Svetlana K Eden

Vanderbilt University, Nashville, Michigan, United States

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Publications (29)138.1 Total impact

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    ABSTRACT: Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients. Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations. Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p<0.05), higher treatment satisfaction (OR 1.76-1.96, all p<0.01), portion size reduction (OR 1.43, p<0.05), diabetes self-efficacy (OR 1.41, p<0.05), and lower A1C (β=-0.06, p<0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p<0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p<0.001). Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction. Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Patient Education and Counseling 10/2014; 98(2). · 2.60 Impact Factor
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    ABSTRACT: Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort.
    PLoS ONE 08/2014; 9(8):e103746. · 3.53 Impact Factor
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    ABSTRACT: Unintentional injury is a leading cause of infant mortality. To examine the role of caregiver health literacy in infant injury prevention behaviors. A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety. Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9). Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.
    American journal of preventive medicine 05/2014; 46(5):449-56. · 4.24 Impact Factor
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    ABSTRACT: To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity. Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson χ(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions. Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037). Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.
    PEDIATRICS 03/2014; · 5.30 Impact Factor
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    ABSTRACT: To examine the relationship between parent health literacy and "obesogenic" infant care behaviors. Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate ≥23; low <23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site. Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (<30 min/d), (aOR = 3.0 [1.5-5.8]). Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.
    The Journal of pediatrics 12/2013; · 4.02 Impact Factor
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    ABSTRACT: Fluoroquinolone exposure before tuberculosis (TB) diagnosis is common. We anticipated that exposure to older-generation fluoroquinolones is associated with greater fluoroquinolone MICs in Mycobacterium tuberculosis than exposure to newer agents. A nested case-control study was performed among newly diagnosed TB patients reported to the Tennessee Department of Health (January 2002-December 2009). Each fluoroquinolone-resistant case (n=25) was matched to two fluoroquinolone-susceptible controls (n=50). Ciprofloxacin and ofloxacin were classified as older-generation fluoroquinolones; levofloxacin, moxifloxacin and gatifloxacin were considered newer agents. There was no difference between median ofloxacin MIC for isolates from 9 patients exposed only to older fluoroquinolones, 25 exposed only to newer fluoroquinolones, 6 exposed to both and 35 fluoroquinolone-unexposed patients (Kruskal-Wallis, P=0.35). Using multivariate proportional odds logistic regression adjusting for age and sex, duration of exposure to newer fluoroquinolones was independently associated with higher MIC (OR=1.79, 95% CI 1.22-2.64), but duration of exposure to older fluoroquinolones was not (OR=0.94, 95% CI 0.50-1.78). Isolates from patients exposed only to newer fluoroquinolones tended to have mutations at gyrA codons 90, 91 or 94 more frequently than those exposed only to older fluoroquinolones (44% vs. 11%). We were surprised to find that duration of exposure to newer fluoroquinolones, but not older ones, was independently associated with higher ofloxacin MIC. This suggests that the mutant selection window lower boundary is likely to have clinical relevance; caution is warranted when newer fluoroquinolones are prescribed to patients with TB risk factors.
    International journal of antimicrobial agents 06/2013; · 3.03 Impact Factor
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    ABSTRACT: The use of novel biomarkers to detect incident acute kidney injury (AKI) in the critically ill is hindered by heterogeneity of injury and the potentially confounding effects of prevalent AKI. Here we examined the ability of urine NGAL (NGAL), L-type fatty acid-binding protein (L-FABP), and cystatin C to predict AKI development, death, and dialysis in a nested case-control study of 380 critically ill adults with an eGFR over 60 ml/min per 1.73 m(2). One-hundred thirty AKI cases were identified following biomarker measurement and were compared with 250 controls without AKI. Areas under the receiver-operator characteristic curves (AUC-ROCs) for discriminating incident AKI from non-AKI were 0.58 (95% CI: 0.52-0.64), 0.59 (0.52-0.65), and 0.50 (0.48-0.57) for urine NGAL, L-FABP, and cystatin C, respectively. The combined AUC-ROC for NGAL and L-FABP was 0.59 (56-0.69). Both urine NGAL and L-FABP independently predicted AKI during multivariate regression; however, risk reclassification indices were mixed. Neither urine biomarker was independently associated with death or acute dialysis (NGAL hazard ratio 1.35 (95% CI: 0.93-1.96), L-FABP 1.15 (0.82-1.61)), although both independently predicted the need for acute dialysis alone (NGAL 3.44 (1.73-6.83), L-FABP 2.36 (1.30-4.25)). Thus, urine NGAL and L-FABP independently associated with the development of incident AKI and receipt of dialysis but exhibited poor discrimination for incident AKI using conventional definitions.Kidney International advance online publication, 22 May 2013; doi:10.1038/ki.2013.174.
    Kidney International 05/2013; · 8.52 Impact Factor
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    ABSTRACT: BACKGROUND: Limited research exists on physician-delivered education interventions. We examined the feasibility and impact of an educational tool on facilitating physician-patient kidney disease communication. STUDY DESIGN: Pilot feasibility clinical trial with a historical control to examine effect size on patient knowledge and structured questions to elicit physician and patient feedback. SETTING & PARTICIPANTS: Adults with chronic kidney disease (CKD) stages 1-5, seen in nephrology clinic. INTERVENTION: 1-page educational worksheet, reviewed by physicians with patients. OUTCOMES: Kidney knowledge between patient groups and provider/patient feedback. MEASUREMENTS: Patient kidney knowledge was measured using a previously validated questionnaire compared between patients receiving the intervention (April to October 2010) and a historical cohort (April to October 2009). Provider input was obtained using structured interviews. Patient input was obtained through survey questions. Patient characteristics were abstracted from the medical record. RESULTS: 556 patients were included, with 401 patients in the historical cohort and 155 receiving the intervention. Mean age was 57 ± 16 (SD) years, with 53% men, 81% whites, and 78% with CKD stages 3-5. Compared with the historical cohort, patients receiving the intervention had higher adjusted odds of knowing they had CKD (adjusted OR, 2.20; 95% CI, 1.16-4.17; P = 0.02), knowing their kidney function (adjusted OR, 2.25; 95% CI, 1.27-3.97; P = 0.005), and knowing their stage of CKD (adjusted OR, 3.22; 95% CI, 1.49-6.92; P = 0.003). Physicians found the intervention tool easy and feasible to integrate into practice and 98% of patients who received the intervention recommended it for future use. LIMITATIONS: Study design did not randomly assign patients for comparison and enrollment was performed in clinics at one center. CONCLUSIONS: In this pilot study, a physician-delivered education intervention was feasible to use in practice and was associated with higher patient kidney disease knowledge. Further examination of physician-delivered education interventions for increasing patient disease understanding should be tested through randomized trials.
    American Journal of Kidney Diseases 03/2013; · 5.76 Impact Factor
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    ABSTRACT: Objective:To determine how an ultra-brief structured tool that would require usually less than a minute for delirium assessment compares with a clinical assessment based on Diagnostic and Statistical Manual-IV (DSM-IV) in a geriatric postacute care (PAC) rehabilitation unit.Design:Prospective observational cohort study.Setting:Postacute geriatric hospital ward of a Veteran's Affairs hospital.Participants:Consecutively admitted patients between 50 and 100 years old for inpatient postacute medical care.Measurements:Two teams, blinded to one another's evaluations, performed daily delirium assessments using either the Confusion Assessment Method for the intensive care unit (CAM-ICU) or clinical assessment based on DSM-IV. RESULTS: There were 61 patients enrolled (median 73 years old, range: 52-94), who underwent 521 paired observations. Delirium was detected in 18 patients (29.5%) by one of the two screening methods over the course of the study, most of whom (14 patients, 23%) were delirious on the first day of enrollment. Delirium was identified by the CAM-ICU on 12.6% of the observations and by the clinical assessment on 6% of the observations (κ = 0.25, 95% confidence interval [CI]: 0.09, 0.40). Examination of disagreement between the 2 evaluations revealed that patients with dementia (κ = 0.11, 95% CI: -0.14, 0.27) had 10.7 times higher odds (95% CI: [3.1, 36.8], p value < .001) of having discordance than patients without dementia.Conclusions:Different delirium assessments may disagree depending on the study population. Dementia patients are especially challenging to evaluate for delirium.
    The Gerontologist 12/2012; · 2.48 Impact Factor
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    ABSTRACT: Background: Mothers with limited literacy skills are more likely to have depressive symptoms; interventions that increase maternal literacy skills may also improve symptoms of depression, and associations are recognized between low health literacy and adverse health outcomes, yet research has yet to be conducted in a large sample of mothers of newborn infants. This study explored the relationship between depressive symptoms and health literacy among low-income mothers of newborn infants. Methods: 429 mothers (M age = 26 years) of diverse racial/ethnic backgrounds (47% Hispanic, 29% Black, 27% white, 44% other) completed the Parent Health Literacy Assessment Test (PHLAT), CES-D to examine depression, and a measure of maternal locus of control during their child's 2 month well-child doctor's visit. Analysis used proportional odds logistic regression and adjusted for a priori covariates, maternal self-efficacy, caregiver's age, race, ethnicity, level of English fluency, income, work status, and education. Results: A ten-unit increase in PHLAT was associated with increased odds of having a higher depression score (OR=1.11, 95% CI (1.04, 1.18)). Higher depression scores were also associated with decreased maternal self-efficacy (OR=1.68, 95% CI (1.27, 2.22)) and with unemployment status (OR=2.52, 95% CI (1.66, 3.83)); however, self-efficacy did not mediate the relationship between health literacy and depression. Conclusions: Prevention programs to screen mothers for depressive symptoms may be beneficial and allow for targeted interventions to increase literacy and self-efficacy skills, possibly improving health for mother and child.
    140st APHA Annual Meeting and Exposition 2012; 10/2012
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    ABSTRACT: Purpose : The CDC’s Healthy People 2020 has prioritized two postpartum outcomes: breastfeeding promotion and early screening and treatment of depression. Reviews have identified low health literacy (HL), which affects at least 1 in 4 women, as an independent risk factor for non-breastfeeding and depressive symptoms (Sanders 2009; Kaufman 2001). Postpartum depressive symptoms may be linked to low breastfeeding initiation rates, short breastfeeding duration, and greater breastfeeding difficulties (Dennis & McQueen, 2009). Little is known about the interaction of demographic and psychosocial factors that affect breastfeeding initiation and early termination of breastfeeding, including the role of HL. The aim of this study was to determine the relationships among postpartum depressive symptoms, HL, and breastfeeding practices in mothers of newborn infants. Methods : 689 mothers (M age = 27 years) of diverse racial backgrounds (26% White, 28% Black, and 46% Other; 49% of the sample was Hispanic) participated in a cluster randomized early obesity prevention trial involving pediatric resident clinics at four universities. Twenty seven percent of mothers reported an annual household income of < $20, 000. Mothers were recruited during their infant’s 2 month well child clinic visit and reported on their infant's nutrition at 2 months to examine breastfeeding practices and completed the CES-D to assess depressive symptoms postpartum. Mothers also provided demographic information and completed questionnaires assessing health literacy (STOFHLA), maternal self-efficacy, and social support. The association of breastfeeding practices (exclusively breastfeeding vs. breastfeeding and/or bottle feeding) and depression score were studied by using logistic regressions and adjusting for a priori defined covariates: caregiver’s age, race (White, Black, Other), ethnicity, income, work status, WIC status, and parity. Results : In this sample there was no statistically significant association between depressive symptoms and breastfeeding practices. However, higher health literacy was associated with higher odds of exclusively breastfeeding (OR=1.42, 95%CI (1.01, 2.00)), and lower levels of social support was associated with increased odds of exclusively breastfeeding (OR=1.90, 95%CI (1.16, 3.13)). In addition, caregivers who identified themselves as White (vs. Black OR=3.09, 95%CI (1.54, 6.21)) or Other (vs. Black OR=2.72, 95%CI (1.24, 5.99)) had higher odds of breastfeeding exclusively. Caretakers who were looking for work, or worked part/full time had lower odds of exclusively breastfeeding. The analysis showed no evidence that age, ethnicity, or parity were associated with breastfeeding practices. Conclusions : For this sample of diverse women at risk for poor health outcomes, maternal HL was the most critical modifiable factor associated with supporting breastfeeding. Improving the HL of expectant mothers or adapting breastfeeding-related materials to those with low literacy could contribute to higher likelihood of initiation and continuation of breastfeeding in the first few months of a newborn’s life. Addressing cultural perceptions and attitudes toward breastfeeding will likely also be important.
    2012 American Academy of Pediatrics National Conference and Exhibition; 10/2012
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    ABSTRACT: BACKGROUND AND OBJECTIVES: Baseline creatinine (BCr) is frequently missing in AKI studies. Common surrogate estimates can misclassify AKI and adversely affect the study of related outcomes. This study examined whether multiple imputation improved accuracy of estimating missing BCr beyond current recommendations to apply assumed estimated GFR (eGFR) of 75 ml/min per 1.73 m(2) (eGFR 75). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: From 41,114 unique adult admissions (13,003 with and 28,111 without BCr data) at Vanderbilt University Hospital between 2006 and 2008, a propensity score model was developed to predict likelihood of missing BCr. Propensity scoring identified 6502 patients with highest likelihood of missing BCr among 13,003 patients with known BCr to simulate a "missing" data scenario while preserving actual reference BCr. Within this cohort (n=6502), the ability of various multiple-imputation approaches to estimate BCr and classify AKI were compared with that of eGFR 75. RESULTS: All multiple-imputation methods except the basic one more closely approximated actual BCr than did eGFR 75. Total AKI misclassification was lower with multiple imputation (full multiple imputation + serum creatinine) (9.0%) than with eGFR 75 (12.3%; P<0.001). Improvements in misclassification were greater in patients with impaired kidney function (full multiple imputation + serum creatinine) (15.3%) versus eGFR 75 (40.5%; P<0.001). Multiple imputation improved specificity and positive predictive value for detecting AKI at the expense of modestly decreasing sensitivity relative to eGFR 75. CONCLUSIONS: Multiple imputation can improve accuracy in estimating missing BCr and reduce misclassification of AKI beyond currently proposed methods.
    Clinical Journal of the American Society of Nephrology 10/2012; · 5.07 Impact Factor
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    ABSTRACT: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. Randomized, controlled trial with concealed allocation and blinded outcome assessors. ( registration number: NCT00632021) Two tertiary care academic hospitals. Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). The characteristics of the study hospitals and participants may limit generalizability. Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention. National Heart, Lung, and Blood Institute.
    Annals of internal medicine 07/2012; 157(1):1-10. · 16.10 Impact Factor
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    ABSTRACT: We examined the effect of hospital admissions on the medical treatment of poorly controlled diabetes mellitus among Veterans Affairs (VA) patients. This retrospective cohort study included male patients admitted to one of three VA hospitals from July 1, 2002, to August 31, 2009, who were receiving medication therapy for diabetes with hemoglobin A1c (HgbA1c) greater than 8.0%. The primary outcome was a change in preadmission and outpatient prescriptions for diabetes at hospital discharge. Covariates for multivariable logistic regression analysis of the primary outcome were defined a priori and retrieved from the electronic health record. Of 2025 admissions for 1359 patients, 454 had some change in diabetes medications at discharge (rate of change 22.4%). In an adjusted analysis, higher preadmission HgbA1c [odds ratio (OR) 1.12 per 1.0 U increase; 95% confidence interval (CI) 1.12-1.05; P < 0.001], higher mean blood glucose during admission (OR 1.07 per 10 mg/dl increase; 95% CI 1.05-1.10; P < 0.0001), occurrence of inpatient hypoglycemia (blood glucose < 50 mg/dl; OR 1.82, 95% CI 1.32-2.51, P < 0.001), and inpatient basal insulin therapy (OR 1.71; 95% CI 1.25-2.35; P < 0.001) were associated with higher odds of change in therapy. A total of 656 admissions (32%) demonstrated aggregate clinical inertia with no change in therapy, no documentation of HgbA1c within 60 d of discharge, and no follow-up appointment within 30 d of discharge. In this multicenter, retrospective study of patients with poorly controlled diabetes and at least one hospitalization, less than a quarter received a change in outpatient diabetes therapy upon discharge, suggesting widespread clinical inertia. Nearly one third had no change in therapy or subsequent follow-up scheduled.
    The Journal of Clinical Endocrinology and Metabolism 03/2012; 97(6):2019-26. · 6.31 Impact Factor
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    ABSTRACT: Fluoroquinolone resistance in Mycobacterium tuberculosis can be conferred by mutations in gyrA or gyrB. The prevalence of resistance mutations outside the quinolone resistance-determining region (QRDR) of gyrA or gyrB is unclear, since such regions are rarely sequenced. M. tuberculosis isolates from 1,111 patients with newly diagnosed culture-confirmed tuberculosis diagnosed in Tennessee from 2002 to 2009 were screened for phenotypic ofloxacin resistance (>2 μg/ml). For each resistant isolate, two ofloxacin-susceptible isolates were selected: one with antecedent fluoroquinolone exposure and one without. The complete gyrA and gyrB genes were sequenced and compared with M. tuberculosis H37Rv. Of 25 ofloxacin-resistant isolates, 11 (44%) did not have previously reported resistance mutations. Of these, 10 had novel polymorphisms: 3 in the QRDR of gyrA, 1 in the QRDR of gyrB, and 6 outside the QRDR of gyrA or gyrB; 1 did not have any gyrase polymorphisms. Polymorphisms in gyrA codons 1 to 73 were more common in fluoroquinolone-susceptible than in fluoroquinolone-resistant strains (20% versus 0%; P = 0.016). In summary, almost half of fluoroquinolone-resistant M. tuberculosis isolates did not have previously described resistance mutations, which has implications for genotypic diagnostic tests.
    Journal of clinical microbiology 12/2011; 50(4):1390-6. · 4.23 Impact Factor
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    ABSTRACT: AKI associates with an increased risk for the development and progression of CKD and mortality. Processes of care after an episode of AKI are not well described. Here, we examined the likelihood of nephrology referral among survivors of AKI at risk for subsequent decline in kidney function in a US Department of Veterans Affairs database. We identified 3929 survivors of AKI hospitalized between January 2003 and December 2008 who had an estimated GFR (eGFR) <60 ml/min per 1.73 m(2) 30 days after peak injury. We analyzed time to referral considering improvement in kidney function (eGFR ≥60 ml/min per 1.73 m(2)), dialysis initiation, and death as competing risks over a 12-month surveillance period. Median age was 73 years (interquartile range, 62-79 years) and the prevalence of preadmission kidney dysfunction (baseline eGFR <60 ml/min per 1.73 m(2)) was 60%. Overall mortality during the surveillance period was 22%. The cumulative incidence of nephrology referral before dying, initiating dialysis, or experiencing an improvement in kidney function was 8.5% (95% confidence interval, 7.6-9.4). Severity of AKI did not affect referral rates. These data demonstrate that a minority of at-risk survivors are referred for nephrology care after an episode of AKI. Determining how to best identify survivors of AKI who are at highest risk for complications and progression of CKD could facilitate early nephrology-based interventions.
    Journal of the American Society of Nephrology 12/2011; 23(2):305-12. · 9.47 Impact Factor
  • Journal of Hospital Medicine 11/2011; 6(9):487. · 2.08 Impact Factor
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    ABSTRACT: Patients' ability to accurately report their preadmission medications is a vital aspect of medication reconciliation, and may affect subsequent medication adherence and safety. Little is known about predictors of preadmission medication understanding. We conducted a cross-sectional evaluation of patients at 2 hospitals using a novel Medication Understanding Questionnaire (MUQ). MUQ scores range from 0 to 3 and test knowledge of the medication purpose, dose, and frequency. We used multivariable ordinal regression to determine predictors of higher MUQ scores. Among the 790 eligible patients, the median age was 61 (interquartile range [IQR] 52, 71), 21% had marginal or inadequate health literacy, and the median number of medications was 8 (IQR 5, 11). Median MUQ score was 2.5 (IQR 2.2, 2.8). Patients with marginal or inadequate health literacy had a lower odds of understanding their medications (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.34 to 0.84; P = 0.0001; and OR = 0.49; 95% CI, 0.31 to 0.78; P = 0.0001; respectively), compared to patients with adequate health literacy. Higher number of prescription medications was associated with lower MUQ scores (OR = 0.52; 95% CI, 0.36 to 0.75; for those using 6 medications vs 1; P = 0.0019), as was impaired cognitive function (OR = 0.57; 95% CI, 0.38 to 0.86; P = 0.001). Lower health literacy, lower cognitive function, and higher number of medications each were independently associated with less understanding of the preadmission medication regimen. Clinicians should be aware of these factors when considering the accuracy of patient-reported medication regimens, and counseling patients about safe and effective medication use.
    Journal of Hospital Medicine 11/2011; 6(9):488-93. · 2.08 Impact Factor
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    ABSTRACT: It is likely that patients with chronic kidney disease (CKD) have a limited understanding of their illness. Here we studied the relationships between objective and perceived knowledge in CKD using the Kidney Disease Knowledge Survey and the Perceived Kidney Disease Knowledge Survey. We quantified perceived and objective knowledge in 399 patients at all stages of non-dialysis-dependent CKD. Demographically, the patient median age was 58 years, 47% were women, 77% had stages 3-5 CKD, and 83% were Caucasians. The overall median score of the perceived knowledge survey was 2.56 (range: 1-4), and this new measure exhibited excellent reliability and construct validity. In unadjusted analysis, perceived knowledge was associated with patient characteristics defined a priori, including objective knowledge and patient satisfaction with physician communication. In adjusted analysis, older age, male gender, and limited health literacy were associated with lower perceived knowledge. Additional analysis revealed that perceived knowledge was associated with significantly higher odds (2.13), and objective knowledge with lower odds (0.91), of patient satisfaction with physician communication. Thus, our results present a mechanism to evaluate distinct forms of patient kidney knowledge and identify specific opportunities for education tailored to patients with CKD.
    Kidney International 08/2011; 80(12):1344-51. · 8.52 Impact Factor
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    ABSTRACT: The consequences of delirium in the emergency department (ED) remain unclear. This study sought to determine if delirium in the ED was an independent predictor of prolonged hospital length of stay (LOS). This prospective cohort study was conducted at a tertiary care, academic ED from May 2007 to August 2008. The study included English-speaking patients aged 65 and older who were in the ED for less than 12 hours at enrollment. Patients were excluded if they refused consent, were previously enrolled, were unable to follow simple commands at baseline, were comatose, or did not have a delirium assessment performed by the research staff. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to determine delirium status. Patients who were discharged directly from the ED were considered to have a hospital LOS of 0 days. To determine if delirium in the ED was independently associated with time to discharge, Cox proportional hazard regression was performed adjusted for age, comorbidity burden, severity of illness, dementia, functional impairment, nursing home residence, and surgical procedure. A sensitivity analysis, which included admitted patients only, was also performed. A total of 628 patients met enrollment criteria. The median age was 75 years (interquartile range [IQR] = 69-81), 365 (58%) patients were female, 111 (18%) were nonwhite, 351 (56%) were admitted to the hospital, and 108 (17%) were delirious in the ED. Median LOS was 2 days (IQR = 0-5.5) for delirious ED patients and 1 day (IQR = 0-3) for nondelirious ED patients (p < 0.001). The hazard ratio (HR) of delirium for time to discharge was 0.71 (95% confidence interval [CI] = 0.57 to 0.89) after adjusting for confounders, and indicated that ED patients with delirium were more likely to have prolonged hospital LOS compared with those without delirium. For the sensitivity analysis, which included only hospitalized patients, the adjusted HR was 0.76 (95% CI = 0.58 to 0.99). Conclusions:  Delirium in older ED patients has negative consequences and is an independent predictor of prolonged hospitalizations.
    Academic Emergency Medicine 05/2011; 18(5):451-7. · 2.20 Impact Factor

Publication Stats

316 Citations
138.10 Total Impact Points


  • 2009–2014
    • Vanderbilt University
      • Department of Biostatistics
      Nashville, Michigan, United States
  • 2011
    • University of Louisville
      Louisville, Kentucky, United States
    • Belmont University
      • School of Pharmacy
      Nashville, TN, United States
  • 2010
    • Harvard Medical School
      Boston, Massachusetts, United States