A prospective cohort study of factors associated with the digital cushion thickness in dairy cattle.

Key factors such as stage of lactation, parity, and body fat reserves have been associated with the digital cushion thickness (DCT), however, there are discrepancies between the results of previously published studies. The objective of this study was to examine the association of stage of lactation, body fat reserves, parity, and lesion incidence with DCT in a large cohort of intensively monitored cows. Across 4 UK farms, 2,352 cows were prospectively enrolled and assessed at 4 time points: before calving (T1-Precalving), immediately after calving (T2-Calving), in early lactation (T3-Early), and in late lactation (T4-Late). At each time point, BCS was recorded, the presence of sole lesions (sole ulcers and sole hemorrhage) and white line lesions was assessed by veterinarians, and an ultrasound image was taken to retrospectively measure the backfat thickness (BFT) in the pelvic region and the digital cushion on the hind left lateral claw. Mixed effects multivariable linear regression models, with the cow as a random effect, were fit to examine the association between the explanatory variables and DCT. The explanatory variables tested were farm, parity, stage of lactation, BCS, BFT, height, the presence of a lesion at the time of measurement, the chronicity of a lesion during early lactation, the predicted maximum daily milk yield, and the rate of milk production rise in early lactation. Stage of lactation and farm were both associated with DCT; however, an interaction was present, and this DCT pattern of change was farm-dependent. Two distinct patterns emerged; one indicated the nadir to occur shortly after calving, the other indicated the nadir to occur during early lactation. Neither BFT nor BCS were significantly associated with DCT. Heifers displayed thinner digital cushions compared with multiparous cows; however, this effect was dependent on the stage of lactation, with heifers having a thinner digital cushion up until late lactation, by which time DCT was commensurate with multiparous animals. Sole lesions and white line lesions at the time of measurement were associated with DCT (sole lesion: estimate = -0.07 mm, 95% CI = -0.14-0.00; white line lesion: estimate = 0.28 mm, 95% CI = 0.15-0.42).

Dynamics of sputum conversion during effective tuberculosis treatment: A systematic review and meta-analysis.

BACKGROUND: Two weeks' isolation is widely recommended for people commencing treatment for pulmonary tuberculosis (TB). The evidence that this corresponds to clearance of potentially infectious tuberculous mycobacteria in sputum is not well established. This World Health Organization-commissioned review investigated sputum sterilisation dynamics during TB treatment. METHODS AND FINDINGS: For the main analysis, 2 systematic literature searches of OvidSP MEDLINE, Embase, and Global Health, and EBSCO CINAHL Plus were conducted to identify studies with data on TB infectiousness (all studies to search date, 1 December 2017) and all randomised controlled trials (RCTs) for drug-susceptible TB (from 1 January 1990 to search date, 20 February 2018). Included articles reported on patients receiving effective treatment for culture-confirmed drug-susceptible pulmonary TB. The outcome of interest was sputum bacteriological conversion: the proportion of patients having converted by a defined time point or a summary measure of time to conversion, assessed by smear or culture. Any study design with 10 or more particpants was considered. Record sifting and data extraction were performed in duplicate. Random effects meta-analyses were performed. A narrative summary additionally describes the results of a systematic search for data evaluating infectiousness from humans to experimental animals (PubMed, all studies to 27 March 2018). Other evidence on duration of infectiousness-including studies reporting on cough dynamics, human tuberculin skin test conversion, or early bactericidal activity of TB treatments-was outside the scope of this review. The literature search was repeated on 22 November 2020, at the request of the editors, to identify studies published after the previous censor date. Four small studies reporting 3 different outcome measures were identified, which included no data that would alter the findings of the review; they are not included in the meta-analyses. Of 5,290 identified records, 44 were included. Twenty-seven (61%) were RCTs and 17 (39%) were cohort studies. Thirteen studies (30%) reported data from Africa, 12 (27%) from Asia, 6 (14%) from South America, 5 (11%) from North America, and 4 (9%) from Europe. Four studies reported data from multiple continents. Summary estimates suggested smear conversion in 9% of patients at 2 weeks (95% CI 3%-24%, 1 single study [N = 1]), and 82% of patients at 2 months of treatment (95% CI 78%-86%, N = 10). Among baseline smear-positive patients, solid culture conversion occurred by 2 weeks in 5% (95% CI 0%-14%, N = 2), increasing to 88% at 2 months (95% CI 84%-92%, N = 20). At equivalent time points, liquid culture conversion was achieved in 3% (95% CI 1%-16%, N = 1) and 59% (95% CI 47%-70%, N = 8). Significant heterogeneity was observed. Further interrogation of the data to explain this heterogeneity was limited by the lack of disaggregation of results, including by factors such as HIV status, baseline smear status, and the presence or absence of lung cavitation. CONCLUSIONS: This systematic review found that most patients remained culture positive at 2 weeks of TB treatment, challenging the view that individuals are not infectious after this interval. Culture positivity is, however, only 1 component of infectiousness, with reduced cough frequency and aerosol generation after TB treatment initiation likely to also be important. Studies that integrate our findings with data on cough dynamics could provide a more complete perspective on potential transmission of Mycobacterium tuberculosis by individuals on treatment. TRIAL REGISTRATION: Systematic review registration: PROSPERO 85226.

Gender and ethnic differences in rates of immune reconstitution, AIDS diagnosis, and survival.

In this work, we use 2011-2013 Texas HIV surveillance data (N=2,175) and apply hierarchical linear and Cox regression modeling to characterize the association of gender and race/ethnicity with rate of immune recovery and determine whether immune recovery contributes to gender and racial/ethnic disparities in AIDS diagnosis and survival. The associations between gender and rate of immune recovery and between race/ethnicity and rate of immune recovery were not statistically significant (p > 0.05). In the multivariate survival analyses, there was no statistically significant association between gender and AIDS diagnosis (Adjusted Hazard Ratio (AHR) = 1.06, p = 0.61, 95%=0.85-1.32) and between race/ethnicity and AIDS diagnosis (Blacks vs Whites: AHR = 1.10, p = 0.24, 95% CI = 0.94-1.30; Hispanics vs Whites: AHR = 1.06, p = 0.46, 95% CI = 0.91-1.24). Similarly, there were no statistically significant associations with death (males vs females: AHR = 0.88, p = 0.73, 95% CI = 0.43-1.81; Blacks vs Whites: AHR = 0.68 p = 0.25, 95% CI = 0.36-1.30; Hispanics vs Whites: AHR = 0.96, p = 0.88, 95% CI = 0.55-1.67). However, the direction of the point estimates were in the reverse direction when compared to the rate of immune recovery or the AIDS diagnosis models. Our findings suggest that differences in rate of immune recovery may better explain disparities in AIDS diagnosis than disparities in survival. Future studies with longer follow-up may potentially generate statistically significant results.

Impact of emergency department opioid use on future health resource utilization among patients with migraine.

OBJECTIVE: The purpose of this study was to evaluate the subsequent health resource utilization (HRU) between patients with migraine who received opioid medications at their emergency department (ED) visits ("opioid recipients") versus patients with migraine who did not receive opioid medications at their ED visits ("non-recipients"). BACKGROUND: Previous studies have found that opioid use is common among patients with migraine at emergency settings. Medication overuse, especially the use of opioids, is associated with migraine progression, which can ultimately lead to substantial health resource use and costs. There is limited evidence on opioid use specifically in emergency settings and its impact on future HRU among people with migraine. METHOD: This retrospective cohort study used electronic health record data from the Baylor Scott & White Health between December 2013 and April 2017. Adult patients who had at least 6 months of continuous enrollment before (baseline or pre-index) and after (follow-up) the first date they had an ED visit with a diagnosis of migraine (defined as index date) were enrolled in the study. Opioid use and HRU during follow-up period between opioid recipients and non-recipients were summarized and compared. RESULTS: A total of 788 patients met the eligibility criteria and were included in this study. During the 6-month follow-up period, compared to patients with migraine who were non-recipients at their index ED visits, opioid recipients had significantly more all-cause (3.6 [SD = 6.3] vs. 1.9 [SD = 4.8], p < 0.0001) and migraine-related (1.6 [SD = 4.2] vs. 0.6 [SD = 2.1], p < 0.0001) opioid prescriptions (RXs), and more all-cause (2.6 [SD = 4.3] vs. 1.6 [SD = 2.6], p = 0.002) and migraine-related (0.6 [SD = 1.4] vs. 0.3 [SD = 0.8], p = 0.001) ED visits. In addition, opioid recipients had higher risk of future migraine-related ED visits controlling for covariates (HR = 1.49, 95% CI = 1.09-2.03, p = 0.013). Factors that were significantly (p < 0.05) related to future migraine-related ED visits include previous opioid use (HR = 2.12, 95% CI = 1.24-3.65, p = 0.007), previous ED visits (HR = 2.38, 95% CI = 1.23-4.58, p = 0.010), hypertension (HR = 1.46, 95% CI = 1.07-2.00, p = 0.017), age between 45 and 64 years (HR = 0.68, 95% CI = 0.48-0.97, p = 0.033), female sex (HR = 1.82, 95% CI = 1.12-2.86, p = 0.015), and tobacco use disorder (HR = 1.45, 95% CI = 1.07-1.97, p = 0.017). Sub-analyses were restricted to the group of patients who were opioid naïve at baseline (n = 274, defined as having ≤1 opioid RXs during the 6-month pre-index period). Patients who were baseline opioid naïve but received opioids during their index ED visits were more likely to have future migraine-related ED visits compared to patients who were baseline opioid naïve and did not receive any opioids during their index ED visits, controlling for covariates (HR = 2.90, 95% CI = 1.54-5.46, p = 0.001). CONCLUSION: Opioid use among patients with migraine presenting to the ED is associated with increased future HRU, which highlights the need for optimizing migraine management in emergency settings.

Patterns and predictors of opioid use among migraine patients at emergency departments: A retrospective database analysis.

OBJECTIVES: To compare medication use and health resource utilization between migraineurs with evidence of opioid use at emergency department visit versus no opioid use at emergency department visit, and to examine predictors of opioid use among migraineurs at emergency department visits. METHODS: This was a retrospective study using REACHnet electronic health records (December 2013 to April 2017) from Baylor Scott & White Health Plan. The index date was defined as the first migraine-related emergency department visit after ≥6 months of enrollment. Adult patients with a migraine diagnosis and ≥6 months of continuous enrollment before and after their index dates were included. Descriptive statistics and bivariate analyses were used to compare medication use and health resource utilization between opioid users and non-opioid users. Multivariable logistic regression was used to examine predictors of opioid use at emergency department visits. RESULTS: A total of 788 migraineurs met eligibility criteria. Over one-third (n = 283, 35.9%) received ≥1 opioid medication during their index date emergency department visit. Morphine (n = 103, 13.1%) and hydromorphone (n = 85, 10.8%) were the most frequently used opioids. Opioid users had more hospitalizations and emergency department visits during their pre-index period (both p < 0.05). Significant (p < 0.05) predictors of opioid use at emergency department visits included past migraine-related opioid use (2-4 prescriptions, Odds Ratio = 1.66; 5-9 prescriptions, Odds Ratio = 2.12; ≥10 prescriptions, Odds Ratio = 4.43), past non-migraine-related opioid use (≥10 prescriptions, Odds Ratio = 1.93), past emergency department visits (1-3 visits, Odds Ratio = 1.84), age (45-64 years, Odds Ratio = 1.45), and sleep disorder (Odds Ratio = 1.43), controlling for covariates. CONCLUSION: Opioids were commonly given to migraineurs at emergency departments. Previous opioid use, health resource utilization, age, and specific comorbidities might be used to identify migraineurs with a high risk of opioid use.

Rhabdomyolysis Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System (FAERS).

Introduction: Daptomycin, macrolides, trimethoprim-sulfamethoxazole, linezolid, fluoroquinolones, and cefdinir are known to be associated with rhabdomyolysis. Other antibiotics may also lead to rhabdomyolysis, but no study has systemically compared rhabdomyolysis associations for many available antibiotics. Objectives: The objective of this study was to evaluate the association between rhabdomyolysis and many available antibiotics using the FDA Adverse Event Report System (FAERS). Methods: FAERS reports from January 1, 2004 to December 31, 2017 were included in the study. The Medical Dictionary for Regulatory Activities (MedDRA) was used to identify rhabdomyolysis cases. Reporting Odds Ratios (RORs) and corresponding 95% confidence intervals (95%CI) for the association between antibiotics and rhabdomyolysis were calculated. An association was considered statistically significant when the lower limit of the 95%CI was greater than 1.0. Results: A total of 2,334,959 reports (including 7,685 rhabdomyolysis reports) were considered, after inclusion criteria were applied. Daptomycin had the greatest proportion of rhabdomyolysis reports, representing 5.5% of all daptomycin reports. Statistically significant rhabdomyolysis RORs (95% CI) for antibiotics were (in descending order): daptomycin 17.94 (14.08-22.85), cefditoren 8.61 (3.54-20.94), cefaclor 7.16 (2.28-22.49), erythromycin 5.93 (3.17-11.10), norfloxacin 4.50 (1.44-14.07), clarithromycin 3.95 (2.77-5.64), meropenem 3.19 (1.51-6.72), azithromycin 2.94 (1.96-4.39), cefdinir 2.84 (1.06-7.62), piperacillin-tazobactam 2.61 (1.48-4.61), trimethoprim-sulfamethoxazole 2.53 (1.52-4.21), linezolid 2.49 (1.47-4.21), ciprofloxacin 2.10 (1.51-2.92). Conclusions: This study confirms prior evidence for rhabdomyolysis associations with daptomycin, macrolides, trimethoprim-sulfamethoxazole, linezolid, fluoroquinolones, and cefdinir. This study also identifies previously unknown rhabdomyolysis associations with meropenem, cefditoren, cefaclor, and piperacillin-tazobactam.

Patterns of antiepileptic drug use in patients with potential refractory epilepsy in Texas Medicaid.

OBJECTIVES: Antiepileptic drug (AED) monotherapy is usually effective in 60% of the patients with epilepsy while the remaining patients have refractory epilepsy. This study compared treatment patterns (adherence, persistence, addition, and switching) associated with refractory and nonrefractory epilepsy. METHODS: Texas Medicaid claims from 09/01/07-12/31/13 were analyzed, and patients eligible for the study 1) were between 18 and 62 years of age, 2) had a prescription claim for an AED during the identification period (03/01/08-12/31/11) with no prior baseline AED use (6-month), and 3) had evidence of epilepsy diagnosis within 6 months of AED use. Based on AED use in the identification period, patients were categorized into "refractory" (≥3AEDs) and "nonrefractory" (<3AEDs) cohorts. The index date was the date of the first AED claim. Patients in both cohorts were matched 1:1 using propensity scoring and compared for adherence (proportion of days covered (PDC) ≥80% vs. <80%), persistence, addition (yes/no), and switching (yes/no) using multivariate conditional regression models. Conditional logistic regression and Cox proportional hazard models were used to address the study objectives. RESULTS: Of the 10,599 eligible patients, 2798 (26.5%) patients in the refractory cohort were matched to patients in the nonrefractory cohort. Patients in the refractory cohort had significantly higher (p < 0.005) mean (±Standard deviation (SD)) adherence (88.6% (±19.1%) vs. 77.0% ±â€¯(25.8%)) and persistence (328.0 (±87.3) days vs. 294.9 ±â€¯(113.4) days) as compared with patients in the nonrefractory cohort. Compared with patients with nonrefractory epilepsy, patients with refractory epilepsy were 3.6 times (odds ratio (OR) = 3.553; 95% confidence interval (CI) = 3.060-4.125; p < 0.0001) more likely to adhere to AEDs and had a 34.7% (hazard ratio (HR) = 0.653; 95% CI = 0.608-0.702; p < 0.0001) lower hazard rate of discontinuation of AEDs. Also, patients with refractory epilepsy were 3.7 times (OR = 3.723; 95% CI = 2.902-4.776; p < 0.0001) more likely to add an alternative AED and 3.6 times (OR = 3.591; 95% CI = 3.010-4.284; p < 0.0001) more likely to switch to an alternative AED. CONCLUSION: Patients with refractory epilepsy were significantly more likely to adhere and persist to AED regimen and were significantly more likely to add and switch to an alternative AED than patients with nonrefractory epilepsy.

Clinical protocol selection for alveolar ridge augmentation at sites exhibiting slight, moderate, and severe horizontal ridge deficiencies.

FOCUSED CLINICAL QUESTION: What factors identify the optimal bone augmentation techniques for managing slight, moderate, and severe horizontal alveolar ridge deficiency (ARD) at dental implant sites? SUMMARY: Horizontal ARD is a concern at a high proportion of sites receiving dental implants, and clinicians have developed a variety of surgical procedures to address such defects. In a particular case, selection of the optimal treatment may depend predominantly on defect severity, location (anterior versus posterior), and configuration (contained versus noncontained). This report provides a framework for selecting an augmentation method when presented with a slight, moderate, or severe horizontal ARD at a site requiring dental implant placement. CONCLUSION: Multiple treatment options are available for planned implant sites exhibiting horizontal ARD; severe posterior and slight anterior defects intuitively call for different approaches. Although rigid guidelines for selecting the optimal augmentation method do not exist, some techniques are poorly suited for esthetically demanding sites. A framework considering defect severity, location, and configuration may help guide clinical decisions on this topic.

Effect of social influences on pharmacists' intention to report adverse drug events.

OBJECTIVES: To identify the groups or individuals that influence pharmacists' decision making to report adverse drug events (ADEs), determine the differences in social influence or subjective norm between intenders and nonintenders, and determine the relationship between subjective norm toward reporting serious ADEs and practice and demographic characteristics. DESIGN: Nonexperimental cross-sectional study. SETTING: Texas during June and July 2009. PARTICIPANTS: 1,500 Texas pharmacists. INTERVENTION: As part of a larger survey, 3 and 18 items were used to assess pharmacists' intentions and subjective norm, respectively, to report serious ADEs to the Food and Drug Administration (FDA). MAIN OUTCOME MEASURE: Pharmacists' subjective norm toward reporting serious ADEs. RESULTS: The survey had a response rate of 26.4% (n = 377). Most pharmacists intended to report serious ADEs that they would encounter (15.87 ± 4.22 [mean ± SD], possible range 3-21, neutral = 12). The mean subjective norm scores were moderately high and positive (28.75 ± 9.38, 1-49, 16), indicating that the referents had a moderate influence on pharmacists regarding reporting serious ADEs to FDA. FDA had the greatest (34.82 ± 12.16) and drug manufacturers the lowest (21.55 ± 13.83) social influence. The most important salient referents (important others) in pharmacists' decisions to report serious ADEs were FDA, patients, pharmacy associations, pharmacy managers/bosses, and hospitals and hospital groups. Gender (female equals higher), pharmacists' years of experience (negative correlation), and knowledge of ADE reporting (positive correlation) were associated with subjective norm. CONCLUSION: Pharmacists had a moderately high subjective norm, suggesting that ADE reporting intentions is influenced by others and that the opinions of others are of great importance in pharmacists' intentions regarding ADE reporting. The main drivers of subjective norm were FDA, patients, pharmacy associations, and managers/bosses.

Pharmacist reporting of serious adverse drug events to the Food and Drug Administration.

OBJECTIVE: To identify barriers to and facilitators of pharmacist reporting of serious adverse drug events (ADEs) to the Food and Drug Administration (FDA). METHOD: Two focus groups consisting of practicing pharmacists were held in Austin, TX, in 2009. The following open-ended questions were used in the focus groups: (1) What do you think would make it easier to report serious ADEs to the FDA? (2) What do you think would make it more difficult to report serious ADEs to the FDA? A content analysis was performed on the generated transcripts. RESULTS: 13 pharmacists practicing in hospital and community settings in Texas participated. Pharmacists identified 27 barriers to and facilitators of reporting serious ADEs to FDA. Lack of patients' complete medical histories and lack of time were the barriers most frequently cited. Knowledge and awareness of ADEs and ADE reporting emerged as important factors that would facilitate reporting serious ADEs to FDA. CONCLUSION: These findings highlight the factors that facilitate and/or inhibit pharmacist reporting of serious ADEs to FDA. Improved knowledge of ADEs and ADE reporting would facilitate reporting behaviors, while lack of time, lack of complete patient medical histories, and lack of compensation issues serve as important barriers to reporting. Interventions are needed to address these factors.

Influence of attitudes on pharmacists' intention to report serious adverse drug events to the Food and Drug Administration.

AIM: To investigate the influence of pharmacists' attitudes on intention to report serious adverse drug events (ADEs) to the Food and Drug Administration (FDA). METHODS: This cross-sectional study used a mail survey to collect data from hospital and community pharmacists practicing in Texas, United States. Three and 16 items were used to measure intention and attitudes, respectively, using a seven-point bipolar scale. Pharmacists' demographic and practice characteristics, and past reporting were also measured. RESULTS: The response rate was 26.4% (n= 377/1500 pharmacists). Most pharmacists intended (n= 297, 78.8%) to report serious ADEs that they will encounter to the FDA through MedWatch. Overall, pharmacists held favourable attitudes towards reporting serious ADEs (mean = 24.5, SD = 6.7, possible range 1-49, neutral = 16). Pharmacists intending to report serious ADEs had more favourable attitudes than those who did not (P < 0.001). About 90% of the pharmacists believed that reporting serious ADEs would improve patient safety. However, 72.6% indicated that reporting serious ADEs was time consuming and over half (55.5%) of the respondents believed that reporting serious ADEs disrupted the normal workflow. Non-intenders held stronger beliefs that ADE reporting would disrupt the normal workflow and was time consuming compared with intenders. Years of experience, number of hours worked and practice setting were associated with pharmacists' attitudes towards reporting (P < 0.05). CONCLUSIONS: Most pharmacists held moderately favourable attitudes and high intentions toward reporting serious ADEs to the FDA. This study's findings contribute to an increased understanding of individual factors that influence pharmacists' attitude and intention towards reporting serious ADEs to the FDA.

Texas pharmacists' knowledge of reporting serious adverse drug events to the Food and Drug Administration.

OBJECTIVES: To assess Texas pharmacists' knowledge of adverse drug event (ADE) reporting to the Food and Drug Administration (FDA) and to determine demographic and practice characteristics associated with this knowledge. DESIGN: Cross-sectional descriptive study. SETTING: Austin, TX, in June and July 2009. PARTICIPANTS: 377 pharmacists practicing in hospital and community settings. INTERVENTION: Survey instrument mailed to participants. MAIN OUTCOME MEASURES: Scores on an eight-item test were used to assess pharmacists' knowledge about ADE reporting to FDA. Pharmacists' demographic and practice characteristics, as well as past reporting, were also measured. RESULTS: 1,500 surveys were mailed and 377 usable responses were obtained (26.4% response rate). Most (67.9%) pharmacists had never reported ADEs to FDA. A majority of pharmacists (65.7%) reported having inadequate knowledge about ADE reporting. Pharmacists had low knowledge scores on ADE reporting, and the pass rate for all items ranged from 56.7% to 96.0%. Pharmacists' age (r = -0.106, P = 0.042) and years of experience (-0.134, P = 0.010) were negatively correlated with knowledge levels, whereas hours worked by pharmacists was positively correlated with knowledge levels (0.130, P = 0.012). Mean knowledge levels differed by practice setting, job title, and area/setting of primary place of employment (P < 0.001). CONCLUSION: Texas pharmacists have knowledge gaps concerning ADE reporting to FDA. Pharmacists need more education, awareness, and training on ADE reporting, especially regarding reportable ADEs, how to report, and what constitutes a good report.

Identifying subgroups within at-risk populations that drive late HIV diagnosis in a Southern U.S. state.

We aimed to identify subgroups within age, racial/ethnic, and transmission categories that drive increased risk for late HIV diagnosis (LHD).A 1996-2013 retrospective study of HIV-diagnosed individuals (N = 77,844) was conducted. The proportion of individuals with LHD (AIDS diagnosis within 365 days of HIV diagnosis) was determined, stratified by age, race/ethnicity, and transmission category. Logistic regression with interaction terms was used to identify groups/subgroups at risk for LHD during 1996-2001, 2002-2007, and 2008-2013.Respectively, 78%, 27%, 38%, and 31% were male, White, Black, and Hispanic. Overall, 39% had LHD with a 6.7% reduction for each year increase (OR = 0.93, 95% CI = 0.93-0.94, p < 0.01). Older age was significantly associated with increased odds of LHD (OR range = 1.90-4.55). Compared to their White counterparts, all Hispanic transmission categories (OR range = 1.31-2.58) and only Black female heterosexuals and men who have sex with men (MSM) (OR range = 1.14-1.33) had significantly higher odds of LHD during 1996-2001 and/or 2002-2007. Significance was limited to Hispanic MSM (all age categories), MSM/IDUs (30-59 years), and heterosexuals (18-29 years) and Black MSM (30-39 years) during 2008-2013.Older individuals and Hispanics (driven by MSM) are at increased risk for LHD. HIV testing interventions directed at seniors and Hispanic MSM can further reduce rates of LHD.

Efavirenz versus Protease Inhibitors in Patients with HIV: A Systematic Review and Meta-Analysis

Efavirenz- and protease inhibitor (PI)-based regimens remain viable options across the globe. We conducted a meta-analysis to compare the effectiveness of efavirenz-based regimens relative to PI-based regimens. EMBASE, PubMed, Cochrane, and clinicaltrials.gov were searched for randomized controlled trials conducted between 1987 and 2018 comparing efavirenz- with PI-based regimens. This was followed by title, abstract, and full-text screens. The quality of selected studies was assessed using the Cochrane risk of bias tool. Meta-analysis of the odds of virological suppression was conducted using the robust variance estimation approach. Fifteen studies met the inclusion criteria and totaled 6712 patients (efavirenz arm = 3339; PI arm = 3373), of which 1610 (24.0%) were females. Follow-up ranged from 24 to 144 weeks. Mean/median age ranged from 33 to 44 years. Mean/median baseline CD4 count ranged from 32 to 557 cells/mL while mean/median baseline viral load ranged from log10 4.5 to log10 5.5 copies/mL. Meta-analysis showed that patients receiving efavirenz-based regimens had 37% higher odds of virological suppression compared to PI-based regimens (odds ratio = 1.37, 95% confidence interval = 1.06-1.77, p = 0.02). The Egger test suggested the presence of publication bias (B = 0.927, t = 2.214, p = 0.033). The main threat to the quality of evidence was attrition bias. Regarding virological suppression, efavirenzbased regimens were more effective than PI-based regimens and, therefore, might be ideal for the management of treatment naïve patients with HIV in settings where NNRTIs and PIs are used.

The Tissue-Supported Sling Suture: Technique and Clinical Applications.

INTRODUCTION: Continuous and interrupted sling sutures (ISSs) are used around teeth in contemporary periodontics. However, conventional ISSs depend upon favorable tooth morphology for stability through the early healing period. The purpose of this report is to present a variation of the classic ISS that does not rely on favorable tooth morphology. CASE SERIES: Tissue-supported sling sutures (TSSs) were used for six patients undergoing root coverage, gingival augmentation, or pontic site development (guided bone regeneration) procedures. CONCLUSIONS: Although techniques such as vertical mattress suturing may support greater coronal flap advancement, the TSS technique does maintain coronal flap position while minimizing trauma to papillae. TSS stability is independent of tooth morphology and may offer clinicians flexibility in achieving reliable closure over hard and soft tissue implants. Like mattress sutures, TSSs reduce tension at the crestal incision line in tissue grafting procedures.

Association between quality-of-care indicators for HIV infection and healthcare resource utilization and costs.

OBJECTIVES: Multiple care quality indicators for HIV infection exist but few studies examine their impact on health outcomes. This study assessed which HIV care quality indicators were associated with healthcare resource utilization and costs. DESIGN: Retrospective analysis of Texas Medicaid claims data (01 January 2012 to 31 September 2016). METHODS: Included patients had at least two HIV-related medical claims during the identification period (01 July 2012 to 31 August 2014) (index = date of first HIV claim), were 18-62 years at index, and were continuously enrolled in the 6-month pre-index and 1-year post-index periods. Dependent variables included emergency department (ED) visits, inpatient hospitalizations, prescription count, and all-cause healthcare costs. Independent variables included CD4 cell count monitoring, syphilis, chlamydia, gonorrhea, hepatitis B, hepatitis C, and tuberculosis screenings, influenza and pneumococcal vaccinations, retention in care, and HAART initiation. Covariates included age, chronic hepatitis C virus infection, AIDS diagnosis, sex, and baseline healthcare cost. The study objective was addressed using generalized linear modeling. RESULTS: CD4 cell count monitoring and HAART initiation were significantly associated with reduced emergency department visits (P < 0.0001 for each). Influenza vaccination was significantly associated with reduced inpatient hospitalization (P < 0.0001). CD4 cell count monitoring (P < 0.0001), TB screening (P = 0.0006), influenza vaccination (P < 0.0001), and HAART initiation (P < 0.0001) were significantly associated with increase prescription claims. CD4 cell count monitoring, TB screening, and HAART initiation (P < 0.0001 for each) were significantly associated with all-cause healthcare costs. CONCLUSION: HAART may reduce use of emergency care services as early as 1 year following initiation.

Fracture necrosis: A risk indicator for tooth loss.

BACKGROUND AND OVERVIEW: The term "fracture necrosis" has been used to describe the condition found in a minimally restored tooth without a history of trauma when the suspected etiology for the loss of pulpal vitality is a crown-originating fracture. Teeth with fracture necrosis have a poor prognosis, and, when accompanied by characteristic radiographic findings, extraction may be considered the primary treatment option. CASE DESCRIPTIONS: Two adult men with crown-originating fractures and suspected fracture necrosis had localized periodontal bone and attachment loss associated with severe pain on mastication from mandibular second molars. In case 1, the patient desired to retain the tooth despite an unfavorable prognosis. Nonsurgical root canal therapy and a crown prolonged tooth survival for only 30 months. The patient in case 2 requested extraction after a thorough review of his dental condition and tooth prognosis. CONCLUSIONS: A tooth with fracture necrosis may continue to harbor virulent microorganisms after root canal therapy. When these microorganisms have access to the periodontal attachment, progressive loss of supporting tissues can be expected. PRACTICAL IMPLICATIONS: When weighing treatment options for teeth with fracture necrosis associated with characteristic radiographic findings, preference toward extraction and tooth replacement, rather than treatment aimed at tooth retention, may represent a sound clinical approach.

Frequency of adequate mesiodistal space and faciolingual alveolar width for implant placement at anterior tooth positions.

BACKGROUND: Prior studies have defined minimum mesiodistal space (MS) and faciolingual alveolar width (FAW) requirements for dental implant sites, and failure to observe these constraints may adversely impact peri-implant health and esthetics. However, to the authors' knowledge, no previous reports have established frequencies at which anterior tooth positions present favorable MS and FAW for implant accommodation. METHODS: A single examiner analyzed 205 cone-beam computed tomographic images, recording MS and FAW available for implant placement at anterior tooth positions. The examiner compared measurements with standardized implant diameters to assess anticipated implant-to-tooth distances and peri-implant bone thicknesses. RESULTS: In the esthetic zone, lateral incisor sites most frequently failed to present favorable MS. At maxillary lateral incisor positions, 22% (left) and 27% (right) of sites offered less than 2 millimeters between the proposed implant platform and the adjacent teeth. In mandibular incisor positions, implant-to-tooth distance was less than 2 mm at 79% through 97% of sites and less than 1.5 mm at 35% through 76% of sites. Over one-half of maxillary incisor sites and 78% through 95% of mandibular incisor sites exhibited FAW of less than 4 mm beyond implant diameter. CONCLUSIONS: In the population evaluated, mandibular incisor positions frequently presented unfavorable MS to accommodate conventional narrow-diameter implants. In addition, considerable proportions of mandibular incisor and maxillary lateral incisor sites may be at risk of developing unfavorable peri-implant bone thickness when conventional narrow-diameter implants are used. PRACTICAL IMPLICATIONS: Practitioners should consider small-diameter implants and nonimplant tooth replacement methods for many patients missing single mandibular incisors or maxillary lateral incisors.

Comparison of Prostaglandin Analog Treatment Patterns in Glaucoma and Ocular Hypertension.

BACKGROUND: Prostaglandin analogs (PGAs) are considered an initial therapy to manage increased intraocular pressure (IOP) for patients with glaucoma. When the initial PGA treatment fails to lower IOP adequately, the patient may add or change medications or have surgery/laser treatment. OBJECTIVE: To compare medication adherence, duration of therapy, and treatment patterns among 3 PGAs-latanoprost, travoprost, and bimatoprost-as initial therapies for patients with glaucoma or ocular hypertension. METHODS: This was a retrospective cohort study using administrative claims data. The cohort consisted of patients newly diagnosed with glaucoma or ocular hypertension with at least 1 prescription claim for latanoprost, travoprost, or bimatoprost and enrolled in a Medicare Advantage plan between 2007 and 2012. The 24-month medication possession ratio (MPR) was used to measure medication adherence. Discontinuation of first-line PGA therapy was defined as nonpersistence (90-day gap allowance) of the index PGA or a change in therapy during the 24-month follow-up period. Types of second-line therapy (i.e., switch, addition, and surgery) were identified. The 1:1:1 propensity score matching was used. RESULTS: Patients who met the inclusion criteria were propensity score matched, resulting in 1,296 patients per PGA group. Latanoprost users showed higher adherence (50.1%) than travoprost (48.8%) and bimatoprost (43.0%) users. The latanoprost and travoprost groups had significantly higher MPRs than bimatoprost (P < 0.0001). The latanoprost group showed significantly longer duration of first-line therapy (372 days) than the bimatoprost group (343 days; P = 0.003) but not the travoprost group (361 days). After controlling for demographic and clinical characteristics, a Cox proportional hazards model showed that the travoprost and bimatoprost groups had a higher risk of discontinuation of first-line therapy than the latanoprost group (P < 0.0001). The percentage of patients continuing on the index PGA without treatment pattern change (i.e., switches, additions, and surgery) was higher for latanoprost users (52.9%) compared with travoprost (39.0%) or bimatoprost users (42.1%; P < 0.001). CONCLUSIONS: Patients who used latanoprost as their initial therapy were more likely to adhere and persist to the index PGA compared with bimatoprost users. The latanoprost group demonstrated a lower risk of discontinuing first-line therapy than the travoprost and bimatoprost groups. The results may assist ophthalmologists in determining the optimal management of this patient population with respect to treatment patterns. DISCLOSURES: No outside funding supported this study. All authors except Heo and Nair are employed by The University of Texas at Austin College of Pharmacy. Heo was with the Health Outcomes Division, The University of Texas at Austin College of Pharmacy during a portion of this study and is employed by Genesis Research. Nair is employed by Humana. The authors have no financial relationships relevant to this article to disclose. This study was presented as a poster at the 2016 International Society for Pharmacoeconomics and Outcomes Research Annual Meeting, May 2016, Washington, DC.

Antipsychotic medication utilization trends among Texas veterans: 1997-2002.

BACKGROUND: An antipsychotic utilization pattern has evolved substantially over the past 20 years or so due to the introduction of the second-generation antipsychotics (SGAs) and the increasing understanding of their adverse effect profile. OBJECTIVE: To understand antipsychotic utilization trends (including monotherapy, antipsychotic switching, and combination therapy) and to investigate factors associated with antipsychotic index medication selection (SGAs vs first-generation antipsychotics [FGAs]) among Texas veterans. METHODS: Data were taken from the Veterans Administration North Texas Health Care System (VANTHCS) and South Texas Veterans Health Care System (STVHCS) from January 1996 to December 2003. Adults with continuous enrollment (1 y before and after the index date) who had newly initiated antipsychotic therapy were included. Prescriptions were followed for up to 12 months. Descriptive analyses examined utilization trends; logistic regression evaluated factors associated with antipsychotic index medication selection. RESULTS: A total of 8096 patients were included in the study (VANTHCS n = 4477; STVHCS n = 3619), with the majority being male (93.6%) and white (62.6%) and nearly half aged 55 years or older (44.1%). Between 1997 and 2002, antipsychotic prescriptions changed from primarily FGAs (1997: 71.7%; 1999: 25.2%; 2002: 5.7%) to SGAs. Over the 6-year time frame, risperidone (31.0%) and olanzapine (30.7%) were most commonly prescribed. The overall combination therapy slightly increased over time (4.3%), switching to another antipsychotic remained stable (14.2%), and antipsychotic monotherapy remained dominant (81.5%). Hispanic and black patients were less likely than white patients to be initiated on SGAs. Patients who were older, had hypertension, and were in STVHCS were less likely to start on SGAs. Patients with dyslipidemia, bipolar disorder, and treatment in recent years were more likely to start on SGAs. CONCLUSIONS: SGAs have replaced FGAs as first-line medications for patients with mental disorders. Race, age, physical comorbidities (ie, dyslipidemia, hypertension), and treatment initiation year were important factors in index medication selection.