Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States.

PURPOSE: To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States. METHODS: We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, ß-lactam + macrolide, ß-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.). RESULTS: Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location. CONCLUSIONS: Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.

Costs Attributable to Clostridioides difficile Infection Based on the Setting of Onset.

BACKGROUND: Although hospital-onset Clostridioides difficile infection (CDI) is associated with significant healthcare costs, the economic burden of CDI with onset in other facilities or the community has not been well studied. METHODS: Incident CDI cases were identified using 2011-2017 Medicare fee-for-service data. Controls were randomly selected in a 4:1 ratio matching to the CDI case surveillance definition. Inverse probability of exposure weights were used to balance on measured confounders. One-, 3-, and 5-year cumulative costs attributable to CDI were computed using a 3-part estimator (parametric survival model and pair of 2-part models predicting costs separately in intervals where death did and did not occur). RESULTS: A total of 60 492 CDI cases were frequency-matched to 241 968 controls. One-, 3-, and 5-year adjusted attributable costs were highest for hospital-onset CDI at $14 257, $18 953, and $21 792, respectively, compared with hospitalized controls and lowest for community-associated CDI compared with community controls at $1013, $3161, and $6454, respectively. Adjusted 1-, 3-, and 5-year costs attributable to community-onset healthcare facility-associated CDI were $8222, $13 066, and $16 329 and for other healthcare facility-onset CDI were $5345, $6764, and $7125, respectively. CONCLUSIONS: Economic costs attributable to CDI in elderly persons were highest for hospital-onset and community-onset healthcare facility-associated CDI. Although lower, attributable costs due to CDI were significantly higher in cases with CDI onset in the community or other healthcare facility than for comparable persons without CDI. Additional strategies to prevent CDI in the elderly are needed to reduce morbidity and healthcare expenditures.

The Geographic Distribution of Dimorphic Mycoses in the United States for the Modern Era.

BACKGROUND: The dimorphic mycoses (DMs) of the United States-Histoplasma, Coccidioides, and Blastomyces-commonly known as endemic mycoses of North America (in addition to Paracoccidioides) are increasingly being diagnosed outside their historical areas of endemicity. Despite this trend, the maps outlining their geographic distributions have not been updated in more than half a century using a large, nationwide database containing individual-patient-level data. METHODS: This was a retrospective analysis of >45 million Medicare fee-for-service beneficiaries from 1 January 2007 through 31 December 2016. Diagnoses of histoplasmosis, coccidioidomycosis, and blastomycosis were defined by International Classification of Diseases, Ninth/10th Revision, codes. The primary outcome was the incidence of histoplasmosis, coccidioidomycosis, and blastomycosis for each US county. Clinically meaningful thresholds for incidence were defined as 100 cases/100 000 person-years for histoplasmosis and coccidioidomycosis and 50 cases/100 000 person-years for blastomycosis. RESULTS: There were 79 749 histoplasmosis, 37 726 coccidioidomycosis, and 6109 blastomycosis diagnoses in unique persons from 2007-2016 across 3143 US counties. Considering all US states plus Washington, DC, 94% (48/51) had ≥1 county above the clinically relevant threshold for histoplasmosis, 69% (35/51) for coccidioidomycosis, and 78% (40/51) for blastomycosis. CONCLUSIONS: Persons with histoplasmosis, coccidioidomycosis, and blastomycosis are diagnosed in significant numbers outside their historical geographic distributions established >50 years ago. Clinicians should consider DM diagnoses based on compatible clinical syndromes with less emphasis placed on patients' geographic exposure. Increased clinical suspicion leading to a subsequent increase in DM diagnostic testing would likely result in fewer missed diagnoses, fewer diagnostic delays, and improved patient outcomes.

Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections.

BACKGROUND: Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS: We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS: Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS: Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.

Utilization of nonguideline concordant antibiotic treatment following acute otitis media in children in the United States.

PURPOSE: Acute otitis media (AOM) is a common indication for antibiotics in children. We sought to characterize the frequency of nonguideline concordant antibiotic therapy for AOM in the United States, by agent and duration. METHODS: Using national administrative claims data (2016-2019), we identified children aged 6 months to 17 years with an oral antibiotic dispensed within 3 days of a new diagnosis of suppurative AOM. Use of nonguideline concordant agents and durations, defined based on national treatment guidelines, were summarized by age, race, rurality, region, and insurance type. Subsequent oral antibiotic dispensing within the year after AOM diagnosis was also evaluated. We created sunburst diagrams to visualize longitudinal patterns of within-person antibiotic utilization for AOM, by agent and duration. RESULTS: We identified 789 424 eligible commercially-insured and 502 239 medicaid-insured children. Among commercially insured children, 35% received nonguideline concordant agents for AOM, including cefdinir (16%), amoxicillin-clavulanate (12%), and azithromycin (7%). Fewer children age <2 years received a nonguideline concordant initial agent (27%) compared to age ≥6 years (41%). More children age <2 years received three or more antibiotics over the following year (34% vs. 3% for children age ≥6 years). The most common treatment duration was 10 days for all ages; treatment duration for the initial antibiotic was nonguideline concordant for 95% and 89% of children age 2-5 years and ≥6 years, respectively. Patterns were similar for medicaid-insured children. CONCLUSIONS: Nonguideline concordant antibiotic use is common when treating AOM in children, including use of broad-spectrum agents and longer-than-recommended antibiotic durations.

Integrase Strand Transfer Inhibitors Are Associated With Incident Diabetes Mellitus in People With Human Immunodeficiency Virus.

BACKGROUND: Integrase strand transfer inhibitors (INSTIs) are associated with weight gain in people with HIV (PWH). Less is known about the risk of other metabolic outcomes such as diabetes mellitus and hyperglycemia. METHODS: IBM® MarketScan® databases for commercially and Medicaid-insured adults were used to identify PWH newly initiating antiretroviral therapy (ART). The primary outcome was a composite of new-onset diabetes mellitus/hyperglycemia in the 6 months following ART initiation and was identified using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis and procedure codes and Current Procedural Terminology, 4th Edition (CPT-4) codes. To examine the relationship between INSTI use and the composite outcome, we estimated the risk using Cox proportional hazards models with calendar time-specific standardized mortality ratio weights. RESULTS: Of 42 382 PWH who initiated ART between 1 July 2007 and 30 June 2018, 22 762 (54%) were treated with INSTI-based regimens. Mean age was 38 years, 74% were male, and 19% were Medicaid insured. PWH on INSTIs were 31% more likely to develop new-onset diabetes mellitus/hyperglycemia (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.15-1.48]) compared with those who initiated non-INSTI-based regimens. When examined individually, the highest risk was associated with elvitegravir (HR, 1.54; 95% CI, 1.32-1.97; P < .001) and the lowest risk with raltegravir (HR, 1.19; 95% CI, 1.03-1.37; P = .02). CONCLUSIONS: INSTI use was associated with increased risk of new-onset diabetes mellitus/hyperglycemia in the 6 months following ART initiation.

Risk of Breast Cancer With Prolactin Elevating Antipsychotic Drugs: An Observational Study of US Women (Ages 18-64 Years).

PURPOSE/BACKGROUND: Antipsychotic drugs are well established to alter circulating prolactin levels by blocking dopamine D2 receptors in the pituitary. Prolactin activates many genes important in the development of breast cancer. Prior studies have found an association with antipsychotic use and risk of breast cancer. METHODS/PROCEDURES: The IBM MarketScan Commercial and Medicaid Databases were used to establish a large, observational cohort of women taking antipsychotics drugs compared with anticonvulsants or lithium. A new user design was used that required 12 months of insurance enrollment before the first antipsychotic or anticonvulsant/lithium prescription. Invasive breast cancer was identified using diagnostic codes. Multivariable Cox proportional hazards models were used to evaluate the risk of breast cancer with antipsychotic drug exposure controlling for age and other risk factors. FINDINGS/RESULTS: A total of 914 cases (0.16%) of invasive breast cancer were identified among 540,737 women. Exposure to all antipsychotics was independently associated with a 35% increased risk of breast cancer (aHR [adjusted hazard ratio], 1.35; 95% confidence interval, 1.14-1.61). Category 1 drugs (high prolactin) were associated with a 62% increased risk (aHR, 1.62; 95% CI, 1.30-2.03), category 2 drugs a 54% increased risk (aHR, 1.54; 95% CI, 1.19-1.99), and category 3 drugs were not associated with breast cancer risk. IMPLICATIONS/CONCLUSIONS: In the largest study of antipsychotics taken by US women, a higher risk between antipsychotic drug use and increased risk for breast cancer was observed, with a differential higher association with antipsychotic categories that elevate prolactin. Our study confirms other recent observational studies of increased breast cancer risk with antipsychotics that elevate prolactin.

Estimating the Effectiveness of Rotavirus Vaccine Schedules.

BACKGROUND: Important questions exist regarding the comparative effectiveness of alternative childhood vaccine schedules; however, optimal approaches to studying this complex issue are unclear. METHODS: We applied methods for studying dynamic treatment regimens to estimate the comparative effectiveness of different rotavirus vaccine (RV) schedules for preventing acute gastroenteritis-related emergency department (ED) visits or hospitalization. We studied the effectiveness of six separate protocols: one- and two-dose monovalent rotavirus vaccine (RV1); one-, two-, and three-dose pentavalent rotavirus vaccine (RV5); and no RV vaccine. We used data on all infants to estimate the counterfactual cumulative risk for each protocol. Infants were censored when vaccine receipt deviated from the protocol. Inverse probability of censoring-weighted estimation addressed potentially informative censoring by protocol deviations. A nonparametric group-based bootstrap procedure provided statistical inference. RESULTS: The method yielded similar 2-year effectiveness estimates for the full-series protocols; weighted risk difference estimates comparing unvaccinated children to those adherent to either full-series (two-dose RV1, three-dose RV5) corresponded to four fewer hospitalizations and 12 fewer ED visits over the 2-year period per 1,000 children. We observed dose-response relationships, such that additional doses further reduced risk of acute gastroenteritis. Under a theoretical intervention to fully vaccinate all children, the 2-year risk differences comparing full to observed adherence were 0.04% (95% CI = 0.03%, 0.05%) for hospitalizations and 0.17% (95% CI = 0.14%, 0.19%) for ED visits. CONCLUSIONS: The proposed approach can generate important evidence about the consequences of delaying or skipping vaccine doses, and the impact of interventions to improve vaccine schedule adherence.

Comparative Effectiveness of High-Dose Versus Standard-Dose Influenza Vaccine Among Patients Receiving Maintenance Hemodialysis.

RATIONALE & OBJECTIVE: Studies of patients on maintenance dialysis therapy suggest that standard-dose influenza vaccine (SDV) may not prevent influenza-related outcomes. Little is known about the comparative effectiveness of SDV versus high-dose influenza vaccine (HDV) in this population. STUDY DESIGN: Cohort study using data from the US Renal Data System. SETTING & PARTICIPANTS: 507,552 adults undergoing in-center maintenance hemodialysis between the 2010 to 2011 and 2014 to 2015 influenza seasons. EXPOSURES: SDV and HDV. OUTCOMES: All-cause mortality, hospitalization due to influenza or pneumonia, and influenza-like illness during the influenza season. ANALYTIC APPROACH: Patients were eligible for inclusion in multiple yearly cohorts; thus, our unit of analysis was the influenza patient-season. To examine the relationship between vaccine dose and effectiveness outcomes, we estimated risk differences and risk ratios using propensity score weighting of Kaplan-Meier functions, accounting for a wide range of patient- and facility-level characteristics. For nonmortality outcomes, we used competing-risk methods to account for the high mortality rate in the dialysis population. RESULTS: Within 225,215 influenza patient-seasons among adults 65 years and older, 97.4% received SDV and 2.6% received HDV. We observed similar risk estimates for HDV and SDV recipients for mortality (risk difference, -0.08%; 95% CI, -0.85% to 0.80%), hospitalization due to influenza or pneumonia (risk difference, 0.15%; 95% CI, -0.69% to 0.93%), and influenza-like illness (risk difference, 0.00%; 95% CI, -1.50% to 1.08%). Our findings were similar among adults younger than 65 years, as well as within other subgroups defined by influenza season, age group, dialysis vintage, month of influenza vaccination, and vaccine valence. LIMITATIONS: Residual confounding and outcome misclassification. CONCLUSIONS: The HDV does not appear to provide additional protection beyond the SDV against all-cause mortality or influenza-related outcomes for adults undergoing hemodialysis. The additional cost and side effects associated with HDV should be considered when offering this vaccine. Future studies of HDV and other influenza vaccine strategies are warranted.

Parental Mental Health Care After Their Child's Pediatric Intensive Care Hospitalization.

OBJECTIVES: Post-traumatic stress disorder, depression, and anxiety have all been found in parents of PICU survivors. How these research findings translate to actual use of mental health services by parents remains unknown. DESIGN: Retrospective observational cohort study. SETTING: Insurance claims data from 2006 to 2013 obtained from the IBM MarketScan Commercial Database. PATIENTS: Parents of PICU survivors. INTERVENTIONS: We examined rates of: 1) mental health diagnoses, 2) outpatient mental health visits, and 3) prescriptions for antidepressants and anxiolytics among parents, 6 months before and 6 months after their child's PICU admission, using each parent as their own control. MEASUREMENTS AND MAIN RESULTS: Of the 95,070 parents identified, 9.5% received a new mental health diagnosis in the 6 months after their child's PICU hospitalization, which represented a 110% increase from pre-PICU rates. A smaller proportion of parents were given new prescriptions for antidepressants (3.4%) and anxiolytics (3.9%) in the 6 months after their child's PICU hospitalization. Mothers were twice as likely to receive a new mental health diagnosis and be taking a new medication than fathers in the post-PICU period. The parental diagnosis of acute stress disorder or post-traumatic stress disorder increased by 87% from the pre-PICU to the post-PICU period. CONCLUSIONS: After their child's PICU hospitalization, the proportion of parents with a new mental health diagnosis nearly doubled. Mothers were at nearly twice the risk of receiving a new mental health diagnosis and receiving a new mental health medication compared with fathers. The proportion of parents receiving mental healthcare is much lower than the proportion reporting mental health symptoms in long-term outcomes studies. Whether this indicates a gap in healthcare delivery for parents with mental health symptoms remains unknown.

Informative censoring by health plan disenrollment among commercially insured adults.

PURPOSE: Health plan disenrollment occurs frequently in commercial insurance claims databases. If individuals who disenroll are different from those who remain enrolled, informative censoring may bias descriptive statistics as well as estimates of causal effect. We explored whether patterns of disenrollment varied by patient or health plan characteristics. METHODS: In a large cohort of commercially insured adults (2007-2013), we examined two primary outcomes: (a) within-year disenrollment between January 1 and December 30, which was considered to occur due to patient disenrollment from the health plan, and (b) end-of-year disenrollment on December 31, which was considered to occur due to either patient disenrollment from the health plan or withdrawal of the entire health plan from the commercial insurance database. In yearly cohorts, we identified factors independently associated with disenrollment by using log-binomial regression models to estimate risk ratios (RR) and 95% confidence intervals (CI). RESULTS: Among 2 053 100 unique patient years, the annual proportion of within-year disenrollment remained steady across years (range, 13% to 14%) whereas the annual proportion of end-of-year disenrollment varied widely (range, 8% to 26%). Independent predictors of within-year disenrollment were related to health status, including age, comorbidities, frailty, hospitalization, emergency room visits, use of durable medical equipment, use of preventive care, and use of prescription medications. In contrast, independent predictors of end-of-year disenrollment were related to health plan characteristics including insurance plan type and geographic characteristics. CONCLUSIONS: Differential risk of disenrollment suggests that analytic approaches to address selection bias should be considered in studies using commercial insurance databases.

Reproductive Viability Analysis (RVA) as a new tool for ex situ population management.

Many animal populations managed by the Association of Zoos and Aquariums' (AZA) Species Survival Plans® (SSPs) have low rates of reproductive success. It is critical that individuals recommended to breed are successful to achieve genetic and demographic goals set by the SSP. Identifying factors that impact reproductive success can inform managers on best practices and improve demographic predictions. A Reproductive Viability Analysis (RVA) utilizes data gathered from Breeding and Transfer Plans, studbooks, and SSP documents, and through modeling identifies factors associated with reproductive success in a given species. Here, we describe the RVA process, including different statistical models with the highest accuracy for predicting reproductive success in fennec foxes (Vulpes zerda) and Mexican wolves (Canis lupus baileyi). Results from the RVA provide knowledge that can be used to make evidence-based decisions about pairing and breeding strategies as well as improving reproductive success and population sustainability.

RANDOMIZED CONTROLLED TRIAL COMPARING THE EFFECTS OF ALFAXALONE AND KETAMINE HYDROCHLORIDE IN THE HAITIAN GIANT GALLIWASP ( CELESTUS WARRENI).

The immobilization properties and cardiopulmonary effects following intramuscular administration of one of two chemical immobilization agents were compared in the Haitian giant galliwasp ( Celestus warreni) in a prospective, blinded, randomized controlled trial. Adult, clinically healthy galliwasps ( n = 30) were given a randomly assigned single intramuscular injection of either 15 mg/kg alfaxalone ( n = 15) or 40 mg/kg ketamine hydrochloride ( n = 15). Heart rate, respiratory rate, and depth classification stage were recorded every 5 min; cloacal temperature was recorded every 15 min to ensure maintenance within this species' preferred optimal temperature range (75-85°F, 24-29°C). Physical examination, radiographs, and phlebotomy were performed in all animals. Alfaxalone given intramuscularly resulted in reliable anesthetic induction, maintenance, and recovery (total duration of anesthesia 57.7 ± 23.6 min, recovery 7.9 ± 7.8 min). Ketamine hydrochloride resulted in variable levels of sedation or anesthesia and a longer recovery (total duration of anesthesia 14 ±17.5 min, recovery 47.9 ± 19.3 min). Heart and respiratory rates remained within clinically acceptable ranges in all lizards using both protocols; however, alfaxalone animals had lower heart rates and respiratory rates associated with increased anesthetic depth as compared to ketamine hydrochloride animals (heart rates: alfaxalone 59.6 ± 13.3 beats/min, ketamine hydrochloride 71.9 ± 7.9 beats/min; respiratory rates: alfaxalone 33.4 ± 16.8 breaths/min, ketamine hydrochloride 50.0 ± 16.2 breaths/min). Duration of anesthesia for alfaxalone-treated galliwasps was longer than previously reported in other studies. This study determined that a single injection of alfaxalone at 15 mg/kg administered intramuscularly can be used for consistent induction and maintenance of anesthesia and prompt recovery in the Haitian giant galliwasp, while ketamine hydrochloride even at 40 mg/kg was unreliable and is not recommended as a sole immobilization agent in the Haitian giant galliwasp.

Changes in human health parameters associated with a touch tank experience at a zoological institution.

Association of Zoos and Aquariums (AZA) institutions provide a variety of benefits to visitors. However, one area that has received little study is the direct human health benefits from zoo and aquarium visits. With the increase in stress related non-infectious diseases in industrialized countries, understanding the extent of these benefits is important. We studied the effects on visitor stress of an experience at a touch tank exhibit featuring stingrays, sharks, and horseshoe crabs. Stress was measured by physiological and psychological parameters. Heart rate was recorded before, during, and after interacting with the animals, and mood was assessed before and after the experience using a psychological instrument. Multilevel models of heart rate show a quadratic trend, with heart rate elevated (b = -3.01, t = 26.4, P < 0.001) and less variable (b = 3.60, t = 15.9, P < 0.001) while touching the animals compared to before or after. Wilcoxon signed-rank tests on mood data suggest that most visitors felt happier (V = 174.5, P < 0.001), more energized (V = 743.5, P < 0.001), and less tense (V = 5618, P < 0.001) after the experience. This suggests that interacting with animals led to a physiological response during interactions reminiscent of a theme park experience along with a decrease in mental stress. The effects of confounding variables such as crowd size are also discussed. Further studies should be conducted to help deepen our understanding of the health benefits of experiences at AZA institutions.

Parent-offspring behavior of Jambu fruit doves (Ptilinopus jambu).

Fruit doves (Ptilinopus) constitute a genus of small to medium-sized, brightly colored arboreal birds, whose diets consist entirely of fruit. Little is known about the behavior of fruit doves because most species inhabit dense forests and are difficult to observe in the wild. This study describes the parental behavior of Jambu fruit dove pairs (Ptilinopus jambu) in a captive breeding program at the Saint Louis Zoo. Continuous video recordings were made of three pairs which raised a total of eight squabs over 2 years; daily rates of parental and squab behaviors were quantified. Overall, females were present at the nest, brooded their squabs, pecked, and attempted feedings more often than males. Parents also cared for their squabs at different times throughout the day. Males fed and brooded squabs during the middle of the day, while females fed throughout the day and brooded in the morning, evening, and overnight. Feeding rates were lower than those described for seed-eating doves (Columbinae), with hours between consecutive feedings, and squabs rarely begged before feeding events. Most squab behaviors involved initiating or terminating brooding and self-preening. These behaviors increased as squabs approached fledging, and coincided with a shift from full to partial brooding, and a decrease in parental allopreening. Older squabs also initiated feeding less frequently. Together, these data provide the first description of parental behavior in a Ptilinopus fruit dove. The results of this study may help improve captive breeding efforts, which are likely to become increasingly important for future conservation and reintroduction programs.

Characterizing timeliness of recommended vaccinations among privately-insured children in the United States, 2009-2019.

BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) recommends early childhood vaccinations, but knowledge is limited about the magnitude and timing of vaccine delay for each recommended dose on a population level. We sought to characterize longitudinal patient-level patterns of early childhood vaccination schedule adherence. METHODS: Using the Merative MarketScan Commercial Database (2009-2019), we identified commercially-insured infants who received at least one timely dose of a 2-month recommended vaccine. We categorized the number of recommended vaccines administered on the same date at 2, 4, 6, and 12-15 months of age (grace period: -7, +21 days). A Sankey diagram illustrated the number of vaccines received concomitantly during each age window and depicted transitions to different states over time (e.g., no vaccine delay to vaccine delay). For each vaccine dose, we estimated the cumulative incidence of receipt. RESULTS: Among 1,239,364 eligible children, 28% of infants aged 4 months and 38% of infants aged 6 months did not receive timely, concomitant administration of all recommended vaccines. The number of timely vaccines received concomitantly and age at receipt varied most for doses recommended during the second year of life. Children with a previously delayed (versus timely) dose consistently experienced longer time to subsequent dose. CONCLUSIONS: National coverage improved over time for all recommended vaccine doses under study, most notably for measles, mumps, and rubella. However, many children do not receive vaccines on schedule. Interventions to maintain adherence to the recommended schedule are needed early in life.

De-escalation of Monitoring in Active Surveillance for Prostate Cancer: Results from the GAP3 Consortium.

BACKGROUND AND OBJECTIVE: There is no consensus on de-escalation of monitoring during active surveillance (AS) for prostate cancer (PCa). Our objective was to determine clinical criteria that can be used in decisions to reduce the intensity of AS monitoring. METHODS: The global prospective AS cohort from the Global Action Plan prostate cancer AS consortium was retrospectively analyzed. The 24656 patients with complete outcome data were considered. The primary goal was to develop a model identifying a subgroup with a high ratio of other-cause mortality (OCM) to PCa-specific mortality (PCSM). Nonparametric competing-risks models were used to estimate cause-specific mortality. We hypothesized that the subgroup with the highest OCM/PCSM ratio would be good candidates for de-escalation of AS monitoring. KEY FINDINGS AND LIMITATIONS: Cumulative mortality at 15 yr, accounting for censoring, was 1.3% for PCSM, 11.5% for OCM, and 18.7% for death from unknown causes. We identified body mass index (BMI) >25 kg/m2 and <11% positive cores at initial biopsy as an optimal set of criteria for discriminating OCM from PCSM. The 15-yr OCM/PCSM ratio was 34.2 times higher for patients meeting these criteria than for those not meeting the criteria. According to these criteria, 37% of the cohort would be eligible for de-escalation of monitoring. Limitations include the retrospective nature of the study and the lack of external validation. CONCLUSIONS: Our study identified BMI >25 kg/m2 and <11% positive cores at initial biopsy as clinical criteria for de-escalation of AS monitoring in PCa. PATIENT SUMMARY: We investigated factors that could help in deciding on when to reduce the intensity of monitoring for patients on active surveillance for prostate cancer. We found that patients with higher BMI (body mass index) and lower prostate cancer volume may be good candidates for less intensive monitoring. This model could help doctors and patients in making decisions on active surveillance for prostate cancer.

Opportunities to Improve Antibiotic Prescribing for Adults With Acute Sinusitis, United States, 2016-2020.

Background: Better understanding differences associated with antibiotic prescribing for acute sinusitis can help inform antibiotic stewardship strategies. We characterized antibiotic prescribing patterns for acute sinusitis among commercially insured adults and explored differences by patient- and prescriber-level factors. Methods: Outpatient encounters among adults aged 18 to 64 years diagnosed with sinusitis between 2016 and 2020 were identified by national administrative claims data. We classified antibiotic agents-first-line (amoxicillin-clavulanate or amoxicillin) and second-line (doxycycline, levofloxacin, or moxifloxacin)-and ≤7-day durations as guideline concordant based on clinical practice guidelines. Modified Poisson regression was used to examine the association between patient- and prescriber-level factors and guideline-concordant antibiotic prescribing. Results: Among 4 689 850 sinusitis encounters, 53% resulted in a guideline-concordant agent, 30% in a guideline-discordant agent, and 17% in no antibiotic prescription. About 75% of first-line agents and 63% of second-line agents were prescribed for >7 days, exceeding the length of therapy recommended by clinical guidelines. Adults with sinusitis living in a rural area were less likely to receive a prescription with guideline-concordant antibiotic selection (adjusted risk ratio [aRR], 0.92; 95% CI, .92-.92) and duration (aRR, 0.77; 95% CI, .76-.77). When compared with encounters in an office setting, urgent care encounters were less likely to result in a prescription with a guideline-concordant duration (aRR, 0.76; 95% CI, .75-.76). Conclusions: Opportunities still exist to optimize antibiotic agent selection and treatment duration for adults with acute sinusitis, especially in rural areas and urgent care settings. Recognizing specific patient- and prescriber-level factors associated with antibiotic prescribing can help inform antibiotic stewardship interventions.

Healthcare Costs of Clostridioides difficile Infection in Commercially Insured Younger Adults.

In a US adult population aged <65 years, attributable costs due to Clostridioides difficile infection (CDI) were highest in persons with hospital onset and lowest in those with community-associated CDI treated outside a hospital. The economic burden of CDI in younger adults underscores the need for additional CDI-preventive strategies.

Age at gonadectomy, sex, and breed size affect risk of canine overweight and obese outcomes: a retrospective cohort study using data from United States primary care veterinary clinics.

OBJECTIVE: To examine the risk of developing an overweight or obese (O/O) body condition score (BCS) in gonadectomized versus intact dogs and, separately, the impact of age at gonadectomy on O/O outcomes among sterilized dogs. ANIMALS: Dogs were patients of Banfield Pet Hospital in the US from 2013 to 2019. After exclusion criteria were applied, the final sample consisted of 155,199 dogs. PROCEDURES: In this retrospective cohort study, Cox proportional hazards models evaluated associations between O/O and gonadectomy status, sex, age at gonadectomy, and breed size. Models were used to estimate the risk of becoming O/O in gonadectomized versus intact dogs and, separately, to estimate risk of O/O BCS according to age at surgery among gonadectomized dogs. RESULTS: Gonadectomy increased O/O risk for most dogs compared to intact dogs. Unlike most prior findings, O/O hazard ratios among gonadectomized versus intact dogs were larger for males than females. O/O risk varied according to breed size but not linearly. Sterilizing at 1 year old tended to yield a lower O/O risk compared to doing so later. Comparative O/O risk among dogs gonadectomized at 6 months versus 1 year varied by breed size. Overall patterns for obesity related to size were similar to patterns in the O/O analysis. CLINICAL RELEVANCE: Veterinarians are uniquely positioned to help prevent O/O in their patients. Results extend understanding of risk factors for O/O development in dogs. In combination with information about other benefits and risks associated with gonadectomy, these data can help tailor recommendations regarding gonadectomy in individual dogs.