Clinical decision support for gastrointestinal panel testing.

Objective: This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel"). Design: Single-center, retrospective, before-after study. Setting: Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care. Patients: All patients tested with a GI panel between June 22, 2022 and April 20, 2023. Intervention: We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022. Results: Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention. Conclusions: Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.

Occupational Health Providers' Perceptions of Employee Vaccine Hesitancy.

OBJECTIVE: This study examined the perspectives of occupational health providers (OHPs) on the most frequently encountered clinically relevant reasons for employee vaccine hesitancy. METHODS: We conducted an anonymous, online, cross-sectional survey of US OHPs ( N = 217). The survey asked OHPs about the major reasons that employees cite for being unwilling to receive the following three categories of vaccines: COVID-19, annual influenza, and others relevant to the workplace. RESULTS: Concern about adverse effects was the most frequently reported reason for employee vaccine hesitancy for each vaccine category. Mistrust was reported more frequently for COVID-19 than for the influenza vaccine or other vaccines (χ 2P < 0.05). Targets of employee mistrust included government and researchers or scientists, but mistrust of healthcare providers was uncommon. CONCLUSIONS: These results can be used to inform interventions to address vaccine hesitancy in the occupational health setting.

Role of Dietary Macronutrients and Fatty Acids in Obesity and Metabolic Risk in Older Adults.

The aim of the study was to examine the role of dietary consumption of different types of fatty acids on metabolic risk factors and regional fat deposition in older men and women. We hypothesized that saturated fatty acid (SFA) intake, monounsaturated fatty acid (MUFA) and low intake of polyunsaturated fatty acids (PUFA) would be associated with markers of insulin resistance, hyperlipidemia, and hypertriglyceridemia. Sedentary, overweight and obese (body mass index: 29-48 kg/m2) adults (N=20) aged 45-78 years underwent two-hour oral glucose tolerance test, blood draw, DXA scan, and completed seven-day diet records. Subjects had low fitness levels (VO2 max=23.5 ± 2.4 mL/kg/min) and high total body fat (43.5 ± 1.7%). The average macronutrient composition of the diet was high in fat as a percent of total kcal (35.5%). The ratio of MUFA to PUFA was associated with serum cholesterol (r=0.48, P=0.03) and tended to be associated with higher fasting glucose (r=0.42, P=0.06) and glucose at 120 min (r=0.43, P=0.06). PUFA intake as a percentage of fat intake was associated with lower serum cholesterol (r=-0.44, P=0.05). Therefore, dietary MUFA intake unbalanced by PUFA may confer increased risk for diabetes among obese, sedentary individuals. Future investigation of food sources, or context of dietary lipids, could lead to individualized dietary recommendations to promote healthy eating habits and potentially alter metabolic risk.

Usual and Dual-Task Walking Speed: Implications for Pedestrians Crossing the Road.

OBJECTIVE: In many countries, pedestrian light crossings require a minimum walking speed of 1.2 m/s. This study examined the proportion of adults in a nationally representative sample whose usual and dual-task walking speeds are <1.2 m/s. METHOD: Community-dwelling adults aged ≥50 years in The Irish Longitudinal Study on Ageing (TILDA) completed walking speed tests on a GAITRite® walkway (N = 4,909). RESULTS: One third of Irish adults aged 65 to 74 years and 61% of adults aged ≥75 years walked slower than 1.2 m/s. In dual-task walking, 54% of adults aged <65 years and 91% of adults aged ≥75 years walked slower than 1.2 m/s. DISCUSSION: Based on these data, many older people would have insufficient time to cross the road at light-controlled pedestrian crossings. Increasing the time provided would be an advantage for many older pedestrians.

Prevalence of age-related macular degeneration in the Republic of Ireland.

BACKGROUND: Age-related macular degeneration (AMD) remains the most common cause of visual loss among subjects over 50 years of age in the developed world. The Irish Longitudinal study on Ageing (TILDA) is a population-based study of subjects aged 50 years or older, designed to investigate factors that influence ageing, and has enabled this investigation of the prevalence of AMD in the Republic of Ireland (ROI). METHODS: Data collected from a nationally representative sample of community-living older adults aged 50 years and over in ROI over the period November 2009 to July 2011. 5035 participants attended the TILDA health centre for assessment. Retinal photographs were obtained in 4859 of these participants. Retinal grading was performed in a masked fashion using a modified version of the International Classification and Grading System for AMD. RESULTS: Adjusting for lower response rates among older subjects, the estimated overall prevalence of any AMD was 7.2% (95% CI 6.5% to 7.9%) in the population aged 50 years or older. The estimated prevalence of early AMD was 6.6% (95% CI 5.9% to 7.3%), and the estimated prevalence of late AMD was 0.6% (95% CI 0.4% to 0.8%). Statistically significant associations with AMD included increasing age and family history of the condition. CONCLUSIONS: This is the first study to provide prevalence estimates of AMD in ROI and will inform eye care professionals and policymakers involved in the delivery and planning of care for those afflicted with this condition.

Stressful life events and orthostatic blood pressure recovery in older adults.

OBJECTIVE: The majority of the literature on stress and blood pressure (BP) concerns the increased risk of cardiovascular morbidity and mortality from high BP. Because the sympathetic nervous system is critical to the maintenance of orthostatic BP, it was hypothesized that older adults who have experienced more stressful life events (SLEs) would be more likely to show impaired recovery of BP in response to orthostatic stress. METHOD: A total of 3,765 participants (Mage = 61.6 years, SD = 8.2; 54% female) from the first wave of The Irish Longitudinal Study on Ageing (TILDA) were included in the current analysis. Exposure to lifetime SLEs was ascertained by self-completion questionnaire, and beat-to-beat orthostatic BP measurement was carried out. Individuals who failed to recover at least 95% of their baseline BP by 60 s post stand were characterized as having impaired orthostatic BP recovery. RESULTS: An independent, dose-response relationship between the number of SLEs reported and the odds of impaired systolic BP recovery was observed after adjustment for covariates (1 event: odds ratio [OR] = 1.19, 95% confidence interval [CI] [0.98, 1.45], p = .078; 2 events: OR = 1.33, 95% CI [1.03, 1.73], p = .031; 3 or more events: OR = 1.56, 95% CI [1.12, 1.73], p = .009). This relationship was not evident for diastolic BP recovery. CONCLUSION: The reporting of a higher number of SLEs is associated with greater risk of impaired systolic BP recovery from orthostatic stress. Potential clinical implications include an increased risk of cerebral hypoperfusion, which predisposes older adults to falls, faints, and changes in cognitive status.

The lasting legacy of childhood adversity for disease risk in later life.

OBJECTIVE: There has been an increased interest in the role of the childhood social environment in the etiology of adult diseases in recent years. The present study examines whether the experience of adversity during childhood increases risk for disease in later life independent of later life socioeconomic, behavioral, and psychosocial factors. METHOD: The study involved a nationally representative sample of 6,912 persons aged 50 years and older who were participating in the first wave of the Irish Longitudinal Study on Ageing. Childhood adversity was indexed using a 4-item measure that captured challenging and potentially noxious childhood environmental exposures including, socioeconomic disadvantage, substance abuse among parents, physical abuse, and sexual abuse. A doctor diagnosis of disease across 9 chronic disease types represented the primary outcome variables. RESULTS: The experience of adversity during childhood was associated with increased risk of disease in midlife and older ages across a large number of chronic disease types including cardiovascular disease, lung disease, and emotional, nervous, or psychiatric disorders. Analysis of the dose-response pattern revealed positively graded associations between the number of adverse events experienced during childhood and the occurrence of chronic disease in later life. Cox proportional hazard models revealed that the experience of adversity during childhood was associated with earlier age of onset for any physical disease type or emotional, nervous, or psychiatric disorders. CONCLUSIONS: These findings indicate that childhood may represent a sensitive or critical period in the development of disease and reinforces the necessity of adopting a life-course approach to the study of chronic diseases.

Atrial fibrillation is associated with impaired mobility in community-dwelling older adults.

OBJECTIVES: To examine the independent associations between atrial fibrillation (AF) and objectively measured mobility in a nationally representative cohort. DESIGN: Wave 1 of The Irish Longitudinal Study on Ageing (TILDA), a population-based study assessing health, economic, and social aspects of ageing. SETTING: Community-dwelling adults completed a home-based interview and a center-based health assessment. PARTICIPANTS: Participants aged 50 years or older, with Mini-Mental State Examination score of 24 or higher, and who completed at least 1 mobility test (n = 4525). MEASUREMENTS: Mobility was assessed with the Timed Up-and-Go (TUG) test and usual and dual task gait speed obtained using a 4.88-m GAITRite® mat. AF was diagnosed using a 10-minute surface electrocardiogram recording. Linear regression analyses were performed to compare mobility in participants with and without AF, adjusting for confounders. RESULTS: In this sample (mean age 62.3 years; range 51-89), overall prevalence of AF was 3.1%, increasing to 6.7% in the over 70s (11.8% men; 2.8% women). In multivariate analysis, AF was independently associated with slower TUG (ß 0.37; 95% confidence interval [CI] 0.07-0.71; P = .043) and slower usual gait speed (ß -3.59; 95% CI -7.05 to -0.12; P = .030). There was a significant age*AF interaction effect for usual gait speed (ß -0.480, 95% CI -0.907 to -0.053, P = .028). Adults with AF walked 3.77 cm/s more slowly than adults without AF at age 70, declining by 4.8 cm/s for each additional decade. CONCLUSION: AF is independently associated with lower usual gait speed in community-dwelling adults and this effect is magnified in those aged 70 and older. This may place them at increased risk of falls, hospitalization, cognitive decline, and mortality, as well as stroke and heart failure. Early recognition and treatment of AF is vital to improve physical function and reduce this risk.

Younger age as a prognostic indicator in breast cancer: a cohort study.

BACKGROUND: The debate continues as to whether younger women who present with breast cancer have a more aggressive form of disease and a worse prognosis. The objectives of this study were to determine the incidence of breast cancer in women under 40 years old and to analyse the clinicopathological characteristics and outcome compared to an older patient cohort. METHODS: Data was acquired from a review of charts and the prospectively reviewed GUH Department of Surgery database. Included in the study were 276 women diagnosed with breast cancer under the age of forty and 2869 women over forty. For survival analysis each women less than 40 was matched with two women over forty for both disease stage and grade. RESULTS: The proportion of women diagnosed with breast cancer under the age of forty in our cohort was 8.8%. In comparison to their older counterparts, those under forty had a higher tumour grade (p = 0.044) and stage (p = 0.046), a lower incidence of lobular tumours (p < 0.001), higher estrogen receptor negativity (p < 0.001) and higher HER2 over-expression (p = 0.002); there was no statistical difference as regards tumour size (p = 0.477). There was no significant difference in overall survival (OS) for both groups; and factors like tumour size (p = 0.026), invasion (p = 0.026) and histological type (p = 0.027), PR (p = 0.031) and HER2 (p = 0.002) status and treatment received were independent predictors of OS CONCLUSION: Breast cancer in younger women has distinct histopathological characteristics; however, this does not result in a reduced survival in this population.

Clinical features, treatment, and survival of patients with colorectal cancer with or without inflammatory bowel disease.

BACKGROUND & AIMS: Inflammatory bowel disease (IBD) increases the risk of colorectal cancer (CRC), indicating that inflammation might alter tumor characteristics and potentially affect treatment and survival. Published data on this topic are inconclusive, so we conducted a population-based study in Ireland to address it. METHODS: We used the National Cancer Registry to collect data on all patients diagnosed with CRC in Ireland from 1994 to 2005 (n = 22,335) and identified those who also had IBD (n = 170). The clinical characteristics, treatment, and survival of patients with IBD and CRC were compared with those of patients with CRC without IBD. RESULTS: Patients with CRC and IBD were, on average, 7.7 years younger than those without IBD at diagnosis of CRC (P = .001), and were less likely to smoke (P = .002). Fewer CRCs in patients with IBD were stage 4 at diagnosis (12% vs 22% in non-IBD patients; P < .001). There was no significant difference in CRC treatment modalities between patients with or without IBD (P = .57). The median survival time of CRC patients with IBD was about 3 years longer than that of patients without IBD (P < .001). However, Cox proportional hazards analysis revealed that IBD was not a significant prognostic factor for CRC (P = .97). However, older age, male sex, smoking, and advanced grade and stage all were associated independently with shorter survival time. When propensity score matching was used to analyze outcomes, the survival times of CRC patients with and without IBD did not differ significantly. CONCLUSIONS: The features of patients with CRC and IBD differ significantly from those of CRC patients without IBD, but each group of patients receive similar treatment and have similar patterns of disease progression after diagnosis.