Clostridioides difficile infection (CDI) may be misdiagnosed if testing is performed in the absence of signs or symptoms of disease. This study sought to support appropriate testing by estimating the impact of signs, symptoms, and healthcare exposures on pre-test likelihood of CDI.

A panel of fifteen experts in infectious diseases participated in a modified UCLA/RAND Delphi study to estimate likelihood of CDI. Consensus, defined as agreement by >70% of panelists, was assessed via a REDCap survey. Items without consensus were discussed in a virtual meeting followed by a second survey.

All fifteen panelists completed both surveys (100% response rate). In the initial survey, consensus was present on 6 of 15 (40%) items related to risk of CDI. After panel discussion and clarification of questions, consensus (>70% agreement) was reached on all remaining items in the second survey. Antibiotics were identified as the primary risk factor for CDI and grouped into three categories: high-risk (likelihood ratio [LR] 7, 93% agreement among panelists in first survey), low-risk (LR 3, 87% agreement in first survey), and minimal-risk (LR 1, 71% agreement in first survey). Other major factors included new or unexplained severe diarrhea (e.g., ≥ 10 liquid bowel movements per day; LR 5, 100% agreement in second survey) and severe immunosuppression (LR 5, 87% agreement in second survey).

Infectious disease experts concurred on the importance of signs, symptoms, and healthcare exposures for diagnosing CDI. The resulting risk estimates can be used by clinicians to optimize CDI testing and treatment.

Contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) have limited data on efficacy and have been associated with patient harm. Still, a 2015 Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) survey showed only 7% of hospitals discontinued routine MRSA/VRE contact precautions. The study objectives were to identify the current proportion of hospitals that have discontinued routine MRSA/VRE contact precautions and motivations for change.

An online survey was conducted of the SRN on current use and views of contact precautions for MRSA/VRE in each facility. An initial survey followed by 2 reminders was sent between 5/18/2021 and 6/9/2021.

SRN facilities.

The response rate was 43% (37/87) of facilities surveyed and 35% of respondents were not routinely using contact precautions for MRSA and VRE. The most frequently reported reason for discontinuing contact precautions was research on the safety of discontinuing contact precautions without an increase in healthcare-associated infections (reported for 92% of facilities for MRSA and 100% for VRE). Of those using contact precautions, the most frequently reported reason to continue was a lack of safety data for discontinuation (MRSA 58% and VRE 46%). Most of those continuing contact precautions were interested in using contact precautions differently in their facility (MRSA 63% and VRE 58%).

Over one in three healthcare facilities surveyed do not use contact precautions for MRSA or VRE. Most facilities choosing to continue contact precautions are interested in a different implementation strategy.

Only a third of people with dementia receive a diagnosis and post-diagnostic support. An eight session, manualised, modular post-diagnostic support system (New Interventions for Independence in Dementia Study (NIDUS) – family), delivered remotely by non-clinical facilitators is the first scalable intervention to improve personalised goal attainment for people with dementia. It could significantly improve care quality.

We aimed to explore system readiness for NIDUS–family, a scalable, personalised post-diagnostic support intervention.

We conducted semi-structured interviews with professionals from dementia care services; the Consolidated Framework for Implementation Research guided interviews and their thematic analysis.

From 2022 to 2023, we interviewed a purposive sample of 21 professionals from seven English National Health Service, health and social care services. We identified three themes: (1) potential value of a personalised intervention – interviewees perceived the capacity for choice and supporting person-centred care as relative advantages over existing resources; (2) compatibility and deliverability with existing systems – the NIDUS–family intervention model was perceived as compatible with service goals and clients’ needs, but current service infrastructures, financing and commissioning briefs constraining resources to those at greatest need were seen as barriers to providing universal, post-diagnostic care; (3) fit with current workforce skills – the intervention model aligned well with staff development plans; delivery by non-clinically qualified staff was considered an advantage over current care options.

Translating evidence for scalable and effective post-diagnostic care into practice will support national policies to widen access to support and upskill support workers, but requires a greater focus on prevention in commissioning briefs and resource planning.

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”).

Single-center, retrospective, before-after study.

Tertiary care Veteran’s Affairs (VA) Medical Center provides inpatient, outpatient, and residential care.

All patients tested with a GI panel between June 22, 2022 and April 20, 2023.

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.

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.

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.

Adaptive emotional regulation strategies, such as cognitive reappraisal, are related to better neuropsychological functioning in the general population. Individuals with PTSD demonstrate difficulty with both emotional regulation and cognitive performance that contribute to clinical presentation (e.g., negative mood, irritability). However the extent to which neuropsychological functioning is associated with emotion regulation, alone and in concert with common comorbid symptoms like depression, remains understudied in this population. Better understanding how specific neuropsychological functions relate to cognitive reappraisal could point to novel treatment targets given preliminary evidence that certain cognitive training techniques can improves neuropsychological and affective outcomes. The present study aims to investigate the relationship between clinical symptoms of PTSD and depression, working memory capacity, and cognitive reappraisal in Veterans with PTSD. We hypothesized that clinical symptoms and working memory capacity would interact to predict cognitive reappraisal, such that elevated depression would relate to worse cognitive reappraisal, particularly for individuals with poor working memory capacity.

Measures of working memory (symmetry span task), mental health symptomatology (Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Beck Depression Inventory-II (BDI-II), and emotional regulation (Emotion Regulation Questionnaire (ERQ)) were collected in 38 Veterans. A regression analysis was conducted with total CAPS score, total BDI score, total symmetry span score, and the interaction between BDI score and symmetry span score as the independent variables and total ERQ cognitive reappraisal score as the dependent variable.

When examining each predictor independently, cognitive reappraisal was not associated with working memory (t=1.42, p=.165), but was significantly associated with PTSD (t=-3.17, p<.003) and depressive (t=-4.15, p<.001) symptom severity. The multiple regression model (F(4, 35)=4.45, p<.005, R2=.26) did not support the hypothesized relationship between working memory and depressive symptoms (t=0.56, p=.579). Depression independently predicted utilization of cognitive reappraisal in veterans with PTSD (t=2.43, p=.020) but PTSD symptom severity and working memory scores did not. However, additional investigation revealed that independently, greater PTSD symptom severity did predict less utilization of cognitive reappraisal (t=-3.17, p<.005).

While depressive symptoms did not moderate the relationship between working memory and cognitive reappraisal, depressive symptoms did best predict utilization of cognitive reappraisal in a population with PTSD. Contrary to the hypothesized outcome, neither working memory nor PTSD symptoms were significant predictors of cognitive reappraisal when controlling for depressive symptoms. This suggests that the phenomenon of lower cognitive reappraisal rates in individuals with PTSD may be due to the presence of depressive symptoms rather than traumatic stress symptoms or neuropsychological ability. Due to the sample size and homogeneous diagnosis of the current study it is possible that the predicted relationship between working memory, PTSD severity, and cognitive reappraisal was not observed due to low power or a restricted range. Further investigation specifically in clinical populations on factors that predict utilization of cognitive reappraisal could expand on these findings in populations experiencing other stress-based disorders.

Religious/spiritual beliefs and behaviours (RSBB) have been associated with health outcomes, with diet a potential mediator of this relationship. We therefore explored whether RSBB were associated with differences in diet.

Dietary patterns and nutrient intakes were derived from food frequency questionnaire completed by pregnant women in 1991–1992 (mean age = 28·3 years, range = 15–46) and by the mothers and partners 4 years post-partum (mothers mean age = 32·3, range = 19–49; partners mean age = 34·5, range = 18–74). RSBB exposures measured in pregnancy included religious belief, affiliation and attendance. We first explored whether RSBBs were associated with dietary patterns in confounder-adjusted linear regression models. If associations were found, we examined whether RSBB were associated with nutrient intake (linear regression) and following nutrient intake guidelines (logistic regression).

Prospective birth cohort study in Southwest England (Avon Longitudinal Study of Parents and Children; ALSPAC).

13 689 enrolled mothers and their associated partners.

In pregnant women, RSBB were associated with higher ‘traditional’ (i.e. ‘meat and two veg’) and lower ‘vegetarian’ dietary pattern scores. Religious attendance and non-Christian religious affiliation were associated with higher ‘health-conscious’ dietary pattern scores. Religious attendance was associated with increased micronutrient intake and following recommended micronutrient intake guidelines, with weaker effects for religious belief and affiliation. Comparable patterns were observed for mothers and partners 4 years post-partum, although associations between RSBB and nutrient intakes were weaker for partners.

RSBBs are associated with broad dietary patterns and nutrient intake in this cohort. If these reflect causal relationships, diet may potentially mediate the pathway between RSBB and health.

Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation.

Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans’ Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites.

We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist.

Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.

Childhood adversity and cannabis use are considered independent risk factors for psychosis, but whether different patterns of cannabis use may be acting as mediator between adversity and psychotic disorders has not yet been explored. The aim of this study is to examine whether cannabis use mediates the relationship between childhood adversity and psychosis.

Data were utilised on 881 first-episode psychosis patients and 1231 controls from the European network of national schizophrenia networks studying Gene–Environment Interactions (EU-GEI) study. Detailed history of cannabis use was collected with the Cannabis Experience Questionnaire. The Childhood Experience of Care and Abuse Questionnaire was used to assess exposure to household discord, sexual, physical or emotional abuse and bullying in two periods: early (0–11 years), and late (12–17 years). A path decomposition method was used to analyse whether the association between childhood adversity and psychosis was mediated by (1) lifetime cannabis use, (2) cannabis potency and (3) frequency of use.

The association between household discord and psychosis was partially mediated by lifetime use of cannabis (indirect effect coef. 0.078, s.e. 0.022, 17%), its potency (indirect effect coef. 0.059, s.e. 0.018, 14%) and by frequency (indirect effect coef. 0.117, s.e. 0.038, 29%). Similar findings were obtained when analyses were restricted to early exposure to household discord.

Harmful patterns of cannabis use mediated the association between specific childhood adversities, like household discord, with later psychosis. Children exposed to particularly challenging environments in their household could benefit from psychosocial interventions aimed at preventing cannabis misuse.

Multiplex polymerase chain reaction (PCR) respiratory panels are rapid, highly sensitive tests for viral and bacterial pathogens that cause respiratory infections. In this study, we (1) described best practices in the implementation of respiratory panels based on expert perspectives and (2) identified tools for diagnostic stewardship to enhance the usefulness of testing.

We conducted a survey of the Society for Healthcare Epidemiology of America Research Network to explore current and future approaches to diagnostic stewardship of multiplex PCR respiratory panels.

In total, 41 sites completed the survey (response rate, 50%). Multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Thirteen sites (32%) reported that testing may support diagnosis or patient care without improving patient outcomes. Furthermore, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1–4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites). Education was reported as “helpful” but with limitations (3 sites).

Many hospital epidemiologists and experts in infectious diseases perceive multiplex PCR respiratory panels as useful tests that can improve diagnosis, patient care, and patient outcomes. However, institutions frequently employ diagnostic stewardship to enhance the usefulness of testing, including most commonly clinical decision support to guide test ordering.

While cannabis use is a well-established risk factor for psychosis, little is known about any association between reasons for first using cannabis (RFUC) and later patterns of use and risk of psychosis.

We used data from 11 sites of the multicentre European Gene-Environment Interaction (EU-GEI) case–control study. 558 first-episode psychosis patients (FEPp) and 567 population controls who had used cannabis and reported their RFUC.

We ran logistic regressions to examine whether RFUC were associated with first-episode psychosis (FEP) case–control status. Path analysis then examined the relationship between RFUC, subsequent patterns of cannabis use, and case–control status.

Controls (86.1%) and FEPp (75.63%) were most likely to report ‘because of friends’ as their most common RFUC. However, 20.1% of FEPp compared to 5.8% of controls reported: ‘to feel better’ as their RFUC (χ2 = 50.97; p < 0.001). RFUC ‘to feel better’ was associated with being a FEPp (OR 1.74; 95% CI 1.03–2.95) while RFUC ‘with friends’ was associated with being a control (OR 0.56; 95% CI 0.37–0.83). The path model indicated an association between RFUC ‘to feel better’ with heavy cannabis use and with FEPp-control status.

Both FEPp and controls usually started using cannabis with their friends, but more patients than controls had begun to use ‘to feel better’. People who reported their reason for first using cannabis to ‘feel better’ were more likely to progress to heavy use and develop a psychotic disorder than those reporting ‘because of friends’.

To evaluate the impact of implementing clinical decision support (CDS) tools for outpatient antibiotic prescribing in the emergency department (ED) and clinic settings.

We performed a before-and-after, quasi-experimental study that employed an interrupted time-series analysis.

The study institution was a quaternary, academic referral center in Northern California.

We included prescriptions for patients in the ED and 21 primary-care clinics within the same health system.

We implemented a CDS tool for azithromycin on March 1, 2020, and a CDS tool for fluoroquinolones (FQs; ie, ciprofloxacin, levofloxacin, and moxifloxacin) on November 1, 2020. The CDS added friction to inappropriate ordering workflows while adding health information technology (HIT) features to easily perform recommended actions. The primary outcome was the number of monthly prescriptions for each antibiotic type, by implementation period (before vs after).

Immediately after azithromycin-CDS implementation, monthly rates of azithromycin prescribing decreased significantly in both the ED (−24%; 95% CI, −37% to −10%; P < .001) and outpatient clinics (−47%; 95% CI, −56% to −37%; P < .001). In the first month after FQ-CDS implementation in the clinics, there was no significant drop in ciprofloxacin prescriptions; however, there was a significant decrease in ciprofloxacin prescriptions over time (−5% per month; 95% CI, −6% to −3%; P < .001), suggesting a delayed effect of the CDS.

Implementing CDS tools was associated with an immediate decrease in azithromycin prescriptions, in both the ED and clinics. CDS may serve as a valuable adjunct to existing antimicrobial stewardship programs.