reported SM adherence: weighing themselves, following a low-sodium diet, taking prescribed medication, and exercising daily (all p < .0005) at 3 and 6 months after discharge. In contrast, groups did not differ in physical activity assessed by actigraphy or in clinical biomarkers. Contrary to expectation, the 30-day readmission rate was significantly higher (p = .088) in the intervention group (19.6 %) than in the control group (6.1 %), with no differences at 90 or 180 days. CONCLUSION: It is feasible to conduct a randomized controlled trial in HF patients discharged from rural critical access hospitals. Significantly higher patient-reported SM adherence was not accompanied by lower clinical biomarkers or readmission rates. Further research is needed to understand mechanisms that influence outcomes and healthcare utilization in this population. CLINICAL TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov; NCT01964053 .

Mechanism of engaging self-management behavior in rural heart failure patients.

AIM: The purpose of this study was to examine the relationships among self-efficacy, patient activation and SM in rural heart failure patients discharged from critical access hospitals. BACKGROUND: Heart failure is one of the most disabling and resource-consuming chronic conditions. Compared to their urban counterparts, rural heart failure patients had higher healthcare utilizations and worse health outcomes. Self-management (SM) plays a significant role in improving patients' outcomes and reducing healthcare use. Despite persistent recommendations of SM, engagement in SM still remains low in rural heart failure patients. SM is a complex behavior, which is influenced by various factors. Evidence on the efficacy of interventions to promote SM is limited and inconsistent. One reason is that the mechanism of engagement of SM in the rural heart failure population has not been fully understood. METHODS: A correlational study was conducted using secondary data from a randomized control trial aimed to improve SM adherence. Path analysis was used to test the hypothesis of patient activation mediating the effect of self-efficacy on SM. RESULTS: Data were collected from a sample of 101 heart failure patients (37% males) with an average age of 70 years. The final model provided a good fit to the data, supporting the hypothesis that self-efficacy contributes to SM through activation. CONCLUSION: The results of this study showed that effective SM interventions should be designed to include strategies to promote both self-efficacy and activation.

Exploring the Association Between Physical Activity and Cognitive Function Among People Living with Dementia.

Background: Physical activity preserves cognitive function in people without dementia, but the relationship between physical activity and cognitive domains among people living with dementia is unclear. Objective: The objective of this study was to explore the association between physical activity and cognition domains among people living with dementia. Methods: Participants living with dementia in residential care facilities (complete case analysis: n = 24/42) completed a battery of cognitive tests (global cognition: Montreal Cognitive Assessment; executive function: Trail-Making Test, Digit Span Forward Test; perception and orientation: Benton Judgement of Line Orientation Test; language: Boston Naming Test; learning and memory: Rey Auditory Verbal Learning Test; complex attention: Digit Symbol Substitution Test). Participants wore an actigraphy monitor on their non-dominant wrist over seven days. We conducted a linear regression for total physical activity (independent variable) with race (white/black), fall risk (Morse Fall Scale), and the number of comorbidities (Functional Comorbidities Index) as covariates, and cognitive tests as variables of interest. Results: Participants were primarily male (75%), white (87.5%), and 50%had unspecified dementia (Alzheimer's disease: 33%). Greater physical activity was associated with poorer global cognition, better executive function, and better learning and memory (ps <  0.05). Physical activity was not related to visuospatial perception, language, or complex attention. Conclusions: Physical activity may preserve executive function and learning and memory among people living with dementia. Wandering is more common in later stages of dementia, which may explain greater physical activity observed with lower global cognition. Regularly assessing physical activity may be useful in screening and monitoring cognitive changes.

Risk factors and mortality in dialysis patients with abdominal aortic aneurysm: A retrospective cohort study.

In the general population, abdominal aortic aneurysm (AAA) is synonymous with vascular disease and associated with increased mortality. Vascular disease is common in end-stage renal disease (ESRD) patients on dialysis, but there is limited information on AAA in this population. To address this issue, we queried the United States Renal Data System for risk factors associated with a diagnosis of AAA as well as the impact of AAA on ESRD patient survival. Incident dialysis patients from 2005 to 2014 with AAA and other clinical comorbidities were identified using ICD-9 and ICD-10 codes. Time to death was defined using the time from the start of dialysis to the date of death or to December 31, 2015. Cox proportional hazards (CPH) modeling was used to determine the adjusted hazard ratio (aHR) and 95% confidence intervals (CI) for death. From a total cohort of 820,826, we identified 21,631 subjects with a diagnosis of AAA. When compared to patients without AAA, AAA patients were older and more likely to be of white race and male gender, have a higher mean Charlson comorbidity index (CCI), have hypertension as the ESRD etiology, and use tobacco. Although a bivariate CPH model showed that AAA patients had an increased mortality risk compared to patients without the diagnosis, in the final CPH model, AAA patients had a decreased risk of mortality (aHR = 0.83, 95% CI 0.81-0.84) due to confounding with age. These results suggest that AAA is not associated with increased risk of death in ESRD patients after controlling for various demographic and clinical risk factors.

Pressure Ulcer Diagnosis Is Associated with Increased Mortality in Patients with End-Stage Renal Disease: A Retrospective Study.

Pressure ulcers are associated with multiple comorbidities and annually affect approximately 3 million Americans, directly accounting for approximately 60,000 deaths per year. Because patients with end-stage renal disease (ESRD) are known to present with unique factors which impair wound healing, pressure ulcers diagnosed in ESRD patients might independently increase the risk of mortality. To investigate the association between pressure ulcer diagnosis and mortality risk in the ESRD population, a retrospective analysis of the United States Renal Data System (USRDS) database was performed. The records of 1,526,366 dialysis patients who began therapy between 1 January 2005 and 31 December 2018 were included. Our analysis showed that the diagnosis of pressure ulcers in this population was independently associated with mortality even after controlling for confounding factors (p < 0.001). A Kaplan-Meier survival analysis demonstrated reduced survival in patients with a pressure ulcer diagnosis compared to those without a pressure ulcer diagnosis. These results establish pressure ulcers as a significant independent risk factor for mortality, as well as suggesting several comorbidities as potential risk factors for pressure ulcers in the ESRD population.

Association of psoriasis and stroke in end-stage renal disease patients.

BACKGROUND: Previous research in the general population suggests that the inflammatory skin disease psoriasis is associated with an increased risk of vascular events, such as stroke. Thus, psoriasis may also represent a risk factor for stroke in end-stage renal disease (ESRD) patients. METHODS: We queried the United States Renal Data System for incident dialysis patients between 2004 and 2015. Psoriasis was defined as having at least two international classification of disease (ICD)-9 or ICD-10 diagnosis codes. ICD codes were also used to query the outcome of interest, stroke, as well as other clinical risk factors. Logistic regression was used to examine the association of psoriasis and other risk factors with stroke. RESULTS: Of 966,399 ESRD patients, we identified 89,700 (9.3%) subjects with stroke and 6,286 (0.7%) with psoriasis. Of these psoriasis patients, 796 (0.9%) also had a stroke. Psoriasis was associated with an increased risk of stroke in an unadjusted model [odds ratio (OR)=1.16; 95% confidence interval (CI)=1.08-1.25]. However, after controlling for demographic and clinical risk factors, the final adjusted model showed that psoriasis was not associated with stroke (OR=0.96, CI=0.88-1.04). Congestive heart failure [adjusted OR of 1.79 (CI=1.75-1.83)] was a confounder of the association of psoriasis with stroke. CONCLUSIONS: Contrary to prior research in the general population, psoriasis in ESRD patients was not associated with the risk of stroke after controlling for various demographic and clinical parameters. Our finding emphasizes the importance of controlling for a variety of factors in population studies examining associations of diseases and risk factors.

Non-tuberculous mycobacterial infections in patients with end-stage renal disease: Prevalence, risk factors, and mortality.

Non-tuberculous mycobacterial (NTM) disease has increased in prevalence in the USA, however, little is known on NTM in the population with end-stage renal disease (ESRD). Thus, we investigated patients with ESRD to determine risk factors for NTM disease and mortality. We queried the United States Renal Data System from 2005 to 2015 using International Classification of Diseases (ICD)-9/ICD-10 codes to identify NTM and risk factors. Logistic regression was used to examine the association of risk factors with NTM and Cox proportional hazards modeling was used to assess the association of NTM with mortality. Of 1,068,634 included subjects, 3232 (0.3%) individuals were identified with any NTM diagnosis. Hemodialysis versus peritoneal dialysis (OR=0.10, 95% CI=0.08 to 0.13) was protective for NTM, whereas black (OR=1.27, 95% CI=1.18 to 1.37) or other race compared with white race (OR=1.39, 95% CI=1.21 to 1.59) increased the risk of NTM. HIV (OR=15.71, 95% CI=14.24 to 17.33), history of any transplant (OR=4.25, 95% CI=3.93 to 4.60), kidney transplant (OR=3.00, 95% CI=2.75 to 3.27), diabetes (OR=1.32, 95% CI=1.23 to 1.43), rheumatologic disease (OR=1.92, 95% CI=1.77 to 2.08), and liver disease (OR=2.09, 95% CI=1.91 to 2.30) were associated with increased risk for NTM diagnosis. In multivariable analysis, there was a significant increase in mortality with any NTM diagnosis (HR=1.83, 95% CI=1.76 to 1.91, p≤0.0001). Controlling for relevant demographic and clinical risk factors, there was an increased risk of mortality associated with any diagnosis of NTM. Early diagnosis and treatment of NTM infection may improve survival in patients with ESRD.

Association of psoriasis with myocardial infarction in end-stage renal disease patients.

BACKGROUND: Previous research in non-dialysis patients suggests that the inflammatory skin disease psoriasis is associated with an increased risk of severe vascular events like myocardial infarction (MI). Thus, we determined whether psoriasis represents a significant risk factor for MI in end-stage renal disease (ESRD) patients. METHODS: We queried the United States Renal Data System for ESRD patients starting dialysis between 2004 and 2015. ICD-9 and ICD-10 codes were used to identify those with at least two diagnoses of psoriasis, a diagnosis of MI, and other clinical risk factors. Logistic regression was used to examine the association of psoriasis and various risk factors with MI. RESULTS: Of a cohort of 1,062,693, we identified 6823 (0.6%) subjects with psoriasis and 181,960 (17.1%) with MI. Of the 6823 patients with psoriasis, 1671 (24%) developed an MI. Psoriasis was associated with an increased risk of MI in an unadjusted model [odds ratio (OR) = 1.34; confidence interval (CI) = 1.26-1.42]. However, after controlling for demographics, dialysis modality, access type, and various conditions related to the Charlson Comorbidity Index, psoriasis was not associated with MI (OR = 0.95, CI = 0.89-1.01). Confounders of the association of psoriasis with MI included congestive heart failure (OR = 5.26, CI = 5.17-5.36), pulmonary disease (OR = 1.25, CI = 1.23-1.26), and diabetes with complications (OR = 1.82, CI = 1.79-1.85). CONCLUSIONS: Contrary to prior research in the general population, in the ESRD population psoriasis was not associated with an increased risk of MI after controlling for various demographic and clinical parameters. These data emphasize the importance of an integrated approach since comorbidities may influence the choice of therapy for psoriasis and outcomes.

Cutaneous squamous cell carcinoma and mortality in end-stage renal disease.

BACKGROUND: In the general population, cutaneous squamous cell carcinoma (cSCC) is associated with increased all-cause mortality. Transplant patients have been shown to have an increased risk of developing cSCC, and their cSCC is associated with an increased risk for mortality. In end-stage renal disease (ESRD) patients, there is extensive mortality and immune dysfunction. Because of this immune system dysfunction, we examined whether cSCC is associated with increased risk of all-cause mortality among ESRD patients, as well as the risk factors for cSCC. METHODS: We analyzed ESRD patients in the United States Renal Data System from 2004-2014, excluding organ transplant recipients. We assessed mortality using a Cox Proportional Hazards (CPH) model to control for various demographic and clinical parameters, identified using international classification of diseases (ICD)-9 codes. RESULTS: Of the 1,035,193 patients included, 624 (0.1%) were diagnosed with cSCC. The median survival time for those with cSCC was 3.91 years [95% confidence interval (CI) = 3.67-4.15], versus 2.92 years [95%CI = 2.92-2.93] for patients without cSCC. ESRD patients with cSCC were at lower risk of death [adjusted hazard ratio = 0.75; 95%CI = 0.69-0.82] compared to those without. Decreased risk of death was also associated with parameters such as black race, Hispanic ethnicity, tobacco dependence and actinic keratosis. Increased mortality risk was associated with increasing age, male sex, hemodialysis (versus peritoneal dialysis) and alcohol dependence. CONCLUSIONS: Contrary to expectations, ESRD patients with a cSCC diagnosis showed reduced all-cause mortality risk relative to those without. The reason for this discrepancy remains unclear, suggesting the need for further study.

Risk factors and mortality in patients with listeriosis and end-stage renal disease.

BACKGROUND: End-stage renal disease (ESRD) is a known immunocompromising status that predisposes patients to developing infections. Disease from Listeria monocytogenes may affect any host but tends to be more severe in the immunocompromised. METHODS: We used a large population of patients with ESRD to identify risk factors for listeriosis and mortality. Patients with a diagnosis of Listeria and other risk factors for listeriosis were identified using claims data from the United States Renal Data System database from 2004-2015. Demographic parameters and risk factors associated with Listeria were modeled using logistic regression while association with mortality was assessed with Cox Proportional Hazards modeling. RESULTS: A diagnosis of Listeria was identified in 291 (0.01%) of a total 1,071,712 patients with ESRD. Cardiovascular disease, connective tissue disease, upper gastrointestinal ulcerative disease, liver disease, diabetes, cancer, and human immunodeficiency virus were all associated with an increased risk of Listeria. Patients with Listeria had an increased risk of death relative to patients without Listeria (adjusted hazard ratio=1.79; 95% confidence interval 1.52-2.10). CONCLUSIONS: Incidence of listeriosis in our study population was over 7 times higher than what has been reported for the general population. The independent association of a Listeria diagnosis with increased mortality is also consistent with the disease's high mortality in the general population. Due to limitations with diagnosis, providers should maintain high clinical suspicion for listeriosis when patients with ESRD present with a compatible clinical syndrome. Further prospective study may help precisely quantify the increased risk of listeriosis in patients with ESRD.

The effects of strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED): Study protocol for a pilot randomized controlled trial.

BACKGROUND: Exercise may improve executive function among people living with all-cause dementia (PWD), but more evidence is needed. The aim of this pilot randomized controlled trial (RCT) is to examine whether exercise plus usual care improves the primary outcome of executive function, and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes compared to usual care alone among PWD. METHODS AND STUDY DESIGN: The strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED) protocol is a pilot parallel, 6-month assessor-blinded RCT (1:1) in residential care facilities, including n = 21 receiving exercise plus usual care and n = 21 usual care alone [NCT05488951]. We will collect primary (Color-Word Stroop Test) and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes at baseline and 6 months. We will obtain falls monthly from medical charts. We will collect physical activity, sedentary behavior, and sleep via wrist-worn accelerometers over 7 days at baseline and 6 months. The physical therapist-led adapted Otago Exercise Program will involve 1-h of strength, balance and walking 3×/week for 6 months in groups of 5-7. We will use generalized linear mixed models to examine differences over time in primary and secondary outcomes between groups and examine potential interactions with sex and race. DISCUSSION: This pilot RCT will examine the direct effects and potential underlying physiological mechanisms of exercise on executive function and other behavioral outcomes in PWD, which may have implications for clinical care management.