Oritavancin vs Standard of Care for Treatment of Nonendovascular Gram-Positive Bloodstream Infections.

Background: Data is limited comparing oritavancin (ORT) to the standard-of-care (SOC) for the treatment gram-positive blood stream infections (BSI). Methods: This was a retrospective study of all patients in the Veteran's Affairs Health Care System treated with at least 1 dose of oritavancin or at least 5 days of vancomycin, daptomycin, ceftaroline, ampicillin, ampicillin-sulbactam, nafcillin, oxacillin, or cefazolin for a documented gram-positive BSI from 1 January 2015 to 30 June 2021. Patients with polymicrobial blood cultures or positive cultures from other sites were included if the organisms were sensitive to the incident antimicrobial; no concomitant antimicrobials could be used once the incident agent was started. Individuals were also excluded if they were diagnosed with endocarditis, had a neutrophil count 96-hours of treatment before the incident antimicrobial was started.The primary composite outcome was clinical failure, defined as all-cause mortality within 30-days from the end of therapy, or blood cultures positive for the incident organisms ≥72 hours after administration of the first dose and ≤30 days after the administration of the final dose of the study antimicrobial, or any drug or line-related readmissions within 30-days of hospital discharge. Results: Two hundred-forty patients were identified for screening with 96 meeting criteria (27 in ORT and 69 in SOC groups). Baseline characteristics were generally balanced between groups except more patients in the ORT group received >96-hours of treatment before the incident antimicrobial was started (70.3% (19/27) vs 13.04% 9/69); P < .001). The pathogen most prevalent was methicillin susceptible Staphylococcus aureus (MSSA) (ORT 33.3% (9/27) vs SOC 46.4% (32/69)). Clinical failure occurred in 7.4% (2/27) in the ORT group and 17.4% (12/69) in SOC (P = .34). No components of the primary outcome were significantly different between groups, but AKI did occur more commonly in the SOC group (27.5% (19/69) vs 3.7% (1/27); P = .01). Conclusions: ORT appears to be a safe and effective option when directly compared to the SOC for non-endocarditis BSIs.

Informatics Tools in Deprescribing and Medication Optimization in Older Adults: Development and Dissemination of VIONE Methodology in a High Reliability Organization.

PURPOSE: Polypharmacy is common in older adults, with almost 20% of older adults taking ≥10 medications. They are at great risk for adverse events related to potentially inappropriate medications (PIMs). Although evidence-based methods for deprescribing have been successful at reducing polypharmacy and improving quality of medication use, there are several challenges to implementing these methods on a large scale. VIONE, a medication deprescribing methodology, was developed to reduce polypharmacy and PIMs across the Veterans Health Administration (VHA). (VIONE stands for Vital, Important, Optional, Not indicated, and Every medication has an indication.) This study describes the tools created for implementation of VIONE and the dashboards used to track VIONE implementation and subsequent deprescribing across the VHA; their use and sustainment are examined in a health system-wide adoption of this deprescribing practice in a high reliability organization (HRO). METHODS: VIONE was disseminated by the VHA via the Diffusion of Excellence Initiative. Dissemination included an implementation toolkit and four dashboards that collect and display data from the electronic medical record to monitor utilization of VIONE, track medication discontinuations, and prospectively identify veterans who may be candidates for deprescribing. FINDINGS: Between 2016 and the present, VIONE has been adopted at >130 medical centers and influenced almost 700,000 unique patients. In addition, a total of >1.6 million medication orders have been discontinued by >15,000 providers. IMPLICATIONS: The VIONE methodology and informatics tools were widely disseminated and successfully adopted and sustained nationally in a high reliability organization, leading to a reduction in PIM use by older adults and improved quality and patient safety. Future efforts should continue to consider ways to leverage electronic medical record data and other relevant informatics tools to provide customized clinical decision support to further medication optimization and deprescribing efforts.

Parenting practices and adolescent delinquency: COVID-19 impact in the United States.

Many past studies found parental monitoring and involvement were associated with reductions in delinquency and substance use among adolescents. However, we do not yet fully understand how the COVID-19 crisis affected parenting practices, nor the corresponding effects for juvenile delinquency and substance use. The study incorporated a repeated cross-sectional design with data drawn from two samples of Pennsylvania parents with teenage children. The first sample completed a web survey about parental monitoring in late 2019. The second completed a similar web survey with additional questions about COVID-19 in February 2021. The results indicated little association between COVID-related financial hardship and parental depression, nor between COVID-related financial hardship and parenting practices. While parents reported high levels of depressive symptoms during the pandemic, these appeared largely unrelated to parenting practices. There were few changes in parenting practices, on average, from before to during the pandemic. Most parents reported that their child's behavior had not worsened during the pandemic.

Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients.

BACKGROUND: The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. METHODS: For each trial, we will recruit 8-12 clinics (24-36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. PROCESS: (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. DISCUSSION: MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05065502 . Registered October 4, 2021-retrospectively registered.

Impact of COVID-19 on the exercise habits of Pennsylvania residents and their families.

AIM: This study investigated how COVID-19 impacted the physical activity and sports participation of Pennsylvania residents and their children. SUBJECT AND METHODS: Data were collected through an online survey of 525 Pennsylvania residents with a child between the ages of 3 and 17. Data were collected in October 2020. RESULTS: Nearly a third of respondents reported a decrease in their physical activity. Hispanics were more likely than non-Hispanics to report a decrease in their physical activity. Older children were more likely to have a decrease in physical activity. Children in homes with more children present were less likely to see such a decline. Men were more likely than women to see COVID-19 as a barrier to physical activity for themselves and their child. CONCLUSIONS: The results of this study underscore the profound impact of the COVID-19 pandemic on our health as a nation. Exercise, in all forms, plays a key role in overall health, weight, and disease resistance. It remains unclear how declines in physical activity might persist over time, and among whom.

Perceptions of Active Shooter Prevention and Preparation Strategies in Pennsylvania: Links to Self-Protective Behavior.

In this study, I document how members of the public perceive active shooter risk in their communities and their perceptions of the effectiveness of common efforts to prevent and respond to active shooters. I further investigate how news media exposure shapes these perceptions. I applied Protection Motivation Theory (PMT) to explore how perceptions and news media exposure might shape self-protective actions taken by individuals and their households. Data were obtained in 2019 from a cross-sectional, state-representative sample of 668 Pennsylvania adults who completed a web survey. Those who perceived higher community active shooter risk and those who felt community prevention and preparation efforts were effective were more likely to take self-protective steps themselves. Increased news exposure through apps, social media, family and friends was associated with increased perceived risk and effectiveness of prevention and preparation strategies. These results suggest that self-selected news and news through personal ties are linked to active shooter perceptions while other news mediums, like television or radio broadcasts, are not. News exposure was largely unrelated to self-protection. Those who felt community efforts were effective in prevention or preparation, however, were more likely to take self-protective actions. This finding indicates that community efforts may be more influential than news media in directing personal behavior.

Pennsylvania Workplace Safety: Employee Perceptions of Active Shooter Preparedness.

This study investigated the role of workplace preparedness actions in employee perceptions of workplace risk, workplace preparedness, and personal self-efficacy in an active shooter event. Data were drawn from an online, state representative survey of 668 Pennsylvania residents in 2019. Nearly 40% of employees reported their workplaces had not taken any preparedness actions. Having a workplace take a greater number of preparedness actions was associated with increased self-efficacy and increased perceptions of workplace preparedness, but also an increase in perceived risk. Males and gun owners perceived lower levels of workplace risk and reported substantially higher self-efficacy. However, associations between workplace efforts and self-efficacy differed from those for perceived workplace preparedness. Associations with firearm policy and the presence of security staff also differed for the two outcomes.

Gun safety discussions with caregivers: timing and demographic associations in a retrospective study.

This study examined individuals' recollection of gun safety conversations during childhood, and with whom these conversations occurred. Data were collected using a retrospective survey of 298 college students aged 18-54 from three campuses of a university in the USA. Respondents reported whether they recalled discussing guns or gun safety with a parent, doctor, or school official in childhood as well as what age they recalled first discussing guns or gun safety with this adult. Those growing up in gun-owning households were more likely to report gun safety conversations with parents and to report having these conversations at earlier ages. More affluent youth were more likely to report gun safety conversations with school officials and to report having gun safety discussions with adults in a variety of roles. Few respondents recalled discussing guns with a doctor or paediatrician. Future investigations are needed to assess the content and form of gun safety conversations between children and caregivers.

College Student Attitudes Towards "Smart" Guns: Results from a Nationwide Survey.

Existing studies focusing on "smart" guns, weapons that can only be fired by an authorized user, have focused largely on overall views towards the topic. Little is known about how views differ within key demographics or why Americans feel positively or negatively towards smart guns. This study used data from a nationwide web survey of 520 college students to address these concerns. Multinomial regression was used to identify patterns of smart gun preference in quantitative data. Respondents' open-ended reasoning for their views was examined through common themes and descriptive statistics. About half of the sample preferred smart guns over traditional firearms, with support more likely among females and liberals. Those with more advanced academic standing were more likely to have a traditional gun preference. The sample did not rank cost as a significant concern. Child protection was a much less prominent theme than concerns over (un)authorized users.

Perceived popularity of adolescents who use weapons in violence and adolescents who only carry weapons.

Prior research has found that persistently delinquent youth or more violent youth were less popular than their less delinquent peers (Young, 2013). However, recent research has also found that weapon carrying is associated with being more popular in adolescence (Dijkstra et al., 2010). The present paper examines the perceived popularity of adolescents who carry weapons in comparison to those who both carry and use weapons in acts of violence or threatened violence. Data consist of two waves from the National Longitudinal Study of Adolescent to Adult Health. Analyses use OLS regression with lagged predictors. This paper found no differences in number of friends between weapon carriers and weapon users. However, among both male and female gang members, those who did not use or carry weapons (abstainers) named significantly fewer friends than weapon users. Among females, weapon abstainers both named and were named by significantly more people than weapon users. These differences were not observed for males. Implications of these results and directions for future research are discussed.

Siblings and Adolescent Weapon Carrying: Contributions of Genetics, Shared Environment, and Nonshared Environment.

Many past studies have observed evidence of sibling similarity and influence for delinquency and substance use. However, studies of sibling similarity for adolescent weapon carrying, particularly for weapons beyond firearms, are largely absent from the literature. The present study assesses sibling similarity in weapon carrying as well as the relative contributions of genetics, shared environment, and nonshared environment. Data are obtained from the first two waves of the National Longitudinal Study of Adolescent to Adult Health and analyzed using biometrical genetic models for twins and actor-partner interdependence models for nontwins. Results indicate little, if any, contribution stemming from genetics. There is also no evidence of a significant shared environment effect. Instead, all or nearly all of the variation and similarity in weapon carrying among siblings are related to the nonshared environment, particularly gang affiliation. Implications and possible extensions of these findings are discussed.

Friendships Lost: The Social Consequences of Violent Victimization.

Few studies have examined the impact of violent victimization on friendship networks. This study used two waves of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine the effects of violent victimization on number peer- and self-reported friendships. Guided by stigma theory (Goffman, 1963), fixed-effect regression models controlling for depression, delinquency, substance use, and school engagement were completed to predict changes in number of friends following victimization. Consistent with the theory, results indicate that experiencing violent victimization (e.g., jumped, stabbed, shot at) was associated with a decrease in number of friends. These effects were magnified for females and for individuals with a greater number of depressive symptoms. These results were consistent even when models were run separately for each individual type of victimization. Treatment and prevention implications are discussed.

Armed Kids, Armed Adults? Weapon Carrying From Adolescence to Adulthood.

While much existing research has examined either juvenile or adult weapon carrying, this study assesses whether carrying a weapon to school as a juvenile is predictive of bringing a handgun to school or work in adulthood. Data are drawn from the National Longitudinal Study of Adolescent Health. Results show a decline in weapon carrying behavior over time. However, youth who report school weapon carrying in adolescence are much more likely to report carrying a handgun to school or work in adulthood. Findings also demonstrate that victimization, rather than offending behavior, is predictive of adulthood handgun carrying at school and work.

American preferences for "smart" guns versus traditional weapons: Results from a nationwide survey.

This study examines Americans' preferences regarding smart guns. The study builds on prior research by including previously unexamined factors, specifically victimization and comfort sharing gun ownership status with a doctor. Further, this study examines differences in preference patterns among gun owners and non-owners. Data were obtained from a nationwide online survey with 524 respondents in February 2016. The study finds that, among non-owners, older respondents and those with pro-gun attitudes are less likely to prefer smart guns to traditional firearms. Among gun owners, those with moderate political views, those with a history of victimization, and those residing in the Northeast are all more likely to prefer smart guns. Males and those with pro-gun attitudes are less likely to prefer smart guns. Education, income, race, marital status, presence of children in the home, and comfort discussing gun ownership with a doctor had no significant association with smart gun preference. Practical implications of these findings are discussed.

Sibling popularity: A moderator of sibling influence for adolescent substance use.

Sibling substance use is a known correlate of adolescent substance use. Yet, not all siblings are equally influential. Sibling influence has been found to vary by age gap, sex, and birth order. Little research, however, has investigated whether siblings' peer context is also a source of variation. The present study tested whether more popular siblings were more influential for adolescent use of cigarettes, alcohol, and marijuana. Data were obtained from sibling pairs in the National Longitudinal Study of Adolescent Health. Findings indicate that older siblings have more influence on younger sibling marijuana use when they have more friends. These findings contribute to prior work examining which siblings are more influential and highlight the need to consider siblings as part of a greater peer context.

Friendship group position and substance use.

This paper examines how an adolescent's position relative to cohesive friendship groups in the school-wide social network is associated with alcohol, tobacco, and marijuana use. We extend prior research in this area by refining the categories of group positions, using more extensive friendship information, applying newer analytic methods to identify friendship groups, and making strategic use of control variables to clarify the meaning of differences among group positions. We report secondary analyses of 6th through 9th grade data from the PROSPER study, which include approximately 9500 adolescents each year from 27 school districts and 368 school grade cohort friendship networks. We find that core members of friendship groups were more likely to drink than isolates and liaisons, especially in light of their positive social integration in school, family, and religious contexts. Isolates were more likely to use cigarettes than core members, even controlling for all other factors. Finally, liaisons were more likely to use marijuana than core members.

Peers and the Emergence of Alcohol Use: Influence and Selection Processes in Adolescent Friendship Networks.

This study addresses not only influence and selection of friends as sources of similarity in alcohol use, but also peer processes leading drinkers to be chosen as friends more often than non-drinkers, which increases the number of adolescents subject to their influence. Analyses apply a stochastic actor-based model to friendship networks assessed five times from 6th through 9th grades for 50 grade cohort networks in Iowa and Pennsylvania, which include 13,214 individuals. Results show definite influence and selection for similarity in alcohol use, as well as reciprocal influences between drinking and frequently being chosen as a friend. These findings suggest that adolescents view alcohol use as an attractive, high status activity and that friendships expose adolescents to opportunities for drinking.

Lack of a pharmacokinetic interaction between steady-state tipranavir/ritonavir and single-dose valacyclovir in healthy volunteers.

OBJECTIVE: This study assessed the single-dose pharmacokinetics of the herpes antiviral acyclovir (administered as the pro-drug valacyclovir) alone and in combination with twice-daily 200 mg ritonavir-boosted tipranavir (500 mg) at steady state. METHODS: The study was an open label, one-sequence cross-over pharmacokinetic study in HIV-negative adults. Plasma drug concentrations were measured by validated LC/MS/MS assays; pharmacokinetics (AUC, C(max)) were determined using noncompartmental methods. The geometric mean ratio and 90% confidence interval [GMR, 90% CI] were used to evaluate the drug interaction. RESULTS: Twenty-six of 29 subjects completed the trial. With steady-state tipranavir/ritonavir, acyclovir C(max) decreased 4.9% [0.95, 0.88-1.02] and AUC increased 6.6% [1.07, 1.04-1.09]. The majority of subjects experienced at least one adverse event, most of which were mild gastrointestinal disorders. Three subjects discontinued tipranavir/ritonavir treatment as a result of drug-related increases in ALT/AST, including one subject who experienced mild upper abdominal pain. All subjects recovered without sequelae. CONCLUSIONS: When administered as a single dose of valacyclovir with steady-state tipranavir/ritonavir, there were no clinically important changes in acyclovir pharmacokinetics. This result indicates that valacyclovir can be co-administered safely with no dose adjustments.