Association Between Antipsychotic Medication Use and Dementia Risk in Patients With Schizophrenia or Schizoaffective Disorder.

OBJECTIVE: To determine the association between antipsychotic prescriptions and incident dementia in patients with schizophrenia or schizoaffective disorder. METHODS: In this retrospective cohort study, Cox Proportional hazard models estimated the association between antipsychotic prescriptions and incident dementia in participants ≥50 years of age with a schizophrenia/schizoaffective disorder diagnosis over 12 years. Confounding was controlled by E-balance. RESULTS: Cumulative dementia incidence was significantly greater among those with an antipsychotic prescription compared to those without (7.9% vs 5.5%, P < 0.0001). After controlling for confounding, antipsychotic prescriptions were associated with a 92% increased risk for dementia (HR = 1.92; 95% CI:1.13-3.27). This association was not significant among those aged ≥65 years. Antipsychotic prescription type (eg, first generation, yes or no) did not affect dementia risk but prescription number did. CONCLUSION: Antipsychotic prescriptions were associated with almost twice the incidence of dementia compared to patients without in those with schizophrenia/schizoaffective disorder.

Neighborhood Characteristics & Walking Behavior Among Adults with Arthritis: An NHIS Study.

OBJECTIVE: This study investigated the association of perceived neighborhood qualities with likelihood of transit walking, leisure walking, neighborhood walking, and meeting physical activity (PA) recommendations among US adults with arthritis. METHODS: This cross-sectional study utilized 2020 National Health Interview Survey data. Included participants were adults reporting clinician-diagnosed arthritis and who reported the ability to walk. Exposures of interest were perceived neighborhood attributes. Outcomes were transit walking, leisure walking, neighborhood walking, and meeting PA recommendations. Standardized mean difference percent (SMD%) was used to assess relationships between exposures and outcomes with SMD% >10% resulting in inclusion in final adjusted multivariate logistic regression models for odds of outcomes. All analyses were weighted to account for complex survey methodology. RESULTS: The analytic sample included 7,322 adults with arthritis. Fully adjusted logistic regression models showed presence of roads to walk on was associated with meeting PA recommendations (OR=1.26[95%CI=1.07-1.49]). Three attributes were positively associated with transit walking, while safety from crime was negatively associated (OR=2.33[95%CI=1.75-3.10], OR=1.49[95%CI=1.17-1.91], OR=1.67[95%CI=1.34-2.08]), OR=0.70[95%CI=0.53-0.92]). Roads to walk and places to walk and relax were associated with leisure and neighborhood walking (OR=1.46[95%CI=1.21-1.76], OR=1.56[95%CI=1.34-1.82], OR=1.58[95%CI=1.29-1.93], OR=1.63[95%CI=1.40-1.90], respectively). CONCLUSION: This study identified several neighborhood characteristics associated with higher likelihood of walking behaviors among adults with arthritis. Factors associated with walking behavior varied by type of walking. The shared correlates between leisure and neighborhood walking imply they occur in the same setting. Patients with arthritis may benefit from exercise recommendations that are informed by the presence or absence of facilitating infrastructure in their neighborhoods.

Posttraumatic Stress Disorder and Type 2 Diabetes Outcomes in Veterans.

Importance: Posttraumatic stress disorder (PTSD) symptom reduction is linked with lower risk of incident type 2 diabetes (T2D), but little is known about the association between PTSD and comorbid T2D outcomes. Whether PTSD is a modifiable risk factor for adverse T2D outcomes is unknown. Objective: To determine whether patients with PTSD who improved and no longer met diagnostic criteria for PTSD had a lower risk of adverse T2D outcomes compared with patients with persistent PTSD. Design, Setting, and Participants: This retrospective cohort study used deidentified data from US Veterans Health Administration (VHA) historical medical records (from October 1, 2011, to September 30, 2022) to create a cohort of patients aged 18 to 80 years with comorbid PTSD and T2D. Data analysis was performed from March 1 to June 1, 2024. Exposures: Diagnoses of PTSD and T2D. Main Outcomes and Measures: The main outcomes were insulin initiation, poor glycemic control, any microvascular complication, and all-cause mortality. Improvement of PTSD was defined as no longer meeting PTSD diagnostic criteria, per a PTSD Checklist score of less than 33. Entropy balancing controlled for confounding. Survival and competing risk models estimated the association between meeting PTSD criteria and T2D outcomes. Subgroup analyses examined variation by age, sex, race, PTSD severity, and comorbid depression status. Results: The study cohort included 10 002 veterans. More than half of patients (65.3%) were aged older than 50 years and most (87.2%) were men. Patients identified as Black (31.6%), White (62.7%), or other race (5.7%). Before controlling for confounding with entropy balancing, patients who no longer met PTSD diagnostic criteria had similar incidence rates for starting insulin (22.4 vs 24.4 per 1000 person-years), poor glycemic control (137.1 vs 133.7 per 1000 person-years), any microvascular complication (108.4 vs 104.8 per 1000 person-years), and all-cause mortality (11.2 vs 11.0 per 1000 person-years) compared with patients with persistent PTSD. After controlling for confounding, no longer meeting PTSD criteria was associated with a lower risk of microvascular complications (hazard ratio [HR], 0.92 [95% CI, 0.85-0.99]). Among veterans aged 18 to 49 years, no longer meeting PTSD criteria was associated with a lower risk of insulin initiation (HR, 0.69 [95% CI, 0.53-0.88]) and all-cause mortality (HR, 0.39 [95% CI, 0.19-0.83]). Among patients without depression, no longer meeting PTSD criteria was associated with a lower risk of insulin initiation (HR, 0.73 [95% CI, 0.55-0.97]). Conclusions and Relevance: The findings of this cohort study of patients with comorbid PTSD and T2D suggest that PTSD is a modifiable risk factor associated with a modest reduction in microvascular complications. Further research is needed to determine whether findings are similar in non-VHA health care settings.

Changes in Emergency Department and Inpatient Encounters for Falls after the Onset of the COVID-19 Pandemic.

OBJECTIVE: This study investigates changes in clinical encounters due to falls before and after the onset of the COVID-19 pandemic. METHODS: De-identified health record data from a large mid-western health system was used to examine the frequency of emergency department (ED) and inpatient (IP) encounters for falls by month among adults age 50+ (N = 485, 886 patients) using joinpoint regression analysis. Also, overall rates before and during the pandemic were compared using log-binomial models. RESULTS: Fall rates increased following the onset of the COVID-19 pandemic for IP encounters but not for ED encounters. There were no differences by age, gender, race, or nSES. Monthly IP fall rates increased by 0.68% per month both before and after the onset of the COVID-19 pandemic. CONCLUSION: Pandemics may occur in the future, and interventions are needed to prevent falls in older adults during the next public health emergency.

Contraceptive uptake in postpartum people with and without opioid use disorder and opioid use with co-occurring substance use.

Background: Using contraception to delay pregnancy allows people with opioid use disorder (OUD) to choose when they are ready to continue their families. Yet, postpartum contraceptive uptake among people with OUD has not been well characterized. Methods: Analyses used 73,811 pregnancy episodes among 61,221 people (2016-2021) from the St. Louis University-SSM Virtual Data Warehouse. OUD was defined from the year prior and through pregnancy. Contraceptive uptake was defined within 90-days after delivery. We used Generalized Estimating Equations-type multinomial logit models to assess association of OUD +/- co-occurring substance use disorders (SUDs) with any contraception (yes/no) and type of contraception (effective - pills, patch, ring, injection; or highly effective - long-acting reversible, LARC methods [intrauterine device, implant] and sterilization). Results: The sample was 66.0 % white and average age was 27.7 years (±5.6). 32.5 % of pregnancies were followed by contraception initiation, 2.3 % had an OUD diagnosis, and 1.3 % OUD with co-occurring SUD. There was no association between OUD and postpartum contraception receipt, but OUD was associated with decreased highly effective compared to effective method initiation (aOR=0.76; 95 % CI: [0.64-0.91]). OUD plus co-occurring SUD was associated with decreased uptake across all contraception types (aOR=0.81[0.70-0.93]), specifically, highly-effective methods (aOR=0.48[0.38-0.61]). Conclusions: Overall postpartum contraception uptake among people with OUD is comparable to uptake in the non-OUD population. People with OUD plus co-occurring SUDs are particularly unlikely to receive contraception. The reasons people choose contraceptive methods are complex and may differ by SUD severity. More information is needed to understand factors that impact postpartum contraception initiation.

Social support and the association between post-traumatic stress disorder and risk for long-term prescription opioid use.

ABSTRACT: Post-traumatic stress disorder (PTSD) is common in patients with chronic pain, adversely affects chronic pain outcomes, and is associated with opioid use and adverse opioid outcomes. Social support is a robust predictor of PTSD incidence and course as well as chronic pain outcome. We determined whether the association between PTSD and persistent opioid use was modified by emotional support in a cohort of patients receiving opioids for noncancer pain. Eligible participants were ≥18 years and had completed a new period of prescription opioid use lasting 30 to 90 days. Bivariate associations between cohort characteristics and each key variable was assessed using χ 2 tests for categorical variables and t -tests for continuous variables. Interaction between PTSD and emotional support was assessed by a priori stratification on low vs high emotional support. Participants (n = 808) were 53.6 (SD ± 11.6) years of age, 69.8% female, 69.6% White, and 26.4% African American. Overall, 17.2% had probable PTSD. High emotional support was significantly ( P < 0.0001) more common among those without probable PTSD. Prescription opioid use at 6-month follow-up was significantly ( P = 0.0368) more common among patients with vs without probable PTSD. In fully adjusted models, PTSD was no longer associated with opioid use at 6-month follow-up among participants with high emotional support. Among those with lower emotional support, PTSD was significantly associated with opioid use at 6-month follow-up in unadjusted (odds ratio = 2.40; 95% confidence interval: 1.24-4.64) and adjusted models (odds ratio = 2.39; 95% confidence interval: 1.14-4.99). Results point to the hypothesis that improvement of emotional support in vulnerable patients with chronic pain and PTSD may help reduce sustained opioid use.

Depression and Time to Knee Arthroplasty Among Adults Who Have Knee Osteoarthritis.

BACKGROUND: Depression is common in osteoarthritis (OA) and is associated with poor outcomes following total knee arthroplasty (TKA). Depression can increase pain sensitivity and may be related to an increased likelihood of TKA. METHODS: Nationally distributed electronic health record data from 2010 to 2018 were used to identify eligible patients (n = 9,466) who had knee OA and were 45 to 80 years of age. Cox proportional hazard models were computed to estimate the association between depression and incident TKA for all patients and by age group (45 to 54, 55 to 64, and 65 to 80 years of age). Confounding was controlled using entropy balancing. Sensitivity analyses determined if the association between depression and TKA differed when depression occurred in the 12 months occurring 90, 60, 30, and 0 days lag time before TKA. RESULTS: The mean age of the sample was 63 (range, 45 to 80), 64.0% were women, 83.3% were White race, and approximately 50% resided in the Midwest. There was no association between depression and incident TKA (hazard ratio = 0.97; confidence interval = 0.81 to 1.16]). Results did not differ in age-stratified analyses. Sensitivity analyses revealed a higher percentage of TKA among depressed versus nondepressed patients (24.2 versus 21.6%; P = .028) when the patient's depression diagnosis was established in the 12 months with no lag time before TKA. CONCLUSIONS: Patients who have knee OA and comorbid depression, compared to those who have only knee OA, do not have an increased likelihood of TKA. The multifactorial, complex decision to obtain TKA does not appear to be influenced by depression, but depression is a common comorbidity.

Characteristics of patients with non-cancer pain and long-term prescription opioid use who have used medical versus recreational marijuana.

OBJECTIVE: Marijuana use is increasingly common among patients with chronic non-cancer pain (CNCP) and long-term opioid therapy (LTOT). We determined if lifetime recreational and medical marijuana use were associated with more frequent and higher dose prescription opioid use. DESIGN: Cross-sectional SUBJECTS: Eligible patients (n=1,037), who had a new period of prescription opioid use lasting 30-90 days, were recruited from two midwestern health care systems to a study of long-term prescription opioid use and mental health outcomes. The present cross-sectional analyses uses baseline data from this on-going cohort study. METHODS: Primary exposures were participant reported lifetime recreational and medical marijuana use versus no lifetime marijuana use. Prescription opioid characteristics included daily versus non-daily opioid use and ≥50 morphine milligram equivalent (MME) dose per day vs. <50 MME. Multivariate, logistic regression models estimated the association between lifetime recreational and medical marijuana use vs. no use and odds of daily and higher dose prescription opioid use, before and after adjusting for confounding. RESULTS: The sample was an average of 54.9 (SD±11.3) years of age, 57.3% identified as female gender, 75.2% identified as White, and 22.5% identified as Black race. Among all participants, 44.4% were never marijuana users, 21.3% were recreational only, 7.7% medical only and 26.6% were both recreational and medical marijuana users. After controlling for all confounders, lifetime recreational marijuana use, as compared to no use, was significantly associated with increased odds of daily prescription opioid use (OR=1.61; 95%CI:1.02-2.54). There was no association between lifetime recreational or medical marijuana use and daily opioid dose. CONCLUSION: Lifetime medical marijuana use is not linked to current opioid dose, but lifetime recreational use is associated with more than a 60% odds of being a daily prescription opioid user. Screening for lifetime recreational marijuana use may identify patients with chronic pain who are vulnerable to daily opioid use which increases risk for adverse opioid outcomes. Prospective data is needed to determine how marijuana use influences the course of LTOT and vice versa.

Pregnancy Rates Among Women Treated with Medication for Opioid Use Disorder.

BACKGROUND: Treatment-seeking people with opioid use disorder (OUD) who are capable of pregnancy need accurate information about the potential impact of medication to treat OUD (MOUD) on fertility to make informed choices about treatment that are consistent with their reproductive wishes. There is a dearth of research on fertility associated with MOUD receipt in birthing people with OUD. OBJECTIVE: To estimate the association between treatment with MOUD and odds of conception among birthing people using national administrative claims. DESIGN: Retrospective case-crossover study using multi-state US administrative data (2006-2016). Dates of conception were estimated from delivery dates and served as "case" days for which MOUD exposures were compared to those on all other ("control") days of insurance enrollment. PARTICIPANTS: Treatment-seeking people with OUD with a delivery during the observation period. MAIN MEASURES: Odds ratios for conception from within-person fixed effects models were modeled as a function of exposure to MOUD (buprenorphine, methadone, extended-release depot naltrexone, or oral naltrexone) using conditional logistic regression. KEY RESULTS: A total of 21,928 births among 19,133 people with OUD were identified. In the sample, 5873 people received buprenorphine, 1825 methadone, 486 extended-release naltrexone, and 714 oral naltrexone. Participants could receive more than one type of MOUD. Mean age was 28.2 years (SD = 2.2; range = 16-45), with 76.2% having Medicaid. vs. commercial insurance. Compared to no MOUD, periods of methadone (aOR = 0.55 [95% CI = 0.48-0.63]) or buprenorphine receipt (aOR = 0.84 [0.77-0.91]) were associated with fewer conceptions. Treatment periods with extended-release depot naltrexone compared to no medication were associated with higher odds of conception (aOR = 1.75 [1.22-2.50]) and there was no significant difference in conception with oral naltrexone (aOR = 1.02 [0.67-1.54]). CONCLUSIONS: The association between MOUD and odds of conception among birthing people varied by type of MOUD, with extended-release naltrexone associated with higher odds of conceiving compared to no treatment. Clinical studies are urgently needed to investigate these findings further.

Baseline Characteristics From a New Longitudinal Cohort of Patients With Noncancer Pain and Chronic Opioid Use in the United States.

Retrospective cohort studies have consistently observed that long-term prescription opioid use is a risk factor for new major depressive episodes. However, prospective studies are needed to confirm these findings and establish evidence for causation. The Prescription Opioids and Depression Pathways cohort study is designed for this purpose. The present report describes the baseline sample and associations between participant characteristics and odds of daily versus nondaily opioid use. Second, we report associations between participant characteristics and odds of depression, dysthymia, anhedonia, and vital exhaustion. Patients with noncancer pain were eligible if they started a new period of prescription opioid use lasting 30 to 90 days. Participants were 54.8 (standard deviation ± 11.3) years of age, 57.3% female and 73% White race. Less than college education was more common among daily versus nondaily opioid users (32.4% vs 27.3%; P = .0008), as was back pain (64.2% vs 51.3%; P < .0001), any nonopioid substance use disorder (12.8% vs 4.8%; P < .0001), and current smoking (30.7% vs 18.4% P < .0001). High pain interference (50.9% vs 28.4%; P < .0001) was significantly associated with depression, as was having more pain sites (6.9 ± 3.6 vs 5.7 ± 3.6; P < .0001), and benzodiazepine comedication (38.2% vs 23.4%; P < .0001). High pain interference was significantly more common among those with anhedonia (46.8% vs 27.4%; P < .0001), and more pain sites (7.0 ± 3.7 vs 5.6 ± 3.6; P < .0001) were associated with anhedonia. Having more pain sites (7.9 ± 3.6 vs 5.5 ± 3.50; P < .0001) was associated with vital exhaustion, as was back pain (71.9% vs 56.8%; P = .0001) and benzodiazepine comedication (42.8% vs 22.8%; P < .0001). Patients using prescription opioids for noncancer pain have complex pain, psychiatric, and substance use disorder comorbidities. Longitudinal data will reveal whether long-term opioid therapy leads to depression or other mood disturbances such as anhedonia and vital exhaustion. PERSPECTIVE: This study reports baseline characteristics of a new prospective, noncancer pain cohort study. Risk factors for adverse opioid outcomes were most common in those with depression and vital exhaustion and less common in dysthymia and anhedonia. Baseline data highlight the complexity of patients receiving long-term opioid therapy for noncancer pain.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management.

OBJECTIVE: Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids. METHODS: Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management. RESULTS: There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant. DISCUSSION: The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

Severity of posttraumatic stress disorder, type 2 diabetes outcomes and all-cause mortality: A retrospective cohort study.

BACKGROUND: Some evidence suggests patients with comorbid PTSD and type 2 diabetes (T2D) have worse T2D outcomes than those with T2D alone. However, there is no evidence regarding PTSD severity and risk for starting insulin, hyperglycemia, microvascular complications, and all-cause mortality. METHODS: In this retrospective cohort study, Veterans Health Affairs (VHA) medical record data from fiscal year (FY) 2012 to FY2022 were used to identify eligible patients (n = 23,161) who had a PTSD diagnosis, ≥1 PTSD Checklist score, controlled T2D (HbA1c ≤ 7.5) without microvascular complications at baseline. PTSD Checklist for DSM-5 (PCL-5) scores defined mild, moderate, and severe PTSD. Competing risk and survival models estimated the association between PTSD severity and T2D outcomes before and after controlling for confounding. RESULTS: Most (70%) patients were ≥ 50 years of age, 88% were male, 64.2% were of white race and 17.1% had mild, 67.4% moderate and 15.5% severe PTSD. After control for confounding, as compared to mild PTSD, moderate (HR = 1.05; 95% CI:1.01-1.11) and severe PTSD (HR = 1.15; 95%CI:1.07-1.23) were significantly associated with increased risk for microvascular complication. Hyperarousal was associated with a 42% lower risk of starting insulin. Negative mood was associated with a 16% increased risk for any microvascular complication. Severe PTSD was associated with a lower risk for all-cause mortality (HR = 0.76; 95%CI:0.63-0.91). CONCLUSIONS: Patients with comorbid PTSD and T2D have an increased risk for microvascular complications. However, they have lower mortality risk perhaps due to more health care use and earlier chronic disease detection. PTSD screening among patients with T2D may be warranted.

Differences Between General Internal Medicine and Family Medicine Physicians' Initiation of Pre-Exposure Prophylaxis.

OBJECTIVE: Preexposure Prophylaxis (PrEP) is under-utilized in primary care. Given differences in treatment approaches for other conditions between family medicine (FM) and general internal medicine (GIM), this study compared PrEP-prescribing between FM and GIM physicians. METHODS: De-identified electronic health record data from a multi-state health care system was used in this retrospective observational study. The time period from 1/1/13 to 9/30/21 was used to identify PrEP eligible patients using measures of current sexually transmitted disease and condomless sex at the time of eligibility. Receipt of PrEP was measured in the 12 months after PrEP eligibility. The odds of receiving PrEP in GIM as compared to FM was computed before and after adjusting for demographics and physical and psychiatric comorbidities. RESULTS: The majority of eligible patients were 18 to 39 years of age, 60.9% were female and 71.6% were White race. Among PrEP eligible patients, 1.1% received PrEP in the first year after index date. Receiving PrEP was significantly more likely among patients treated in GIM versus FM (OR = 2.30; 95% CI:1.63-3.25). After adjusting for covariates, this association remained statistically significant (OR = 2.02; 95% CI:1.41-2.89). CONCLUSIONS: PrEP is grossly under-utilized in primary care. The majority of Americans enter the health care system through primary care and not through HIV providers or other specialties. Therefore, educational interventions are needed to increase confidence and knowledge and to encourage PrEP prescribing by FM and GIM physicians.

Pre-pregnancy weight loss associations with prenatal and postpartum mental health conditions: A retrospective cohort study.

Background: Obesity is a risk factor for adverse outcomes during and following pregnancy. Most women are advised to lose weight prior to becoming pregnant, to help alleviate complications including prenatal and postpartum depression and anxiety. Yet, no studies have examined how the process of losing weight prior to pregnancy interacts with the development of prenatal and postpartum mental health disorders.The objective of the study was to determine if women with pre-pregnancy weight loss (≥10%) vs. those who do not, in the two years prior to pregnancy, have a lower risk for new onset prenatal and postpartum mental health conditions. Methods: This retrospective cohort study used data from the Virtual Data Warehouse of a large Midwestern, U.S. based hospital system. The final sample consisted of 6,085 female patients of reproductive age that had given birth between 10/1/2011-6/30/2020 and had two recorded weights in the year prior to conception. Univariate analysis between weight loss and outcome variables (pre-natal and post-partum depression and anxiety) and multivariate analysis using logistic regression was conducted for variable significant on univariate analysis. Results: On univariate analysis, women with pre-pregnancy weight loss had increased odds of post-partum depression (OR=1.47, 95%CI=1.03-2.10), though decreased odds of prenatal anxiety (OR=0.59, 95% CI 0.33-0.90). After controlling for confounders in the multivariate analysis, there was not a significant difference in the odds of post-partum depression; however, women who lost weight had approximately half the odds of having prenatal anxiety than those who did not lose weight (OR=0.54, 95%CI=0.33-0.90). Discussion: The experience of achieving weight loss prior to pregnancy may foster a sense of agency within pregnant women, helping them to reduce their experience of pre-natal anxiety. Providers could engage in patient conversations around weight loss and mental health management in a strengths-based framework to continue to foster this sense of agency. Conclusion: Anxiety and depression were uniquely related to pre-pregnancy weight loss. Pre-pregnancy weight loss was associated with lower odds of prenatal anxiety and higher odds of postpartum depression. These results highlight the need for real world examination of pre-conception treatment recommendations and their association with non-physical health-based outcomes.

Association Between Antibiotic Prescribing and Time to Diagnosis of Head and Neck Cancer.

Importance: Diagnostic delay can negatively affect patient outcomes in head and neck cancer (HNC). Neck mass and other symptoms of undiagnosed HNC may be treated with antibiotics, delaying diagnosis and treatment, despite current clinical practice guidelines. Objective: To investigate temporal trends, associated factors, and time from symptom onset to antibiotic prescribing before an HNC diagnosis. Design, Setting, and Participants: A retrospective cohort study was conducted using data obtained from a deidentified electronic health records data set from January 1, 2011, to December 31, 2018. Patients with HNC enrolled in the data set for at least 1 year before diagnosis date determined by either 1 inpatient encounter or first of 2 outpatient encounters within 6 months were included. Data analysis was conducted from May 1 to November 9, 2022. Exposure: Antibiotic prescription within 3 months before HNC diagnosis date. Main Outcomes and Measures: The primary outcome was days from the first documented symptom to HNC diagnosis. Results: The cohort included 7811 patients with HNC (4151 [53.1%] men, mean [SD] age, 60.2 [15.8] years). At least 1 antibiotic was prescribed for 1219 patients (15.6%) within 3 months before HNC diagnosis. This represented an increase over the 8.9% prescribing rate during the baseline period 12 to 9 months before diagnosis. The rate of antibiotic prescribing within 3 months before diagnosis did not change significantly over time (quarterly percent change, 0.49%; 95% CI, -3.06% to 4.16%). Patients receiving an antibiotic prescription within 3 months of an HNC diagnosis had a 21.1% longer time between symptom onset and HNC diagnoses (adjusted rate ratio [ARR], 1.21; 95% CI, 1.14-1.29). Compared with diagnosis by otolaryngologists, primary care/internal medicine physicians were most likely to prescribe antibiotics for patients who were diagnosed with a presenting symptom (adjusted prevalence ratio, 1.60; 95% CI, 1.27-2.02). In patients presenting with neck mass/swelling, those presenting with other symptoms were more likely to have longer intervals from symptom onset to diagnosis (ARR, 1.31; 95% CI, 1.08-1.59). Conclusions and Relevance: The findings of this cohort study suggest there is an increased rate of antibiotic prescription in the 3 months before HNC diagnosis, which is associated with an increased time to diagnosis. These findings identify an area for improvement in HNC care and guidelines.

Anxiety disorders, benzodiazepine prescription, and incident dementia.

BACKGROUND: Prescribing benzodiazepines to older patients is controversial. Anxiety disorders and benzodiazepines have been associated with dementia, but literature is inconsistent. It is unknown if anxiety treated with a benzodiazepine, compared to anxiety disorder alone is associated with dementia risk. METHODS: A retrospective cohort study (n = 72,496) was conducted using electronic health data from 2014 to 2021. Entropy balancing controlled for bias by indication and other confounding factors. PARTICIPANTS: Eligible patients were ≥65 years old, had clinic encounters before and after index date and were free of dementia for 2 years prior to index date. Of the 72,496 eligible patients, 85.6% were White and 59.9% were female. Mean age was 74.1 (SD ± 7.1) years. EXPOSURE: Anxiety disorder was a composite of generalized anxiety disorder, anxiety not otherwise specified, panic disorder, and social phobia. Sustained benzodiazepine use was defined as at least two separate prescription orders in any 6-month period. MAIN OUTCOME AND MEASURES: ICD-9 or ICD-10 dementia diagnoses. RESULTS: Six percent of eligible patients had an anxiety diagnosis and 3.6% received sustained benzodiazepine prescriptions. There were 6640 (9.2%) incident dementia events. After controlling for confounders, both sustained benzodiazepine use (HR 1.28, 95% CI: 1.11-1.47) and a diagnosis of anxiety (HR 1.19, 95% CI: 1.06-1.33) were associated with incident dementia in patients aged 65-75. Anxiety disorder with sustained benzodiazepine, compared to anxiety disorder alone, was not associated with incident dementia (HR 1.18, 95% CI: 0.92-1.51) after controlling for confounding. Results were not significant when limiting the sample to those ≥75 years of age. CONCLUSIONS: Benzodiazepines and anxiety disorders are associated with increased risk for dementia. In patients with anxiety disorders, benzodiazepines were not associated with additional dementia risk. Further research is warranted to determine if benzodiazepines are associated with a reduced or increased risk for dementia compared to other anxiolytic medications in patients with anxiety disorders.

Erectile dysfunction associated with undiagnosed prediabetes and type 2 diabetes in young adult males: A retrospective cohort study.

Erectile dysfunction (ED) is a common comorbidity in type 2 diabetes (T2D). ED has been studied as an outcome in diabetes, but it is not known if ED is a risk factor for T2D. We determined if patients with ED have an increased risk for prediabetes and/or T2D and measured the duration between ED and prediabetes/T2D diagnosis. Retrospective cohort study using de-identified medical record data from a large mid-western health care system to measure ED, T2D and potential confounding factors. Patients were 18 to 40 years of age because we were interested in early onset pre-diabetes/T2D. Eligible patients had ED and were free of prediabetes, hyperglycemia and T2D at index. Entropy balancing controlled for confounding. Modified Poisson regression models with robust error variances calculated relative risk (RR) and 95% confidence intervals for the association of ED and pre-diabetes/T2D. Patients' mean age was 28.3 (±7.0) years, 81.7% were White and 14.0% were Black. After controlling for confounding, ED was associated with increased risk for prediabetes/T2D (RR = 1.34; 95%CI:1.16-1.55). This association was similar to that between ED and T2D alone (RR = 1.38; 95% CI: 1.10-1.74). About 30% had ED and prediabetes/T2D diagnosed on the same day and nearly 75% were diagnosed within a year of ED. ED is a marker for undiagnosed prediabetes/T2D and a risk factor for near term onset of prediabetes/T2D. ED may offer the opportunity for earlier detection and diagnoses of T2D, particularly in younger men. Younger patients presenting with ED should be screened for hyperglycemia.

Lower risk for COVID-19 hospitalization among patients in the United States with past vaccinations for herpes zoster and tetanus, diphtheria and pertussis.

Influenza, tetanus, diphtheria, and herpes zoster (HZ) vaccination received within 10 years of the COVID-19 pandemic have been associated with less severe COVID-19 infection. We expanded on this evidence to determine if a receiving two different vaccinations (i.e., HZ and tetanus, diphtheria, and pertussis (Tdap)) was associated with a lower risk for COVID-19 hospitalization. De-identified medical record data from a large mid-western health care system was used to determine if, compared to those with neither HZ or Tdap vaccination, patients with either HZ or Tdap and patients with both HZ and Tdap vaccination had lower risk for COVID-19 hospitalization between 4/1/2020 and 12/31/2020. Confounding was controlled using entropy balancing. Patients (n = 363,293) were 71.5 (±8.4) years of age, 57.8% female and 89.2% White race. Prior to controlling for confounding, as compared to patients without either vaccination, those that had either HZ or Tdap were significantly less likely to have a COVID-19 hospitalization (RR = 0.85; 95 %CI: 0.75-0.95). The risk for hospitalization decreased further among those with both HZ and Tdap vaccination (RR = 0.45; 95 %CI:0.28-0.71). After controlling for confounding, including healthy patient bias, receiving both vs. neither vaccinations remained significantly associated with a lower risk of COVID-19 hospitalization (RR = 0.48; 95 %CI: 0.26-0.90). Receiving both Tdap and HZ vaccination is associated with lower risk for COVID-19 hospitalization. Whether there is any benefit of past vaccination exposure in COVID-19 vaccinated patients should be investigated.

Temporal Location of Changes in the US Suicide Rate by Age, Ethnicity, and Race: A Joinpoint Analysis 1999-2020.

ABSTRACT: Suicide rates differ over time. Our objective was to determine when significant changes occurred by age, race, and ethnicity in the United States between 1999 and 2020. National Center for Health Statistics WONDER data were used in joinpoint regression. The annual percent change in suicide rate increased for all race, ethnic, and age groups, except for those 65 years and older. For American Indian/Alaska Natives, the largest increase occurred between 2010 and 2020 for those with ages 25 to 34 years. For Asian/Pacific Islander, the largest increase occurred among those 15 to 24 years old between 2011 and 2016. For Black/African-Americans, the largest increases occurred between 2010 and 2020 among 15- to 34-year-olds. For Whites, the largest increase occurred between 2014 and 2017 among 15- to 24-year-olds. Between 2018 and 2020, suicide rates significantly declined among Whites 45 to 64 years of age. Among Hispanics, significant increases in suicide rate occurred between 2012 and 2020 among those with ages 15 to 44 years. Between 1999 and 2020, the contour of suicide burden varied by age groups, race, and ethnicity.

Obesity Epidemic in U.S. Prison Populations: A Meta-Analysis and Review of the Literature.

Limited existing evidence and health provider perceptions suggest that prevalence of obesity among incarcerated people residing in U.S. correctional institutions is high. Evaluating evidence of obesity and weight change during incarceration will allow for the determination of whether people are subject to weight gain during incarceration. A systematic review of three online databases, gray literature, and reference lists of articles of interest was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. A meta-analysis to obtain pooled prevalence estimates of obesity among U.S. incarcerated people was then completed. A total of 11 studies met our inclusion criteria. Results show the estimated pooled prevalence of obesity in incarcerated men (30.0%) was less than the national average. The estimated pooled prevalence of obesity in females (39.8%) was similar to the national average.