Antibiotics and Nosocomial Clostridioides difficile, a Retrospective Chart Review.

C. difficile is a complication of antibiotic therapy. Certain antibiotics are associated with a higher rate of developing C. difficile. The charts of 54 patients with nosocomial C. difficile were reviewed and very few had received a high-risk antibiotic. Seven (13%) of 54 patients had not received any antibiotics in the hospital prior to the positive stool test for C. difficile. Moreover, 6 of the 7 had no documentation of receiving an antibiotic in the 56 days prior to admission suggesting that they might be colonized with C. difficile.

Distress: Characterizing What Causes the Thermometer to Shift in Patients with Newly Diagnosed Breast Cancer Attending a Multidisciplinary Clinic.

BACKGROUND: A diagnosis of breast cancer (BC) can result in multifactorial stress. If not addressed, distress can have a negative impact on outcomes. The experience of patients with newly diagnosed BC has not been sufficiently investigated. This study characterizes distress among new patients in a multidisciplinary care (MDC) clinic. The study aimed to determine the degree of distress at presentation, to characterize the sources, and to evaluate the impact of an MDC visit. METHODS: A retrospective review was performed from January 2015 to November 2017. Charts were accessed for demographics, tumor characteristics, and treatment data. Distress scores (DS) and problems as captured using the National Comprehensive Cancer Network (NCCN) Distress Thermometer were completed before evaluation and in a subgroup after an MDC visit. Predictors of severe distress (DS ≥4) were investigated using multivariable logistic regression. The paired t test was used to determine the impact of an MDC visit. RESULTS: The mean initial DS (n = 474) was 4.98. The top four sources of distress were worry, anxiety, fears, and sadness. Age younger than 65 years was significantly associated with a higher DS at presentation (p < 0.003). Among the patients queried before and after MDC (n = 137), a significant reduction in distress was identified (5.58-2.94; p < 0.0005). CONCLUSIONS: Severe distress was found in 66 % of the patients with a recent diagnosis of BC, with younger age related to higher distress scores at presentation. Emotional stressors were the predominant factors accounting for distress. A same-day MDC visit was associated with a significant reduction in DS. These data indicate the importance and feasibility of proactively screening patients. Our research lends support to the value of multidisciplinary evaluation in this setting.

Attending Physician Attitudes Toward Choice of Oral Anticoagulant for the Treatment of Venous Thromboembolism.

Until recently, warfarin has been the primary treatment of venous thromboembolism (VTE). Limited data are available regarding physician attitudes toward anticoagulant choice in the setting of novel oral anticoagulant (NOAC) availability. This study sought to evaluate attending physician attitudes toward NOACs. A survey was sent to attending physicians from internal medicine (primary care and hospitalist medicine), family medicine, cardiology, and hematology-oncology asking about their preference and reasoning for choice of oral anticoagulant for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Warfarin was the most common choice of initial treatment of both DVT (85.6%) and PE (89%). Among the specialties surveyed, cardiologists were more likely to use rivaroxaban as initial treatment of VTE as compared to other specialties including internal medicine or hematology (p=0.011 for DVT and 0.004 for PE). Cost-effectiveness and lack of a reversal agent were cited as the major disadvantages for NOAC use.

Impact of a program of Tai Chi plus behaviorally based dietary weight loss on physical functioning and coronary heart disease risk factors: a community-based study in obese older women.

This study employed a quasi-experimental design in a community-based study translating the results of our recent findings on the combined effects of Tai Chi and weight loss on physical function and coronary heart disease (CHD) risk factors. A 16-week intervention was conducted to assess the impact of Tai Chi plus a behavioral weight loss program (TCWL, n = 29) on obese (body mass index [BMI] = 35.4 ± 0.8 kg/m²) older (68.2 ± 1.5 yr.) women compared to a control group (CON, n = 9, BMI = 38.0 ± 1.5 kg/m², 65.6 ± 2.7 yr.), which was asked to maintain their normal lifestyle. The TCWL group lost weight (1.6 ± 2.9 kg, P = 0.006) while the CON group did not (1.2 ± 1.9 kg, P = 0.106). Physical functioning as measured by the short physical performance battery improved in TCWL when compared to the CON group (ß = 1.94, 95% Confidence Interval [CI]: 1.12, 2.76, P < 0.001). TCWL also improved in sit-and-reach flexibility (ß = -2.27, 95% CI: -4.09, -0.46, P = 0.016), body fat mass (BMI, ß = -0.65, 95% CI: -1.03, -0.26, P = 0.002), waist circumference (ß = -1.78, 95% CI: -2.83, -0.72, P = 0.002), systolic blood pressure (ß = -16.41, 95% CI: -21.35, -11.48, P < 0.001), and diastolic blood pressure (ß = -9.52, 95% CI: -12.65, -6.39, P < 0.001). Thus, TCWL intervention may represent an effective strategy to improve physical function and ameliorate CHD risk in the older adult population.

Assessment of Food Intake, Obesity, and Health Risk among the Homeless in Rhode Island.

OBJECTIVE: The objective of this study was to examine the relationship between the nutritional status, incidence of food insecurity, and health risk among the homeless population in Rhode Island. DESIGN AND SAMPLE: This correlational study utilized a convenience sample of 319 homeless adults from Rhode Island's largest service agency for the homeless. Information on use of services such as access to emergency foods, shelters, and the Supplemental Nutrition Assistance Program (SNAP) was requested. MEASURES: Food security was measured by the six-item subset of the USDA Food Security Core Module. Anthropometric measures included height, weight, and waist circumference. A 24-hr dietary recall was collected to determine the food intake for a subset of participants who agreed to supply this information (n = 197). CONCLUSION: Average dietary recall data indicated insufficient intake of vegetables, fruit, dairy, and meats/beans. It also indicated excessive intake of fats. Of the 313 participants, 29.4% were overweight and 39% were obese. Over 94% of the participants were food insecure, with 64% of this subset experiencing hunger. Fifty-five percent of the participants were currently receiving SNAP benefits. The majority of the sample was found to be food insecure with hunger.

Profiles of medicinal cannabis patients attending compassion centers in rhode island.

Little is understood regarding medicinal marijuana dispensary users. We sought to characterize socio-demographics and reasons for medicinal marijuana use among medical cannabis dispensary patients in Rhode Island. Participants (n=200) were recruited from one of two Compassion Centers in Rhode Island and asked to participate in a short survey, which included assessment of pain interference using the Brief Pain Inventory (BPI). The majority of participants were male (73%), Caucasian (80%), college educated (68%), and had health insurance (89%). The most common reason for medicinal marijuana use was determined to be chronic pain management. Participants were more likely to have BPI pain interference scores of > 5 if they were older (OR: 1.36, 95% CI: 1.04-1.78) or reported using cannabis as a substitute for prescription medications (OR: 2.47, 95% CI: 1.23-4.95), and were less likely to have interference scores of >5 if they had higher income levels (OR: 0.53, 95% CI: 0.40-0.70) or reported having ever received treatment for an alcohol use disorder. One-fifth of participants had a history of a drug or alcohol use disorder. Most participants report that medicinal cannabis improves their pain symptomology, and are interested in alternative treatment options to opioid-based treatment regimens.

Effects of state medical marijuana laws on adolescent marijuana use.

OBJECTIVES: Medical marijuana laws (MMLs) have been suggested as a possible cause of increases in marijuana use among adolescents in the United States. We evaluated the effects of MMLs on adolescent marijuana use from 2003 through 2011. METHODS: We used data from the Youth Risk Behavior Survey and a difference-in-differences design to evaluate the effects of passage of state MMLs on adolescent marijuana use. The states examined (Montana, Rhode Island, Michigan, and Delaware) had passed MMLs at different times over a period of 8 years, ensuring that contemporaneous history was not a design confound. RESULTS: In 40 planned comparisons of adolescents exposed and not exposed to MMLs across states and over time, only 2 significant effects were found, an outcome expected according to chance alone. Further examination of the (nonsignificant) estimates revealed no discernible pattern suggesting an effect on either self-reported prevalence or frequency of marijuana use. CONCLUSIONS: Our results suggest that, in the states assessed here, MMLs have not measurably affected adolescent marijuana use in the first few years after their enactment. Longer-term results, after MMLs are more fully implemented, might be different.

The care transitions intervention: translating from efficacy to effectiveness.

BACKGROUND: Well-executed communication among hospital providers, patients, and receiving providers at the time of hospital discharge contributes to better health outcomes and lower overall health care costs. The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system but requires real-world testing to establish effectiveness in other settings. We hypothesized that coaching would reduce 30-day readmission rates for fee-for-service Medicare beneficiaries, even in open, urban health care delivery systems. METHODS: This was a quasi-experimental prospective cohort study. From January 1, 2009, through June 30, 2010, coaches recruited a convenience sample of fee-for-service Medicare patients in 6 Rhode Island hospitals to receive the Care Transitions Intervention. We paired coaching data with Medicare claims and enrollment data and used logistic regression to compare the odds of 30-day readmission for the intervention group vs internal and external control groups. RESULTS: Compared with individuals who did not receive any part of the intervention (20.0% readmission rate), 30-day readmissions were fewer for participants who received coaching (12.8%; odds ratio, 0.61; 95% confidence interval, 0.42-0.88). Individuals in the internal control group (declined to participate or were lost to follow-up before completing a home visit) had readmission rates similar to those of the external control group (18.6%; odds ratio, 0.94, 95% confidence interval, 0.77-1.14). CONCLUSIONS: The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.

Low vitamin D status among obese adolescents: prevalence and response to treatment.

PURPOSE: To explore the prevalence of low vitamin D status among obese adolescents and to examine the effect of current management of low vitamin D status in these patients. METHODS: A retrospective chart review of obese adolescents who had been screened for vitamin D status by serum total 25-hydroxyvitamin D (25(OH)D) level. Vitamin D deficiency was defined as 25(OH)D level of <20 ng/mL, vitamin D insufficiency as 25(OH)D level of 20-30 ng/mL, and vitamin D sufficiency as 25(OH)D level of >30 ng/mL. Adolescents with vitamin D deficiency were treated with 50,000 IU of vitamin D once a week for 6-8 weeks, whereas adolescents with vitamin D insufficiency were treated with 800 IU of vitamin D daily for 3 months. Repeat 25(OH)D was obtained after treatment. RESULTS: The prevalence rate of low vitamin D status among 68 obese adolescents (53% females, 47% males, age: 17 ± 1 years, body mass index: 38 ± 1 kg/m(2), Hispanic: 45%, African American: 40%, Caucasian: 15%) was 100% in females and 91% in males. Mean (±SE) 25(OH)D level was significantly higher in summer (20 ± 8 ng/mL) than in spring (14 ± 4 ng/mL, p < .02), and significantly lower in winter (15 ± 7 ng/mL) than in fall (25 ± 15 ng/mL, p < .05). Although there was a significant (p < .00001) increase in mean 25(OH)D after the initial course of treatment with vitamin D, 25(OH)D levels normalized in only 28% of the participants. Repeat courses with the same dosage in the other 72% did not significantly change their low vitamin D status. CONCLUSIONS: Increased surveillance and possibly higher vitamin D doses are warranted for obese adolescents whose total 25(OH)D levels do not normalize after the initial course of treatment.

Dietary supplement use and nutrient intake in HIV-infected persons.

Dietary supplement use was assessed in 368 HIV-infected patients enrolled in the Nutrition for Healthy Living cohort. The objective was to describe the dietary, demographic, and health characteristics of the HIV-infected persons who use different types of dietary supplements. Each patient was categorized in 1 of 4 dietary supplement groups. Extremes in intake of micronutrients were common. Men and women who consumed no supplements reported inadequate intakes of a number of micronutrients. Men using nonvitamin/nonmineral (NVNM) supplements had diets higher in fiber, protein, and 13 of 14 vitamins and minerals. Almost 90% of male NVNM supplement users ingested 1 or more vitamins or minerals in amounts above the tolerable upper limit. Male NVNM supplement users were more likely to be white, well educated, and receiving highly active antiretroviral therapy and more likely to have higher annual incomes, higher CD4 counts, and lower HIV RNA levels. HIV-infected women who were using NVNM supplements exhibited similar trends. Micronutrient inadequacy and excess are relatively common in persons living with HIV infection. Practitioners need to judiciously address optimal nutrient intake from both diet and dietary supplements in this population.

Lead poisoning associated with use of litargirio--Rhode Island, 2003.

Lead can damage the neurologic, hematologic, and renal systems. Deteriorated leaded paint in older housing remains the most common source of lead exposure for children in the United States; however, other lead sources increasingly are recognized, particularly among certain racial/ethnic populations. In 2003, the Rhode Island Department of Health (RIDOH) recognized litargirio (also known as litharge or lead monoxide), a yellow or peach-colored powder used as an antiperspirant/deodorant and a folk remedy in the Hispanic community, as a potential source of lead exposure for Hispanic children. This report summarizes a case investigation of elevated blood lead levels (BLLs > or =10 microg/dL) associated with litargirio use among two siblings in Rhode Island, the public health action taken, and a survey of parents/guardians in three pediatric clinics in Providence, Rhode Island, to assess litargirio use. Findings underscore the importance of follow-up of elevated BLLs and thorough investigation to identify all lead sources.

Use of complementary and alternative therapies by patients with human immunodeficiency virus disease in the era of highly active antiretroviral therapy.

BACKGROUND: Complementary and alternative medical therapies (CAM) are popular with patients who are human immunodeficiency virus (HIV) seropositive, despite effective drug treatments, potential drug interactions, and overlapping toxicities. OBJECTIVE: To determine rates and correlates of ingested and noningested CAM use, and to examine temporal changes in the rates of ingested CAM use during the introduction of highly active antiretroviral therapy (HAART). DESIGN: Cross-sectional analysis with repeated measures from a cohort study, with the study visit as the unit of analysis. SETTING: Eastern Massachusetts and Rhode Island. PARTICIPANTS: Adults who are HIV seropositive followed semiannually (n = 642) in Nutrition for Healthy Living (NFHL) study. MEASUREMENTS: Rates of ingested and noningested CAM use were assessed by interview every 6 months between 1995 and 1999. RESULTS: Ingested CAM use was reported at 60% of visits. Between 1995 and 1999, HAART use increased from 0% to 70%, and ingested CAM use decreased from 71% to 52%. In multivariate analyses, users of ingested complementary therapies were more likely to be gay men (prevalence ratio [PR] 1.40, 95% confidence interval [CI] 1.23-1.58; p < 0.0001), at least high school educated (PR 1.37, 95% CI 1.12-1.68, p = 0.002), and with secure housing (PR 0.75, 95% CI 0.61-0.92; p = 0.007). Even in the lowest risk group (less educated, nongay males with insecure housing), CAM use rates were 27% (95% CI 21%-34%). There was no association between HAART and CAM use. CONCLUSIONS: CAM therapies complement, rather than replace, HAART. Even among poorly educated, nongay male patients with insecure housing, rates of ingested CAM use were substantial. Physicians should routinely ask about ingested CAM therapy use and become knowledgeable about potential hazards.

Delay in obtaining conventional healthcare by female internal medicine patients who use herbal therapies.

The use of herbal products has been studied in the general population, but few studies have focused on the prevalence of herbal therapy use for treatment of symptoms or disease among female internal medicine patients or on predictors for delaying obtaining conventional care while using herbal therapy. Cross-sectional 34-item self-report surveys were mailed to female patients in two private practice internal medicine sites and interviewer administered to patients in a resident ambulatory clinic. The survey included sociodemographics, medical problems, use of herbal therapies, and whether conventional care was delayed while using herbal therapy. Of 354 patients, 220 (62%) participated. Their mean age was 51 years, and most were Caucasian (77%) and had more than a high school education (60%). Of these, 81 (37%) women used herbal therapies for treatment of symptoms or disease, and use did not differ by study site. Twenty-six (32%) delayed obtaining conventional care while waiting for an herbal product to work, although most eventually obtained conventional care. In multivariate analysis, predictors for delay of care included negative experience with prescription medicines, history of failed treatments, and desire for increased control over personal healthcare. Among female patients of general internists, there was a high prevalence of herbal therapy use for treatment of illness, and some women delay obtaining conventional care while using an herbal product. Predictors for delay may alert physicians to educate their patients before delaying care.

Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in southeastern New England.

Sun exposure is the most important avoidable cause of skin cancers. We report characteristics of a representative sample (N = 2,324) of beachgoers in Southeastern New England during the summer of 1995. This sample was not employing adequate sun protection behaviors (83% did not often avoid the sun during midday and only 45% often used sunscreen). Important demographic and skin cancer risk factor differences in sun protective behaviors and stages of change for sun protection were found, especially differences based on age, gender, and degree of sun sensitivity. Consistent with previous research, increased age, female gender, and greater sun sensitivity were each independently associated with more sun protective behaviors. These findings underscore the need for interventions targeting high-risk populations, such as those receiving high-intensity sun exposures at the beach.

Risk factors for surgery for prostatic hypertrophy.

The purpose of this case-control study was to evaluate potential risk factors for prostatic hypertrophy. The cases were 910 residents of Rhode Island who had a partial or total prostatectomy that was not related to cancer in the years 1985-1987. The controls were 2,003 members of the source population who were selected from a list of holders of Rhode Island driver's licenses or a roster of older Americans compiled by the Health Care Financing Administration. Cases and controls were interviewed by telephone. The risk of prostatic hypertrophy was elevated in Jewish men compared with Protestants and Catholics and in blacks compared with whites. Risk was reduced in ever-married compared with never-married men, in men who had left school at age 16 years or more compared with those who had left earlier, and in relatively tall or relatively heavy men. Coffee drinking and cigarette smoking were inversely but only weakly related to prostatic hypertrophy. There was a relatively strong, although irregular, inverse relation of beer drinking to prostatic hypertrophy. The associations of spirits and wine consumption with prostatic hypertrophy were weak.