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Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use. We conducted a survey (n = 564) between January 2020 to June 2021 in public and private primary care clinics in Texas to study the prevalence and predictors of patients' antibiotic expectations for common symptoms/illnesses. We surveyed Black patients (33%) and Hispanic/Latine patients (47%), and over 93% expected to receive an antibiotic for at least 1 of the 5 pre-defined symptoms/illnesses. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu than private clinic patients. Lack of knowledge of potential risks of antibiotic use was associated with increased antibiotic expectations for diarrhea (odds ratio [OR] = 1.6; 95% CI, 1.1-2.4) and cold/flu symptoms (OR = 2.9; 95% CI, 2.0-4.4). Lower education and inadequate health literacy were predictors of antibiotic expectations for diarrhea. Future antibiotic stewardship interventions should tailor patient education materials to include information on antibiotic risks and guidance on appropriate antibiotic indications. Key words: antibiotic use; antimicrobial stewardship; primary care; antibiotic risks; patient expectations, https://doi.org/10.1370/afm.3161 INTRODUCTION Patients often receive antibiotic prescriptions to treat common viral symptoms/ illnesses, such as respiratory tract infection, (1-6) cold/flu, (7,8) and diarrhea, (9,10) despite guidelines recommending against these practices. [...]

Background: SARS CoV-2 virus (COVID-19) impacted the practice of healthcare in the United States, with technology being used to facilitate access to care and reduce iatrogenic spread. Since then, patient message volume to primary care providers has increased. However, the volume and trend of electronic communications after lockdown remain poorly described in the literature. Methods: All incoming inbox items (telephone calls, refill requests, and electronic messages) sent to providers from patients amongst four primary care clinics were collected. Inbox item rates were calculated as a ratio of items per patient encountered each week. Trends in inbox rates were assessed during 12 months before and after lockdown (March 1st, 2020). Logistic regression was utilized to examine the effects of the lockdown on inbox item rate post-COVID-19 lockdown as compared to the pre-lockdown period. Results: Before COVID-19 lockdown, 2.07 new inbox items per encounter were received, which increased to 2.83 items after lockdown. However, only patient-initiated electronic messages increased after lockdown and stabilized at a rate higher than the pre-COVID-19 period (aRR 1.27, p -value < 0.001). In contrast, prescription refill requests and telephone calls quickly spiked, then returned to pre-lockdown levels. Conclusion: Based on our observations, providers experienced a quick increase in all inbox items. However, only electronic messages had a sustained increase, exacerbating the workload of administrators, staff, and clinical providers. This study directly correlates healthcare technology adoption to a significant disruptive event but also shows additional challenges to the healthcare system that must be considered with these changes. [ABSTRACT FROM AUTHOR]

Background: The SARS CoV-2 virus (COVID-19) and associated lockdown have impacted healthcare practice in the United States. Technology has played an emerging role in providing access to care while also reducing iatrogenic infection amongst patients and providers. This rapid adoption of technology has resulted in unintended consequences. Since COVID-19 lockdown, providers have noticed an increase in the volume of patient messages to request various clinical services from their primary care providers, which has placed further stress on an already overwhelmed healthcare system. However, quantitative information about the volume of electronic messages as a result of the COVID-19 lockdown is lacking. Methods: In one large academic healthcare system, all incoming inbox items (telephone calls, refill requests, and electronic messages) received by providers from patients were retrospectively analyzed between March 1, 2019 and March 31, 2021. Inbox item rates were evaluated as a ratio of items per patient encounters (in person or telemedicine) each week. Trends in inbox rates were assessed during the 12 months before lockdown in March 2020 and 12 months post-lockdown. Logistic regression was utilized to examine effects of post-COVID-19 lockdown on inbox message volume as compared to the pre-lockdown period. Results: There was an increase in total new inbox volume, from 2.07 before COVID lockdown and 2.87 items post-lockdown, although this was not statistically significant. However, the rate of patient-initiated messaging increased dramatically after lockdown and stabilized at a rate higher than pre-COVID-19 pandemic rates (RR 1.27, p-value < 0.001). Prescription refill requests and telephone calls spiked quickly and then returned to pre-pandemic levels. Conclusion: On average, if a provider saw 20 patients per day before COVID-19, they would expect to receive 40 new inbox items per day. Post-COVID they would expect to receive 57 new inbox items per day, with the majority being electronic messages. These messages require additional time that adds to the workload of administrators, staff and clinical providers typically devoted to healthcare responsibilities. Interventions are needed to reduce the amount of time that healthcare providers and staff spend on increasing rates of electronic patient requests., Presenters Jacqueline Hirth, James Langabeer, PhD, EdD, Roger Zoorob, MD, MPH, Michael Hansen, MD, MPH, MS, MPH, [...]

Substance misuse and substance use disorder continue to be major causes of morbidity and mortality, and family physicians are well positioned to provide evidence-based prevention and management for these conditions. Of people 12 years and older, 13% reported using a nonprescribed controlled substance in the past month, and 24% had at least one episode of binge drinking of alcohol, defined as five or more drinks for men and four or more drinks for women on one occasion. Benzodiazepines are used by 12% of the U.S. population. Clinicians should incorporate standardized screening and brief intervention for use of alcohol and other substances into routine care of adult patients, as well as referral to specialized treatment services when indicated. Use of nonstigmatizing, person-first language has been shown to positively affect care for patients with substance use disorders. Alcohol screening and brief intervention have been shown to reduce excessive drinking by 40% in patients at 6 months postintervention. Office-based treatment of alcohol use disorder with medications approved by the U.S. Food and Drug Administration, such as acamprosate and naltrexone, remains underutilized, presenting another opportunity for family physicians to positively affect the health of their patients and communities. With elimination of the X-waiver, any clinician with Schedule III prescriptive authority can treat opioid use disorder with buprenorphine in their office-based practice. Opioid overdose education and naloxone coprescribing are other tools family physicians can employ to combat the overdose crisis. (Am Fam Physician. 2024; 109(5):430–440. Copyright © 2024 American Academy of Family Physicians.) Substance misuse and substance use disorder continue to be major causes of morbidity and mortality, and family physicians are well positioned to provide evidence-based prevention and management for these conditions. Of people 12 years and older, 13% reported using a nonprescribed controlled substance in the past month, and 24% had at least one episode of binge drinking of alcohol, defined as five or more drinks for men and four or more drinks for women on one occasion. Benzodiazepines are used by 12% of the U.S. population. Clinicians should incorporate standardized screening and brief intervention for use of alcohol and other substances into routine care of adult patients, as well as referral to specialized treatment services when indicated. Use of nonstigmatizing, person-first language has been shown to positively affect care for patients with substance use disorders. Alcohol screening and brief intervention have been shown to reduce excessive drinking by 40% in patients at 6 months postintervention. Office-based treatment of alcohol use disorder with medications approved by the U.S. Food and Drug Administration, such as acamprosate and naltrexone, remains underutilized, presenting another opportunity for family physicians to positively affect the health of their patients and communities. With elimination of the X-waiver, any clinician with Schedule III prescriptive authority can treat opioid use disorder with buprenorphine in their office-based practice. Opioid overdose education and naloxone coprescribing are other tools family physicians can employ to combat the overdose crisis. [ABSTRACT FROM AUTHOR]

Background Risk factors for ciprofloxacin or MDR in primary care urine specimens are not well defined. Objectives We created a primary care-specific antibiogram for Escherichia coli isolates from cases with complicated and uncomplicated urinary tract infection (UTI) and evaluated risk factors for ciprofloxacin, trimethoprim/sulfamethoxazole and MDR among Enterobacterales. Methods We conducted a cross-sectional study to determine resistance and risk factors by collecting urine cultures from all patients (≥18 years) presenting with provider-suspected UTI at two primary care, safety-net clinics in Houston, TX, USA between November 2018 and March 2020. Results Among 1262 cultures, 308 cultures grew 339 uropathogens. Patients with Enterobacterales (n  = 199) were mostly female (93.5%) with a mean age of 48.5 years. E. coli was the predominant uropathogen isolated (n  = 187/339; 55%) and had elevated trimethoprim/sulfamethoxazole (43.6%) and ciprofloxacin (29.5%) resistance, low nitrofurantoin (1.8%) resistance, and no fosfomycin resistance. Among E. coli , 10.6% were ESBL positive and 24.9% had MDR. Birth outside the U.S.A. prior (2 year) trimethoprim/sulfamethoxazole resistance, and diabetes mellitus were associated with trimethoprim/sulfamethoxazole resistance. Prior (60 day) fluoroquinolone use, prior ciprofloxacin resistance and both diabetes mellitus and hypertension were strongly associated with ciprofloxacin resistance. Prior fluoroquinolone use and a history of resistance to any studied antibiotic were associated with MDR, while pregnancy was protective. Conclusions We found elevated resistance to UTI-relevant antimicrobials and novel factors associated with resistance; these data can be incorporated into clinical decision tools to improve organism and drug concordance. [ABSTRACT FROM AUTHOR]

The publication of this supplement is funded by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $603,907, with 100 percent funding by the CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, or an endorsement by, the CDC/HHS or the U.S. government. This supplement is brought to you by the AAFP. Journal editors were not involved in the development of this content. [ABSTRACT FROM AUTHOR]

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

Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children eight years and older; there is insufficient evidence to support screening in children younger than eight years. Symptoms of anxiety disorders in children and adolescents are similar to those in adults and can include physical and behavioral symptoms such as diaphoresis, palpitations, and tantrums. Care should be taken to distinguish symptoms of a disorder from normal developmental fears and behaviors, such as separation anxiety in infants and toddlers. Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration. (Am Fam Physician. 2022;106(6):657–664. Copyright © 2022 American Academy of Family Physicians.) Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children eight years and older; there is insufficient evidence to support screening in children younger than eight years. Symptoms of anxiety disorders in children and adolescents are similar to those in adults and can include physical and behavioral symptoms such as diaphoresis, palpitations, and tantrums. Care should be taken to distinguish symptoms of a disorder from normal developmental fears and behaviors, such as separation anxiety in infants and toddlers. Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration. [ABSTRACT FROM AUTHOR]

The Peer Recovery Expansion Project (PREP) was designed to expand outreach and deliver enhanced treatment services via peer-recovery coaches for individuals with substance use disorder (SUD) and limited access to healthcare. PREP was implemented in low-socioeconomic areas with historic challenges to accessing SUD treatment. Services were provided to 153 clients through tailored cultural responsiveness, use of peer-based recovery coaching, and development of a Recovery Support Network. Outcome data were collected using the Government Performance and Reporting Act tool at intake and at 6-month follow-up for coaches and clients. The vast majority of peer-recovery coaches were satisfied with the overall quality of the training and their training experience (96.8%). Around 95% agreed that the training enhanced their skills in the topic area and 93% agreed that the training was relevant to substance use disorder treatment at the 6-month post training survey. Majority of clients were from low-income, minority demographics that had a high prevalence history of incarceration, homelessness, and inconsistent employment. At 6-month follow-up, they reported a 22% increase in stable housing and a 25% increase in full-time/part-time employment/training program enrollment. They also demonstrated a significant decline in reported depression, anxiety, and prescribed medication use at 6-month follow-up when compared to baseline. Clients enrolled in a tailored evidence based peer-led program decreased their psychiatric symptoms and increased their housing stability and employment. Study outcomes support the use of an integrated peer-led support for increasing engagement in care for adults experiencing substance use disorders. [ABSTRACT FROM AUTHOR]

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

Background: Data are sparse about firearm fatalities among Texas schoolchildren. Purpose: Explore firearm fatalities among children ages 5-18 years from 1999 to 2020. Key Methods. We utilized publicly available Multiple Cause of Death Files from the National Center for Health Statistics (NCHS) and International Classification of Diseases (ICD) Codes (10th Edition) Accident (W32-W34), Suicide (X72-X74), Assault (X93-X95), and Undetermined Intent (Y22-Y24) to identify firearm fatality as an underlying or contributory cause. We used Annual Percent Change (APC) as a measure of the magnitude of effect and 95% confidence intervals (CIs), p values, and joinpoint regression analyses to test for statistical significance. Key Results: From 1999 to 2020 there were 4,090 firearm fatalities among Texas school-age children. Following significant declines from 1999 to 2013, firearm fatality rates significantly increased. The APC from 2013-2020 was 12.6 (95% CI 9.7, 15.6 p<0.001). The APCs were statistically significant for boys; non-Hispanic Black, non-Hispanic White, and Hispanic children; residents of Large Central Metropolitan areas, Medium Metropolitan, Large Fringe Metropolitan, and smaller areas; for residents of the Texas-Mexico Border and non-Border areas; and for residents of counties with a military base. From 2013 to 2020, rates were highest among non-Hispanic Black children, followed in order by non-Hispanic White, Hispanic, and Asian and Pacific Islander children. Public Health Significance: There are alarming increases in firearm fatalities among Texas school age children (5-18 years). Analytic epidemiologic studies designed a priori to do so are necessary to test hypotheses generated by these data. In the meanwhile, the data pose clinical and public health challenges. [ABSTRACT FROM AUTHOR]