Substance Misuse in Adults: A Primary Care Approach.

Substance misuse and substance use disorder continue to be major causes of morbidity and mortality, and family physicians are well positioned to provide evidence-based prevention and management for these conditions. Of people 12 years and older, 13% reported using a nonprescribed controlled substance in the past month, and 24% had at least one episode of binge drinking of alcohol, defined as five or more drinks for men and four or more drinks for women on one occasion. Benzodiazepines are used by 12% of the U.S. population. Clinicians should incorporate standardized screening and brief intervention for use of alcohol and other substances into routine care of adult patients, as well as referral to specialized treatment services when indicated. Use of nonstigmatizing, person-first language has been shown to positively affect care for patients with substance use disorders. Alcohol screening and brief intervention have been shown to reduce excessive drinking by 40% in patients at 6 months postintervention. Office-based treatment of alcohol use disorder with medications approved by the U.S. Food and Drug Administration, such as acamprosate and naltrexone, remains underutilized, presenting another opportunity for family physicians to positively affect the health of their patients and communities. With elimination of the X-waiver, any clinician with Schedule III prescriptive authority can treat opioid use disorder with buprenorphine in their office-based practice. Opioid overdose education and naloxone coprescribing are other tools family physicians can employ to combat the overdose crisis.

Factors associated with intention to implement SBI and SUD treatment: a survey of primary care clinicians in Texas enrolled in an online course.

BACKGROUND: Substance use disorder (SUD) presents a range of public health challenges and consequences. Despite the prevention potential of screening and brief intervention (SBI) in the primary care setting, implementation is low. The purpose of this study was to assess associations of primary care clinicians' knowledge of SBI and SUD treatment, subjective norms, and perceived behavioral control with intention to incorporate SBI and SUD treatment into regular clinical practice. METHODS: This online survey was administered to primary care clinicians who practice in Texas between March 1, 2021, and February 5, 2023. Survey questions were mapped to factors in the Theory of Planned Behavior and included measures of knowledge, subjective norms, and perceived behavioral controls related to SBI and SUD treatment. Intention to engage in SBI and SUD treatment was assessed as the outcome. RESULTS: Of 645 participants included in this study, 59.5% were physicians. Knowledge was low, with less than half correctly reporting what was considered a standard drink (39.6%) and only 20% knew the correct number of alcoholic beverages considered risky drinking in 21-year-old non-pregnant women. Subjective norms, such as having colleagues within their practice support addressing SUDs, and perceived behavioral control such as having SUD screening routinized within clinic workflows, were positively associated with intention to implement SBI and SUD treatment in primary care settings. CONCLUSIONS: Modifying knowledge gaps, subjective norms, and perceived behavioral control requires a multipronged interventional approach that blends accessible clinician training with systemic workplace enhancements and a collective shift in professional norms.

Predicting Antibiotic Susceptibility Among Patients With Recurrent Urinary Tract Infection Using a Prior Culture.

PURPOSE: Recurrent cystitis guidelines recommend relying on a local antibiogram or prior urine culture to guide empirical prescribing, yet little data exist to quantify the predictive value of a prior culture. We constructed a urinary antibiogram and evaluated test metrics (sensitivity, specificity, and Bayes' positive and negative predictive values) of a prior gram-negative organism on predicting subsequent resistance or susceptibility among patients with uncomplicated, recurrent cystitis. MATERIALS AND METHODS: We performed a retrospective database study of adults with recurrent, uncomplicated cystitis (cystitis occurring 2 times in 6 months or 3 times in 12 months) from urology or primary care clinics between November 1, 2016, and December 31, 2018. We excluded pregnant females, patients with complicated cystitis, or pyelonephritis. Test metrics were calculated between sequential, paired cultures using standard formulas. RESULTS: We included 597 visits from 232 unique patients wherein 310 (51.2%) visits had a urine culture and 165 had gram-negative uropathogens isolated. Patients with gram-negative uropathogens were mostly females (97%), with a median age of 58.5 years. Our antibiogram found 38.0%, 27.9%, and 5.5% of Escherichia coli isolates had resistance to trimethoprim-sulfamethoxazole, ciprofloxacin, and nitrofurantoin, respectively. Prior cultures (within 2 years) had good predictive value for detecting future susceptibility to first-line agents nitrofurantoin (0.85) and trimethoprim-sulfamethoxazole (0.78) and excellent predictive values (≥0.90) for cefepime, ceftriaxone, cefuroxime, ciprofloxacin, levofloxacin, gentamicin, tobramycin, piperacillin-tazobactam, and imipenem. CONCLUSIONS: Considerable antibiotic resistance was detected among E coli isolates in patients with recurrent, uncomplicated cystitis. Using a prior culture as a guide can enhance the probability of selecting an effective empirical agent.

Anxiety Disorders in Children and Adolescents.

Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children eight years and older; there is insufficient evidence to support screening in children younger than eight years. Symptoms of anxiety disorders in children and adolescents are similar to those in adults and can include physical and behavioral symptoms such as diaphoresis, palpitations, and tantrums. Care should be taken to distinguish symptoms of a disorder from normal developmental fears and behaviors, such as separation anxiety in infants and toddlers. Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration.

Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions.

Objectives: We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim-sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or ß-lactam prescribing, or longer duration of therapy. Methods: This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis. Results: Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and ß-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a ß-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58-15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07-4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15-1.44) were associated with longer antibiotic duration. Conclusions: We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.

Salary Differences Between Schools of Medicine and Schools of Public Health for Nonclinical PhD Faculty: A Case Study of One Large Multicampus University System.

There are no evidence-based findings to assist professionals with advanced public health and social science degrees in choosing the appropriate academic location. A cross-sectional case study in 2019 was conducted using publicly available online data of full-time, nonclinical, doctoral-level academic faculty in schools of public health (SOPHs) and schools of medicine (SOMs), within one large university system. Analyses included descriptive statistics and generalized linear regression models comparing salaries between school types by academic rank, after gender and race/ethnicity adjustment. The study included 181 faculty members, 35.8% assistant, 34.1% associate, and 30.1% full professors. After accounting for race/ethnicity and gender, SOM assistant and associate professors had 9% (P = .03) and 14% (P = .008) higher mean salaries than SOPH counterparts. Findings suggest slight salary advantages for SOM faculty for early- to mid-career PhDs in one university system. Factors such as start-up packages, time to promotion, and grant funding need further exploration.

Smoking history and adherence to cancer-related recommendations in a primary care setting.

Public health prevention efforts have led to overall reductions in mortality from screening-preventable cancers. We explored cancer screening behaviors of smokers, former smokers, and nonsmokers among patients of large primary care practices to discover the relationship between smoking status and previous adherence to the United States Preventive Services Task Force breast, cervical, and colorectal cancer screening recommendations. Our descriptive study of electronic medical record data included 6,029 established primary care patients. Multi-predictor log-binomial regression models yielded prevalence ratios (PRs) and 95% confidence intervals (CIs) to determine associations between smoking status and the likelihood of nonadherence. All models were adjusted for race/ethnicity, age, insurance, primary care specialty, number of comorbidities, and sex. Smoking history was obtained from all participants in January 2020. Current smokers accounted for 4.8%, while 22.7% were former smokers, and 72.5% were never smokers. Current smokers (compared to never smokers) were 63% more likely to be mammogram nonadherent (PR: 1.63, 95% CI: 1.31 to 2.02), 26% more likely to be Pap smear nonadherent (PR: 1.26, 95% CI: 1.04 to 1.53), and 39% more likely to be colonoscopy nonadherent (PR: 1.39, 95% CI: 1.16 to 1.66). Current smokers and former Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation smokers had on average 2.9 comorbidities while never smokers had on average 2.1 comorbidities. Our findings showed that current smokers experienced significantly lower rates of cancer screening compared to never smokers. Further research is needed to investigate and identify best practices for increasing cancer screening uptake in this population.

Improving Student Confidence With Electronic Health Record Order Entry.

INTRODUCTION: Despite near-universal utilization of electronic health records (EHRs) by physicians in practice, medical students in most ambulatory settings gain limited experience with placing EHR orders. In this study, an individual preceptor site investigated the usefulness of a targeted curriculum in improving students' EHR confidence and clinical reasoning skills. METHODS: Family medicine clerkship students assigned to one community health center were invited to participate in this prospective, survey-based study. In their first week, students observed a preceptor performing EHR tasks. For the remainder of the 4-week clerkship, students utilized decision support tools, assigned a working diagnosis, entered unsigned orders in the EHR, proposed an assessment, and discussed a plan with a preceptor. Students completed weekly questionnaires to self-report confidence across several EHR domains while preceptors synchronously evaluated students' accuracy with entering orders correctly. RESULTS: From February 2017 to March 2020, all 49 eligible students completed the study. One hundred percent of students reported that placing EHR orders was beneficial to their medical education. The difference over time in learner confidence with placing EHR orders was statistically significant across every domain (eg, writing prescriptions, ordering labs and imaging). Preceptors' evaluations of students' accuracy with placing orders also showed significant improvement between each week. CONCLUSION: Clerkship-wide EHR training may be limited by multiple sites with multiple EHR products. This pilot study suggests that committed faculty at an individual preceptor site can offer a targeted curriculum to help students develop EHR confidence. We propose other preceptors similarly offer students this opportunity to maximize clerkship education.

Hospital- and Patient-Level Characteristics Associated With Unplanned Readmissions and In-Patient Mortality in Men and Women With Alcoholic Cardiomyopathy.

OBJECTIVE: The aims of the study were to (a) determine rates of early, late, and overall 30-day all-cause readmission for women and men with the diagnosis of alcoholic cardiomyopathy (ACM), (b) examine hospital- and patient-level characteristics associated with the risk of readmission and how these factors differed by sex, and (c) examine the association between sex and in-patient mortality during readmission. METHOD: We conducted a multi-year cross-sectional analysis of adult (≥18 years) inpatient hospitalizations in the United States. Descriptive statistics including frequencies and percentages were used to describe the study population, stratified by sex. We then used Poisson regression with robust error variance estimation to estimate risk ratios (RRs) and 95% confidence intervals (CIs) that represented the associations between sex and likelihood of 30-day all-cause readmission and inpatient mortality. RESULTS: Among more than 116 million hospitalizations, there were 53,207 ACM-related hospitalizations (45,573 men and 7,634 women). Thirty-day all-cause readmission rates following an ACM-related index hospitalization were similar between men (20.3%) and women (20.5%). For men and women, cancer, hepatitis, chronic renal failure, cirrhosis, asthma, and anemia were associated with a higher risk of readmission. Although crude in-hospital mortality rates were higher among women (6.6%) than men (4.3%), there were no sex differences in mortality after adjusting for confounders (RR = 1.26, 95% CI [0.88, 1.81]). CONCLUSIONS: Although men are more likely to be hospitalized for ACM, readmission risk is high (approximately 20%) and is similar in men and women following hospitalization for ACM. Hospital care transition programs that include a multidisciplinary approach are needed to help prevent these readmissions and associated morbidity and mortality.

Cancer incidence and survival trends among infants in the United States from 1975 to 2014.

BACKGROUND: Cancer among infants (<1 year old) has unique epidemiologic, clinical, and genetic characteristics compared with cancer in older children. Nonetheless, data on secular trends in infant cancer incidence and survival in the United States is sparse. METHODS: Population-based data from nine areas of the Surveillance Epidemiology and End Results (SEER) were used to estimate the incidence, average annual percentage change (APC) for trends, and survival of malignant neoplasm among infants from 1975 to 2014. Data were stratified by gender, race, registry, and cancer type. RESULTS: There were 3437 new infant cancer cases with an overall incidence of 23.6/100 000. Neuroblastoma was the most common infant malignancy (6.5/100 000), followed by leukemia (3.8/100 000), and brain and central nervous system tumors (3.3/100 000). The incidence rate increased significantly from 1975 to 2014 (APC 0.68; 95% CI 0.30-1.06; P < .05). Variations in overall incidence rates were uneven across SEER registry geographic areas, with the lowest rates among both males and females in New Mexico. Relative to other racial distribution, infant cancer rates were highest among Whites. The relative survival rates improved over time for all tumors except for renal, sarcomas, and germ cells and were not significantly different by gender or race. CONCLUSIONS: Cancer incidence among infants increased over time largely driven by leukemia, germ cell, and sarcoma mainly among male infants. The overall survival for infant cancer has improved over the past 40 years, especially since 1990 for hepatic tumors, lymphoma, and leukemia. Further research is needed to explore the potential impacts of genetic, environmental, and perinatal factors for possible explanations for these increased cancer incidence trends.

Increased risk of 30-day hospital readmission among patients discharged against medical advice: a nationwide analysis.

PURPOSE: Annually, 1%-2% of hospitalized patients are discharged against medical advice (AMA), positioning them at an increased risk of readmission, morbidity, and mortality. Our study aim was to examine 30-day all-cause readmission rates and estimate readmission odds among AMA discharges in the United States, across clinically distinct diagnostic subgroups. METHODS: We conducted a retrospective, serial cross-sectional analysis of data from the 2010-2017 Nationwide Readmissions Database. Descriptive statistics and 30-day all-cause readmission rates for hospitalizations among adults aged 18 years or older were estimated by major diagnostic subgroup, discharge disposition, and patient and hospital characteristics. Odds ratios and 95% confidence intervals were calculated using multipredictor logistic regression. RESULTS: We found the AMA discharge to be an independent predictor of hospital readmission within 30 days, with a 25.6% readmission rate and an overall adjusted likelihood of readmission that was almost double to quadruple that of routine discharges. Furthermore, although hospitalizations experienced decreased odds of readmission after the Hospital Readmission Reduction Program implementation (October 1, 2012), our results demonstrate that the Hospital Readmission Reduction Program did not modify the impact of an AMA discharge on readmission. CONCLUSION: These findings have implications for practice, policies, and interventions aimed at improving care quality, preventing AMA discharge, and reducing hospital readmissions in inpatient settings.

A descriptive study of racial inequalities in mortality from hepatocellular cancer before and after licensure of lifesaving drugs for hepatitis C virus in the United States.

BACKGROUND: Since 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US. METHODS: The US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations. FINDINGS: From 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes. INTERPRETATION: These descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

The association between use of opiates, cocaine, and amphetamines during pregnancy and maternal postpartum readmission in the United States: A retrospective analysis of the Nationwide Readmissions Database.

BACKGROUND: Substance use during pregnancy has increased in the United States, with adverse consequences for mother and baby. Similarly, postpartum readmission (PPR) imposes physical, emotional, and financial stressors causing disruption to family functioning and childcare. We used national data to estimate the extent to which women who used opiates, cocaine, and amphetamines during pregnancy are at increased risk of PPR. METHODS: We analyzed 2010-2014 data from the Nationwide Readmissions Database (NRD). Our exposure, drug use during pregnancy, was identified using diagnosis codes indicative of opioid, cocaine or amphetamine use, abuse, or dependence. The outcome was all-cause PPR, maternal readmission within 42 days following discharge from the delivery hospitalization. Multivariable logistic regression was used to estimate odds ratios (OR) that represented associations between drug use and PPR. RESULTS: Among 11 million delivery hospitalizations, nearly 1 % had documented use of opiates, cocaine and/or amphetamines. The crude PPR rate was nearly four times higher among users (54.6 per 1000) compared to non-users (14.0 per 1000), and 1 in 10 women who had documented use of more than one drug category experienced postpartum readmission. Even after controlling for sociodemographic and clinical confounders, we observed a two-fold increased odds of PPR among users compared to non-users (OR = 1.95; 95 % CI: 1.82, 2.07). CONCLUSIONS: The national opioid epidemic should encourage a paradigm shift in health care public policy to facilitate the management of all substance use disorders as chronic medical conditions through evidence-based public health initiatives to prevent these disorders, treat them, and promote recovery.

Different Trends in US Tobacco Use: Inpatient Databases and Population-Based Surveys.

OBJECTIVES: There is considerable evidence to support the effectiveness of inpatient tobacco cessation interventions. However, national trends data in tobacco-use disorder among hospitalized patients in the United States is scarce. We compared temporal trends (2002-2017) in diagnoses of tobacco-use disorder among hospitalized patients with estimates of current and former smoking in the general population, based on 2 multiyear national databases. METHODS: We used data from the National Inpatient Sample (NIS) and the Behavioral Risk Factor Surveillance Survey (BRFSS) to establish annual estimates of current and former smoking. We assessed temporal trends (Joinpoint regression analysis) overall and within levels of several sociodemographic factors. To describe the burden and risk of tobacco-use disorder in inpatient settings, we used principal codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) that corresponded with the highest volume (burden) and rates (risk) of tobacco-use disorder. RESULTS: There were contrasting trends in the prevalence of current tobacco-use disorder between the NIS population (significantly increasing) and BRFSS (significantly decreasing). Concordance (at 16%) was only recorded in 2017, with approximately 5,022,000 hospitalizations with a recorded diagnosis of tobacco-use disorder. Among all hospitalizations, the highest number of cases of tobaccouse disorder occurred for mood disorders (n = 2,415,985), chronic obstructive pulmonary disease and bronchiectasis (n = 2,406,551), and acute myocardial infarction (n = 1,873,326). CONCLUSIONS: Despite the underestimation of current smoking by NIS, we believe the trends toward improved identification and documentation-which is likely leading to the increasing prevalence we observed among hospitalized patients of all ages-bodes well for future utilization of smoking data in the NIS for epidemiological and health services research.

Opioid, cocaine, and amphetamine use disorders are associated with higher30-day inpatient readmission rates in the United States.

Background: Patients with substance use disorders (SUDs) are more likely to experience serious health problems, high healthcare utilization, and premature death. However, little is known about the contribution of SUDs to medical 30-day readmission risk. We examined the association between SUDs and 30-day all cause readmission among non-pregnant adult in-patients in the US. Methods: We conducted a retrospective study using 2010-2014 data from the Nationwide Readmissions Database. Our primary focus was on opioid use compared to stimulant use (cocaine and amphetamine) identified by ICD-9-CM diagnosis codes in index hospitalizations. Multivariable logistic regression models were used to estimate adjusted odds ratios and 95% CI representing the association between substance use and 30-day readmission, overall and stratified by the principal reason for the index hospitalization. Results: Nearly 118 million index hospitalizations were included in the study, 4% were associated with opioid or stimulant use disorder. Readmission rates for users (19.5%) were higher than for nonusers (15.7%), with slight variation by the type of substance used: cocaine (21.8%), opioid (19.0%), and amphetamine (17.5%). After adjusting for key demographic, socioeconomic, clinical, and health system characteristics, SUDs and stimulant use disorders increased the odds of 30-day all-cause readmission by 20%. Conclusions: Reducing the frequency of inpatient readmission is an important goal for improving the quality of care and ensuring proper transition to residential/outpatient care among patients with SUDs. Differences between groups may suggest directions for further investigation into the distinct needs and challenges of hospitalized opioid- and other drug-exposed patients.

Accidental Infant Suffocation and Strangulation in Bed: Disparities and Opportunities.

Objectives (a) Update previous descriptions of trends in ASSB; (b) determine if factors previously associated with ASSB are replicated by updated data; and (c) generate new hypotheses about the occurrence of ASSB and racial inequalities in ASSB mortality. Methods National Center for Health Statistics files (International Classification of Diseases, Tenth Edition) Code W75 to describe race-ethnicity-specific ASSB occurrence. Results (a) ASSB mortality continues to increase significantly; for 1999-2016, 4.4-fold for NHB girls (45.8 per 100,000 in 2016), 3.5-fold for NHB boys (53.8), 2.7-fold for NHW girls (15.8) and 4.0-fold for NHW boys (25.9); (b) F actors previously associated with ASSB (unmarried mothers and mothers with low educational attainment, low infant birth weight, low gestational age, lack of prenatal care, male infant, multiple birth, high birth order) continue to be associated with both overall ASSB and inequalities adversely affecting NHB; (c) (1) geographic differences and similarities in ASSB occurrence support hypotheses related to positive deviance; (2) lower ASSB mortality for births attended by midwives as contrasted to physicians generate hypotheses related to both medical infrastructure and maternal engagement; (3) high rates of ASSB among infants born to teenage mothers generate hypotheses related to the possibility that poor maternal health may be a barrier to ASSB prevention based on education, culture and tradition. Conclusions for Practice These descriptive data may generate new hypotheses and targets for interventions for reducing both ASSB mortality and racial inequalities. Analytic epidemiologic studies designed a priori to do so are required to address these hypotheses.

No Clinical Benefit to Treating Male Urinary Tract Infection Longer Than Seven Days: An Outpatient Database Study.

BACKGROUND: The optimal approach for treating outpatient male urinary tract infections (UTIs) is unclear. We studied the current management of male UTI in private outpatient clinics, and we evaluated antibiotic choice, treatment duration, and the outcome of recurrence of UTI. METHODS: Visits for all male patients 18 years of age and older during 2011-2015 with International Classification of Diseases, Ninth Revision, Clinical Modification codes for UTI or associated symptoms were extracted from the EPIC Clarity Database of 2 family medicine, 2 urology, and 1 internal medicine clinics. For eligible visits in which an antibiotic was prescribed, we extracted data on the antibiotic used, treatment duration, recurrent UTI episodes, and patient medical and surgical history. RESULTS: A total of 637 visits were included for 573 unique patients (mean age 53.7 [±16.7 years]). Fluoroquinolones were the most commonly prescribed antibiotics (69.7%), followed by trimethoprim-sulfamethoxazole (21.2%), nitrofurantoin (5.3%), and beta-lactams (3.8%). Antibiotic choice was not associated with UTI recurrence. In the overall cohort, longer treatment duration was not significantly associated with UTI recurrence (odds ratio [OR] = 1.95; 95% confidence interval [CI], 0.91-4.21). Longer treatment was associated with increased recurrence after excluding men with urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, and benign prostatic hyperplasia (OR = 2.62; 95% CI, 1.04-6.61). CONCLUSIONS: Our study adds evidence that men with UTI without evidence of complicating conditions do not need to be treated for longer than 7 days. Shorter duration of treatment was not associated with increased risk of recurrence. Shorter treatment durations for many infections, including UTI, are becoming more attractive to reduce the risk of resistance, adverse events, and costs.

Coaching and Education for Diabetes Distress (CEDD): Protocol for a Randomized Controlled Trial.

BACKGROUND: Diabetes distress (DD), a type of psychological distress specific to people with diabetes, is strongly associated with difficulties in performing self-care and inability to meet glycemic targets. Despite increased recognition of the need to manage DD, interventions that are both feasible and effective for reducing DD in routine care settings are not yet known. A pilot study showed that health coaching (HC) has some efficacy in addressing DD, but no adequately powered study has implemented a pragmatic research design capable of assessing the real-world effectiveness of HC in reducing DD. OBJECTIVE: The aim of this study is to describe the rationale and design of an ongoing clinical trial, Coaching and Education for Diabetes Distress trial, that seeks to assess whether HC effectively reduces DD among primary care patients with diabetes and whether HC is more effective than an educational program targeting DD. METHODS: The 2-arm randomized controlled trial is taking place at an academic family medicine practice in Houston, Texas. Both arms will receive usual care, which includes education about DD. In addition, the intervention arm will receive 8 HC sessions over a 5-month period. The primary outcome measure is reduction in DD over a 6-month period. Additional outcome measures include changes in hemoglobin A1c and self-care practices (medication-taking, dietary, and physical activity behaviors). RESULTS: As of March 2019, screening and recruitment are ongoing, and the results are expected by July 2020. CONCLUSIONS: HC is feasible in primary care and has been successfully applied to improving chronic disease self-management and outcomes. This study will provide evidence as to whether it has significant value in addressing important unmet psychological and behavioral needs of patients with diabetes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03617146; https://clinicaltrials.gov/ct2/show/NCT03617146 (Archived by WebCite at http://www.webcitation.org/76Va37dbO). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12166.