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Objectives To present a new method for displaying blood utilization data based on analysis of decision time intervals (DTIs). Methods Retrospective study of patients treated in a medical intensive care unit (ICU), surgical ICU, or postcardiac surgery ICU at an academic hospital between January 2018 and June 2023. Each patient's episode of care was divided into a series of DTIs. Transfusions during each time interval were recorded. Results In total, 16,562 patients received 6980 units of plasma and 21,034 units of red blood cells during 111,557 time intervals of care. Patients had international normalized ratio (INR) values ranging from less than 1.0 to more than 4.0. Data on plasma transfusion at different INR values were displayed as the number of transfusion episodes, number of units given, or the proportion of DTIs with transfusion. Clinicians transfused plasma on 1.5% of occasions when the INR was 1.5 or less and on 2.2% of occasions when the INR was less than 2.0. Plasma was transfused without red blood cells in only 0.75% of DTIs. Transfusion practice was statistically different among the 3 ICUs. Conclusions Compared with traditional methods of displaying the results of blood audits, DTI analysis displays information regarding the decision both to transfuse and to not transfuse. Utilization reviews that display data based on decision time analysis reveal clinical practice patterns very different from those suggested by traditional displays of plasma audit data. [ABSTRACT FROM AUTHOR]

Purpose This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2021 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring, and monitoring/medication reconciliation. Articles evaluating at least one step of the MUP were assessed for their usefulness toward practice improvement. Summary A PubMed search was conducted in January 2022 for articles published in calendar year 2021 using targeted Medical Subject Headings (MeSH) keywords, and searches of the table of contents of selected pharmacy journals were conducted, providing a total of 7,178 articles. A thorough review identified 79 potentially practice-enhancing articles: 15 for prescribing/transcribing, 17 for dispensing, 4 for administration, 21 for monitoring, and 22 for monitoring/medication reconciliation. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of their importance within health-system pharmacy. The other articles are listed for further review and evaluation. Conclusion It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful publications. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level. [ABSTRACT FROM AUTHOR]

Background Coronavirus disease 2019 (COVID-19) vaccination has been associated with reduced outpatient antibiotic prescribing among older adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed the impact of COVID-19 vaccination on outpatient antibiotic prescribing in the broader population of older adults, regardless of SARS-CoV-2 infection status. Methods We included adults aged ≥65 years who received their first, second, and/or third COVID-19 vaccine dose from December 2020 to December 2022. We used a self-controlled risk-interval design and included cases who received an antibiotic prescription 2–6 weeks before vaccination (pre-vaccination or control interval) or after vaccination (post-vaccination or risk interval). We used conditional logistic regression to estimate the odds of being prescribed (1) any antibiotic, (2) a typical "respiratory" infection antibiotic, or (3) a typical "urinary tract" infection antibiotic (negative control) in the post-vaccination interval versus the pre-vaccination interval. We accounted for temporal changes in antibiotic prescribing using background monthly antibiotic prescribing counts. Results 469 923 vaccine doses met inclusion criteria. The odds of receiving any antibiotic or a respiratory antibiotic prescription were lower in the post-vaccination versus pre-vaccination interval (aOR,.973; 95% CI,.968–.978; aOR,.961; 95% CI,.953–.968, respectively). There was no association between vaccination and urinary antibiotic prescriptions (aOR,.996; 95% CI,.987–1.006). Periods with high (>10%) versus low (<5%) SARS-CoV-2 test positivity demonstrated greater reductions in antibiotic prescribing (aOR,.875; 95% CI,.845–.905; aOR,.996; 95% CI,.989–1.003, respectively). Conclusions COVID-19 vaccination was associated with reduced outpatient antibiotic prescribing in older adults, especially during periods of high SARS-CoV-2 circulation. [ABSTRACT FROM AUTHOR]

In a retrospective, ecological analysis of US medical claims, visit rates explained more of the geographic variation in outpatient antibiotic prescribing rates than per-visit prescribing. Efforts to reduce antibiotic use may benefit from addressing the factors that drive higher rates of outpatient visits, in addition to continued focus on stewardship. [ABSTRACT FROM AUTHOR]

Purpose We describe the implementation and ongoing maintenance of CYP2C19 and CYP2D6 focused pharmacogenetic (PGx) testing to guide antidepressant and antianxiety medication prescriptions in a large rural, nonprofit health system. Summary Depression and anxiety are common psychiatric conditions. Sanford Health implemented PGx testing for metabolism of cytochrome P450 (CYP) isozymes 2C19 and 2D6 in 2014 to inform prescribing for multiple medications, including antidepressant and antianxiety therapies. As guidelines, genotype to phenotype translation, panel offerings, and other resources are updated, we adapt our approach. We make educational and informational materials available to providers and patients. Pharmacogenomic clinical pharmacists review PGx results with discrete values and provide guidance documentation in the electronic medical record. A robust clinical decision support system is in place to provide interruptive alerts, noninterruptive alerts, and genomic indicators. A referral-based interdisciplinary clinic is also available to provide in-depth education to patients regarding PGx results and implications. Additionally, partnering with our health plan has expanded access to PGx testing for patients with anxiety or depression. Conclusion The implementation and maintenance of Sanford Health's PGx program to guide antidepressant and antianxiety medication use continues to evolve and requires a multipronged approach relying on both human and informatics-based resources. [ABSTRACT FROM AUTHOR]

The article examines the relationship between gabapentin prescriptions and hospitalization rates among U.S. veterans, revealing that gabapentin use is associated with increased odds of hospitalization, regardless of dose. Topics discussed include the patterns of gabapentin prescriptions, the demographic and clinical characteristics of patients prescribed gabapentin, and the potential impact of gabapentin on hospitalization across different age groups.

Blood transfusion remains an important aspect of patient management in visceral leishmaniasis (VL). However, transfusion triggers considered are poorly understood. This review summarises the transfusion practices adopted in VL efficacy studies using the Infectious Diseases Data Observatory VL clinical trials library. Of the 160 studies (1980–2021) indexed in the IDDO VL library, description of blood transfusion was presented in 16 (10.0%) (n=3459 patients) studies. Transfusion was initiated solely based on haemoglobin (Hb) measurement in nine studies, combining Hb measurement with an additional condition (epistaxis/poor health/clinical instability) in three studies and the criteria was not mentioned in four studies. The Hb threshold range for triggering transfusion was 3–8 g/dL. The number of patients receiving transfusion was explicitly reported in 10 studies (2421 patients enrolled, 217 underwent transfusion). The median proportion of patients who received transfusion in a study was 8.0% (Interquartile range: 4.7% to 47.2%; range: 0–100%; n=10 studies). Of the 217 patients requiring transfusion, 58 occurred before VL treatment initiation, 46 during the treatment/follow-up phase and the time was not mentioned in 113. This review describes the variation in clinical practice and is an important initial step in policy/guideline development, where both the patient's Hb concentration and clinical status must be considered. [ABSTRACT FROM AUTHOR]

Purpose To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2024 in the United States, with a focus on the nonfederal hospital and clinic sectors. Methods Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2024 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2024 were based on a combination of quantitative analyses and expert opinion. Results In 2023, overall pharmaceutical expenditures in the US grew 13.6% compared to 2022, for a total of $722.5 billion. Utilization (a 6.5% increase), new drugs (a 4.2% increase) and price (a 2.9% increase) drove this increase. Semaglutide was the top drug in 2023, followed by adalimumab and apixaban. Drug expenditures were $37.1 billion (a 1.1% decrease) and $135.7 billion (a 15.0% increase) in nonfederal hospitals and clinics, respectively. In clinics, increased utilization drove growth, with a small impact from price and new products. In nonfederal hospitals, a drop in utilization led the decrease in expenditures, with price and new drugs modestly contributing to growth in spending. Several new drugs that will influence spending are expected to be approved in 2024. Specialty, endocrine, and cancer drugs will continue to drive expenditures. Conclusion For 2024, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate an 11.0% to 13.0% increase and a 0% to 2.0% increase, respectively, compared to 2023. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending. [ABSTRACT FROM AUTHOR]

Background Infectious conjunctivitis affects 1 in 8 children annually, resulting in high ophthalmic antibiotic prescribing and absenteeism from childcare and school. We aimed to quantify the cost-effectiveness and annual savings of 3 evidence-based approaches to conjunctivitis management and return to childcare and school compared to usual care. Methods Using a decision analytic model from a societal perspective over a 1-year time horizon, we conducted a cost-effectiveness analysis of 3 management strategies for children aged 6 months to 17 years with non-severe conjunctivitis compared to usual care in the United States. Strategies accounted for rate of transmission. Strategies included (1) refraining from prescribing ophthalmic antibiotics for non-severe conjunctivitis, (2) allowing children without systemic symptoms to attend childcare and school, (3) and the combined approach of refraining from prescribing ophthalmic antibiotics and allowing children without systemic symptoms to attend childcare and school. Results The estimated annual expenditure for pediatric conjunctivitis was $1.95 billion. Usual care was the most expensive ($212.73/episode), followed by refraining from ophthalmic antibiotic prescribing ($199.92) and allowing children without systemic symptoms to attend childcare and school ($140.18). The combined approach was the least costly ($127.38). Disutility was similar between approaches (quality-adjusted life days 0.271 vs 0.274). Refraining from antibiotic prescribing and the combination approach were dominant compared to usual care. The combined approach resulted in an estimated $783 million annual savings and 1.6 million ophthalmic antibiotic courses averted. Conclusions Conjunctivitis poses an economic burden that could be reduced by refraining from ophthalmic antibiotic use and allowing children without systemic symptoms to remain at school or childcare. [ABSTRACT FROM AUTHOR]

Within a multistate clinical cohort, SARS-CoV-2 antiviral prescribing patterns were evaluated from April 2022–June 2023 among nonhospitalized patients with SARS-CoV-2 with risk factors for severe COVID-19. Among 3247 adults, only 31.9% were prescribed an antiviral agent (87.6% nirmatrelvir/ritonavir, 11.9% molnupiravir, 0.5% remdesivir), highlighting the need to identify and address treatment barriers. [ABSTRACT FROM AUTHOR]

Objectives Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this. Methods From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models. Results Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids). Conclusion IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing. [ABSTRACT FROM AUTHOR]

Objective In this study, we explored key prescription drug monitoring program-related outcomes among clinicians from a broad cohort of Massachusetts healthcare facilities following prescription drug monitoring program (PDMP) and electronic health record (EHR) data integration. Methods Outcomes included seven-day rolling averages of opioids prescribed, morphine milligram equivalents (MMEs) prescribed, and PDMP queries. We employed a longitudinal study design to analyze PDMP data over a 15-month study period which allowed for six and a half months of pre- and post-integration observations surrounding a two-month integration period. We used longitudinal mixed effects models to examine the effect of EHR integration on each of the key outcomes. Results Following EHR integration, PDMP queries increased both through the web-based portal and in total (0.037, [95% CI = 0.017, 0.057] and 0.056, [95% CI = 0.035, 0.077]). Both measures of clinician opioid prescribing declined throughout the study period; however, no significant effect following EHR integration was observed. These results were consistent when our analysis was applied to a subset consisting only of continuous PDMP users. Conclusions Our results support EHR integration contributing to PDMP utilization by clinicians but do not support changes in opioid prescribing behavior. [ABSTRACT FROM AUTHOR]

Introduction Problematic polypharmacy is the prescribing of five or more medications potentially inappropriately. Unintentional prescribing cascades represent an under-researched aspect of problematic polypharmacy and occur when an adverse drug reaction (ADR) is misinterpreted as a new symptom resulting in the initiation of a new medication. The aim of this study was to elicit key stakeholders' perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. Methods qualitative one-to-one semi-structured interviews were conducted with predefined key stakeholder groups. Inductive thematic analysis was employed. Results Thirty-one stakeholders were interviewed: six patients, two carers, seven general practitioners, eight pharmacists, four hospital doctors, two professional organisation representatives and two policymakers. Three main themes were identified: (i) ADRs and prescribing cascades—a necessary evil. Healthcare professionals (HCPs) expressed concern that experiencing an ADR would negatively impact patients' confidence in their doctor. However, patients viewed ADRs pragmatically as an unpredictable risk. (ii) Balancing the risk/benefit tipping point. The complexity of prescribing decisions in the context of polypharmacy made balancing this tipping point challenging. Consequently, HCPs avoided medication changes. (iii) The minefield of medication reconciliation. Stakeholders, including patients and carers, viewed medication reconciliation as a perilous activity due to systemic communication deficits. Conclusion Stakeholders believed that at a certain depth of polypharmacy, the risk that a new symptom is being caused by an existing medication becomes incalculable. Therefore, in the absence of harm, medication changes were avoided. However, medication reconciliation post hospital discharge compelled prescribing decisions and was seen as a high-risk activity by stakeholders. [ABSTRACT FROM AUTHOR]

Background Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. Materials and Methods We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. Results Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). Conclusions Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents. [ABSTRACT FROM AUTHOR]

Background A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. Methods RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. Results We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P <.001) but remained lower than the 35.2% pre-intervention rate (P <.001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10–1.30; P <.05) and tier 3 (OR, 1.20; 95% CI: 1.12–1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59–0.73 tier 2; OR, 0.68; 95% CI: 0.61–0.75 tier 3). Conclusions The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects. [ABSTRACT FROM AUTHOR]

Objective The objectives of this Society of Breast Imaging (SBI)-member survey study were to assess the current imaging patterns for evaluation of symptomatic and asymptomatic breast implant integrity, including modalities used and imaging intervals. Methods A 12-question survey assessing the frequency of imaging modalities used to evaluate implant integrity, approximate number of breast implant integrity studies requested per month, intervals of integrity studies, and referring provider and radiology practice characteristics was distributed to members of the SBI. Results The survey response rate was 7.6% (143/1890). Of responding radiologists, 54.2% (77/142) were in private, 29.6% (42/142) in academic, and 16.2% (23/142) in hybrid practice. Among respondents, the most common initial examination for evaluating implant integrity was MRI without contrast at 53.1% (76/143), followed by handheld US at 46.9% (67/143). Of respondents using US, 67.4% (91/135) also evaluated the breast tissue for abnormalities. Among respondents, 34.1% (46/135) reported being very confident or confident in US for diagnosing implant rupture. There was a range of reported intervals for performing implant integrity studies: 39.1% (43/110) every 2-3 years, 26.4% (29/110) every 4-5 years, 15.5% (17/110) every 6-10 years, and 19.1% (21/110) every 10 years. Conclusion For assessment of implant integrity, the majority of respondents (53.2%, 76/143) reported MRI as initial imaging test. US is less costly, but the minority of respondents (34.1%, 46/135) had confidence in US performance. Also, the minority of respondents (39.1%, 43/110) performed implant integrity evaluations every 2-3 years per the FDA recommendations for asymptomatic surveillance. [ABSTRACT FROM AUTHOR]

Objective To identify structure, benefits, and shortcomings of a multi-institutional virtual visiting professorship (VVP) program from 2020 to 2022, 2 years after inception and after gradual resumption of an in-person, prepandemic academic environment. Methods An IRB-exempt, 70-question survey about structure, benefits, and shortcomings of the VVP program was distributed to its participants (14 breast imaging departments across the U.S.), using the snowball sampling technique. Results A total of 72 responses were received; 54.2% (32/59) radiologists >5 years of experience, 18.6% (11/59) radiologists <5 years of experience, 15.3% (9/59) residents, and 8.5% (5/59) fellows. Radiologists' attendance increased from 8% (5/59) to 53% (31/59) over 2 years, with 69% (41/59) of respondents supporting continued participation. The most important factors for attendance were expanding breast imaging knowledge (86.4% [51/59]) and the virtual format (76.2% [45/59]). The number of presented lectures increased from 1 to 3 lectures in 43.7% (7/16) of programs in year 1 and from 4 to 9 lectures in 50% (8/16) of programs in year 2. The greatest professional benefits were collaborations on publications for organizers (56.3% [9/16]) and building academic portfolios for presenters (50% [7/14]). For trainees, attending the program increased their knowledge (64.3% [9/14]) and enthusiasm for breast imaging (50% [7/14]). Conclusion The VVP program facilitated scholarly collaboration among breast imaging radiologists, promoted academic portfolios for junior faculty, and increased enthusiasm for breast imaging for trainees. These accomplishments extended beyond the COVID-19 pandemic, as evidenced by the growth of the program after resumption of an in-person academic environment. Future expansion to other programs would benefit more practicing radiologists. [ABSTRACT FROM AUTHOR]

Purpose This study retrospectively reviewed the outcomes of patients with advanced hepatocellular carcinoma (HCC) receiving atezolizumab with bevacizumab (A + B) therapy at the Veterans Health Administration (VHA). Patients and Methods Patients with advanced HCC who received first-line systemic therapy with A + B at the VHA between December 1, 2019, and March 1, 2022, were selected from electronic medical records (EMR) using ICD-9 and ICD-10 codes. Abstractors reviewed the EMR of the patients from their index date of A + B initiation until death or their last VHA visit, with the study period ending on January 31, 2023. The chi-square test was used to compare rates, and the Mann-Whitney test was used to compare medians. Results A total of 332 patients met the study criteria. The median age was 67 years; 99% were male, 63% were non-Hispanic Whites, 26% were Black, and 66% had an Eastern Cooperative Oncology Group performance status of ≥1. 84% had child Pugh score (CPS) class A, 16% had CPS classes B and C, 62% had a grade 2 albumin-bilirubin score, 56% had HCC caused by viral hepatitis, 80% had cirrhosis, and 67% had received prior local therapies. The 6-month progression-free survival (PFS) was 59%, while the 1-year PFS rate was 36%. Overall survival (OS) at 1-year was 52% in our study. Conclusion In real world, despite having similar PFS as the phase III IMbrave 150 trial, our OS at 12 months was lower (52% vs. 67%) because our study included a higher proportion of elderly patients with moderate liver dysfunction and a 40% non-White. This study provided real-world outcomes that differed from the study population in a pivotal trial. [ABSTRACT FROM AUTHOR]

Objective To investigate opioid prescribing trends and assess the impact of the COVID-19 pandemic on opioid prescribing in rheumatic and musculoskeletal diseases (RMDs). Methods Adult patients with RA, PsA, axial spondyloarthritis (AxSpA), SLE, OA and FM with opioid prescriptions between 1 January 2006 and 31 August 2021 without cancer in UK primary care were included. Age- and gender-standardized yearly rates of new and prevalent opioid users were calculated between 2006 and 2021. For prevalent users, monthly measures of mean morphine milligram equivalents (MME)/day were calculated between 2006 and 2021. To assess the impact of the pandemic, we fitted regression models to the monthly number of prevalent opioid users between January 2015 and August 2021. The time coefficient reflects the trend pre-pandemic and the interaction term coefficient represents the change in the trend during the pandemic. Results The study included 1 313 519 RMD patients. New opioid users for RA, PsA and FM increased from 2.6, 1.0 and 3.4/10 000 persons in 2006 to 4.5, 1.8 and 8.7, respectively, in 2018 or 2019. This was followed by a fall to 2.4, 1.2 and 5.9, respectively, in 2021. Prevalent opioid users for all RMDs increased from 2006 but plateaued or dropped beyond 2018, with a 4.5-fold increase in FM between 2006 and 2021. In this period, MME/day increased for all RMDs, with the highest for FM (≥35). During COVID-19 lockdowns, RA, PsA and FM showed significant changes in the trend of prevalent opioid users. The trend for FM increased pre-pandemic and started decreasing during the pandemic. Conclusion The plateauing or decreasing trend of opioid users for RMDs after 2018 may reflect the efforts to tackle rising opioid prescribing in the UK. The pandemic led to fewer people on opioids for most RMDs, providing reassurance that there was no sudden increase in opioid prescribing during the pandemic. [ABSTRACT FROM AUTHOR]

The article focuses on the need for equity in clinical trials for invasive Staphylococcus aureus infections, highlighting racial and socioeconomic disparities in both disease incidence and treatment. Topics include the challenges of antimicrobial resistance and its impact on racial disparities, the importance of including diverse demographics in clinical trials to ensure generalizability of results.

Background Optimization of antimicrobial stewardship is key to tackling antimicrobial resistance, which is exacerbated by overprescription of antibiotics in pediatric emergency departments (EDs). We described patterns of empiric antibiotic use in European EDs and characterized appropriateness and consistency of prescribing. Methods Between August 2016 and December 2019, febrile children attending EDs in 9 European countries with suspected infection were recruited into the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management) study. Empiric systemic antibiotic use was determined in view of assigned final "bacterial" or "viral" phenotype. Antibiotics were classified according to the World Health Organization (WHO) AWaRe classification. Results Of 2130 febrile episodes (excluding children with nonbacterial/nonviral phenotypes), 1549 (72.7%) were assigned a bacterial and 581 (27.3%) a viral phenotype. A total of 1318 of 1549 episodes (85.1%) with a bacterial and 269 of 581 (46.3%) with a viral phenotype received empiric systemic antibiotics (in the first 2 days of admission). Of those, the majority (87.8% in the bacterial and 87.0% in the viral group) received parenteral antibiotics. The top 3 antibiotics prescribed were third-generation cephalosporins, penicillins, and penicillin/β-lactamase inhibitor combinations. Of those treated with empiric systemic antibiotics in the viral group, 216 of 269 (80.3%) received ≥1 antibiotic in the "Watch" category. Conclusions Differentiating bacterial from viral etiology in febrile illness on initial ED presentation remains challenging, resulting in a substantial overprescription of antibiotics. A significant proportion of patients with a viral phenotype received systemic antibiotics, predominantly classified as WHO Watch. Rapid and accurate point-of-care tests in the ED differentiating between bacterial and viral etiology could significantly improve antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Objective Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. Setting Eight primary care clinics within a Veterans Health Administration health care system. Methods A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. Results Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. Conclusion This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed. [ABSTRACT FROM AUTHOR]

Post-transplantation diabetes mellitus (PTDM) remains a leading complication after solid organ transplantation. Previous international PTDM consensus meetings in 2003 and 2013 provided standardized frameworks to reduce heterogeneity in diagnosis, risk stratification and management. However, the last decade has seen significant advancements in our PTDM knowledge complemented by rapidly changing treatment algorithms for management of diabetes in the general population. In view of these developments, and to ensure reduced variation in clinical practice, a 3rd international PTDM Consensus Meeting was planned and held from 6–8 May 2022 in Vienna, Austria involving global delegates with PTDM expertise to update the previous reports. This update includes opinion statements concerning optimal diagnostic tools, recognition of prediabetes (impaired fasting glucose and/or impaired glucose tolerance), new mechanistic insights, immunosuppression modification, evidence-based strategies to prevent PTDM, treatment hierarchy for incorporating novel glucose-lowering agents and suggestions for the future direction of PTDM research to address unmet needs. Due to the paucity of good quality evidence, consensus meeting participants agreed that making GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) recommendations would be flawed. Although kidney-allograft centric, we suggest that these opinion statements can be appraised by the transplantation community for implementation across different solid organ transplant cohorts. Acknowledging the paucity of published literature, this report reflects consensus expert opinion. Attaining evidence is desirable to ensure establishment of optimized care for any solid organ transplant recipient at risk of, or who develops, PTDM as we strive to improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Aims To address the question of tailored baclofen prescribing in alcohol use disorder (AUD) in relation to dose-dependent efficacy and the potential danger of high doses and to provide suggestions for the use of high doses of baclofen in the treatment of AUD. The context is the approvement in France of baclofen in the treatment of AUD without dose limitation, making French physicians, who usually prescribe baclofen in a tailored manner, often use high or very high doses. Methods A narrative review of the results of randomized controlled trials (RCTs) and observational studies that used tailored baclofen prescribing and of the severe adverse effects of baclofen that have been reported in the literature. Results The results show that RCTs using tailored doses of baclofen in AUD are not completely demonstrative, though they are encouraging according to certain meta-analyses, while observational studies that used tailored doses constantly show a good effectiveness of baclofen treatment. The results suggest that many severe adverse effects of baclofen could be related to a nonrespect by physicians of prescription rules and appropriate treatment monitoring. Conclusions The use of tailored doses shows that the dose required to suppress cravings is highly variable, low or high, depending on each case. Analysis of the circumstances in which severe adverse effects occur suggest that a careful monitoring of baclofen prescribing might prevent a large majority of severe adverse effects. We propose that the education of the patients and the prescription skills, seriousness, and availability of the prescribing physicians are of major importance in the managing of tailored baclofen treatment of AUD. [ABSTRACT FROM AUTHOR]

Background Infectious diseases remain a major risk for refugees living in camps. Limited research has been undertaken into the burden and impact of infections in the current refugee crisis around the Mediterranean. This analysis examines the frequency and incidence rates of common infections, and use of antibiotics at a healthcare facility inside Moria refugee camp on the island of Lesvos, Greece, during the winter and summer seasons of 2019. Methods This is a retrospective analysis of routinely, prospectively collected service data from the main acute healthcare facility inside Moria camp. Results Of a total of 9601 consultations, 25.16% were for infections (winter: 31.53%, summer: 19.45%). Respiratory, skin and gastrointestinal infections were the most frequent, with incidence rates up to 3.5 times, 50 times and twice as high as those in Western Europe, respectively. Antibiotic prescribing was high (27.7% of all respiratory infections) with high use of broad-spectrum antibiotics (40.2%), raising concerns about induction of antimicrobial resistance. Conclusions The burden of infectious diseases in refugee camps remains high throughout all seasons. Antimicrobial stewardship programmes should be adapted to refugee camp settings to prevent the development of unnecessary antimicrobial resistance. Improving living conditions and access to healthcare in refugee camps is likely to reduce infection rates and antimicrobial resistance among refugees. [ABSTRACT FROM AUTHOR]

Objective The availability of same-day services in breast imaging is an important topic given potential advantages for timely diagnoses and patient experiences, but there are potential barriers that lead facilities to not offer these services. We sought to understand current practice patterns and radiologist perspectives on offering same-day services. Methods The Society of Breast Imaging (SBI) Patient Care & Delivery Committee developed a 19-question survey that was emailed to all 3449 active members of the SBI in May 2023. An exemption from the institutional review board was obtained at the lead author's institution. The survey consisted of 19 questions that were designed to understand the scope, perceptions, barriers, and logistics of same-day services. Comparisons were made between responses for offering same-day services (screening interpretation, diagnostic examinations, biopsies) and respondent demographics. Results A total of 437 American and Canadian members participated, yielding a response rate of 12.7%. Respondents were most commonly in private practice (43.0%, 188/437), working in an outpatient medical center–based clinic (41.9%, 183/437), and without trainees (64.5%, 282/437). Respondents estimated 12.1% of screening examinations were interpreted while patients waited, which was significantly more common in free-standing breast imaging clinics (P =.028) and practices without trainees (P =.036). Respondents estimated 15.0% of diagnostic examinations were performed same day, which was more common in academic and private practices (P =.03) and practices without trainees (P =.01). Respondents estimated 11.5% of biopsies were performed the same day as the recommendation, which had no association with practice type/context, presence of trainees, number of mammography units, number of radiologists, or number of technologists. Long patient travel distance and limited patient mobility were the most cited reasons for offering patients same-day services. Conclusion Offering same-day breast imaging services varies among institutions and may be influenced by factors such as practice context and type and the presence of trainees. [ABSTRACT FROM AUTHOR]

Background The treatment landscape for locally advanced/metastatic urothelial carcinoma (la/mUC) has evolved. This study examined US prescribing patterns and clinical decision-making for first-line (1L) and first-line maintenance (1LM) treatment. Materials and Methods US-based oncologists (N  = 150) completed an online survey on patient demographics, practice patterns, and important factors considered in 1L/1LM selection. Multivariable logistic regression was used to assess factors associated with more vs less frequent 1L/1LM prescribing. Results Physician reports estimated that 23% of patients with la/mUC had not received any systemic therapy in the previous 6 months; however, 46% received 1L, 32% received second-line, and 22% received subsequent-line systemic treatments. Of patients who were receiving 1L treatment, 72% were estimated to be receiving 1L platinum-based chemotherapy. Around 69% of patients eligible for 1LM received the treatment. Physicians categorized as frequent prescribers reported overall survival (OS), disease control rate (DCR), and rate of grade 3/4 adverse events (AEs) as factors associated with 1L treatment selection (all P  < .05). OS, rate of grade 3/4 immune-mediated AEs, and inclusion in institutional guidelines were reported as attributes used in 1LM treatment selection (all P  < .05). Multivariable analysis revealed OS, DCR, and rate of grade 3/4 AEs as important factors in oncologists' 1L treatment selection; academic practice setting and use of Response Evaluation Criteria in Solid Tumors version 1.1 were associated with 1LM use (all P  < .05). Conclusion OS and AEs were found to be relevant factors associated with offering 1L and 1LM treatment. Variability exists in physicians' decision-making in the real-world setting for la/mUC. [ABSTRACT FROM AUTHOR]

Medical cannabis (MC) may offer therapeutic benefits for children with complex neurological conditions and chronic diseases. In Canada, parents, and caregivers frequently report encountering barriers when accessing MC for their children. These include negative preconceived notions about risks and benefits, challenges connecting with a knowledgeable healthcare provider (HCP), the high cost of MC products, and navigating MC product shortages. In this manuscript, we explore several of these barriers and provide recommendations to decision-makers to enable a family-centered and evidence-based approach to MC medicine and research for children. [ABSTRACT FROM AUTHOR]

Background Understanding how analgesics are used in different countries can inform initiatives to improve the pharmacological management of pain in nursing homes. Aims To compare patterns of analgesic use among Australian and Japanese nursing home residents; and explore Australian and Japanese healthcare professionals' perspectives on analgesic use. Methods Part one involved a cross-sectional comparison among residents from 12 nursing homes in South Australia (N  = 550) in 2019 and four nursing homes in Tokyo (N  = 333) in 2020. Part two involved three focus groups with Australian and Japanese healthcare professionals (N  = 16) in 2023. Qualitative data were deductively content analysed using the World Health Organization six-step Guide to Good Prescribing. Results Australian and Japanese residents were similar in age (median: 89 vs 87) and sex (female: 73% vs 73%). Overall, 74% of Australian and 11% of Japanese residents used regular oral acetaminophen, non-steroidal anti-inflammatory drugs or opioids. Australian and Japanese healthcare professionals described individualising pain management and the first-line use of acetaminophen. Australian participants described their therapeutic goal was to alleviate pain and reported analgesics were often prescribed on a regular basis. Japanese participants described their therapeutic goal was to minimise impacts of pain on daily activities and reported analgesics were often prescribed for short-term durations, corresponding to episodes of pain. Japanese participants described regulations that limit opioid use for non-cancer pain in nursing homes. Conclusion Analgesic use is more prevalent in Australian than Japanese nursing homes. Differences in therapeutic goals, culture, analgesic regulations and treatment durations may contribute to this apparent difference. [ABSTRACT FROM AUTHOR]

Background Lenvatinib plus pembrolizumab significantly improved efficacy compared with chemotherapy in patients with advanced endometrial cancer (aEC) regardless of microsatellite instability status or histologic subtype, who had disease progression following prior platinum-based therapy, in Study-309/KEYNOTE-775. The safety profile of the combination was generally consistent with that of each monotherapy drug and of the combination in patients with endometrial cancer and other solid tumors. Given the medical complexity of patients with aEC, this paper aims to characterize key adverse reactions (ARs) of the combination treatment and review management strategies, providing a guide for AR management to maximize anticancer benefits and minimize treatment discontinuation. Materials and Methods In Study-309/KEYNOTE-775, patients received lenvatinib (20 mg orally once daily) plus pembrolizumab (200 mg intravenously every 3 weeks) or chemotherapy (doxorubicin or paclitaxel). The incidence and median time to the first onset of ARs, dose modifications, and concomitant medications are described. Key ARs characterized include hypothyroidism, hypertension, fatigue, diarrhea, musculoskeletal disorders, nausea, decreased appetite, vomiting, stomatitis, weight decreased, proteinuria, and palmar-plantar erythrodysesthesia syndrome. Results As expected, the most common any-grade key ARs included: hypothyroidism, hypertension, fatigue, diarrhea, and musculoskeletal disorders. Grades 3-4 key ARs with incidence ≥10% included: hypertension, fatigue, and weight decreased. Key ARs first occurred within approximately 3 months of treatment initiation. AR management strategies consistent with the prescribing information and the study protocol are discussed. Conclusion Successful AR management strategies for lenvatinib plus pembrolizumab include education of the patient and entire treatment team, preventative measures and close monitoring, and judicious use of dose modifications and concomitant medications. Clinicaltrials.gov ID NCT03517449 [ABSTRACT FROM AUTHOR]

The article offers information on the development and validation of an indicator to identify non-opioid pharmacological therapies used for pain management using electronic health record data. Topics include the prevalence of chronic pain, with 20% of adults in the United States experiencing chronic pain that can limit life or work activities, highlighting the need for additional resources to support clinicians in managing chronic pain.

The article highlights the challenge of sustaining outpatient antimicrobial stewardship despite its critical importance, as most efforts focus on inpatient settings. Topics discussed include the limited progress in outpatient programs, challenges in development, and the necessity for multifaceted, resource-intensive interventions for sustainable change.

Background In 2015, the UK government established the Fleming Fund with the aim to address critical gaps in surveillance of antimicrobial resistance (AMR) in low- and middle-income countries in Asia and Africa. Among a large portfolio of grants, the Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia (CAPTURA) project was awarded with the specific objective of expanding the volume of historical data on AMR, consumption (AMC), and use (AMU) in the human healthcare sector across 12 countries in South and Southeast Asia. Methods Starting in early 2019, the CAPTURA consortium began working with local governments and >100 relevant data-holding facilities across the region to identify, assess for quality, prioritize, and subsequently retrieve data on AMR, AMC, and AMU. Relevant and shared data were collated and analyzed to provide local overviews for national stakeholders as well as regional context, wherever possible. Results From the vast information resource generated on current surveillance capacity and data availability, the project has highlighted gaps and areas for quality improvement and supported comprehensive capacity-building activities to optimize local data-collection and -management practices. Conclusions The project has paved the way for expansion of surveillance networks to include both the academic and private sector in several countries and has actively engaged in discussions to promote data sharing at the local, national, and regional levels. This paper describes the overarching approach to, and emerging lessons from, the CAPTURA project, and how it contributes to other ongoing efforts to strengthen national AMR surveillance in the region and globally. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is a growing global public health challenge associated with 4.95 million deaths in 2019 and an estimated 10 million deaths per year by 2050 in the absence of coordinated action. A robust AMR surveillance system is therefore required to avert such a scenario. Based on an analysis of country-level AMR data in 8 Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia (CAPTURA) countries, we present a list of key recommendations to strengthen AMR surveillance. We propose 10 primary considerations under 3 broad categories, including recommendations on (1) laboratory and testing practices, (2) data management and analysis, and (3) data use. [ABSTRACT FROM AUTHOR]

Background Immunocompromised patients are at high risk of severe coronavirus disease 2019 (COVID-19) and death, yet treatment strategies for immunocompromised patients hospitalized for COVID-19 reflect variations in clinical practice. In this comparative effectiveness study, we investigated the effect of remdesivir treatment on inpatient mortality among immunocompromised patients hospitalized for COVID-19 across all variants of concern (VOC) periods. Methods Data for immunocompromised patients hospitalized for COVID-19 between December 2020 and April 2022 were extracted from the US PINC AITM Healthcare Database. Patients who received remdesivir within 2 days of hospitalization were matched 1:1 using propensity score matching to patients who did not receive remdesivir. Additional matching criteria included admission month, age group, and hospital. Cox proportional hazards models were used to examine the effect of remdesivir on risk of 14- and 28-day mortality during VOC periods. Results A total of 19 184 remdesivir patients were matched to 11 213 non-remdesivir patients. Overall, 11.1% and 17.7% of remdesivir patients died within 14 and 28 days, respectively, compared with 15.4% and 22.4% of non-remdesivir patients. Remdesivir was associated with a reduction in mortality at 14 (hazard ratio [HR], 0.70; 95% confidence interval,.62–.78) and 28 days (HR, 0.75; 95% CI,.68–.83). The survival benefit remained significant during the pre-Delta, Delta, and Omicron periods. Conclusions Prompt initiation of remdesivir in immunocompromised patients hospitalized for COVID-19 is associated with significant survival benefit across all variant waves. These findings provide much-needed evidence relating to the effectiveness of a foundational treatment for hospitalized COVID-19 patients among a high-risk population. [ABSTRACT FROM AUTHOR]

Background Missed opportunities constitute a main driver of suboptimal seasonal influenza vaccination (SIV) coverage in older adults. Vaccine co-administration is a way to reduce these missed opportunities. In this study, we quantified missed opportunities for SIV, identified some of their socio-structural correlates and documented SIV co-administration patterns. Methods In this registry-based retrospective cohort study, we verified the SIV status of all subjects aged ≥65 years who received at least one dose of coronavirus disease 2019 (COVID-19), pneumococcal or herpes zoster vaccines during the 2022/23 influenza season. The frequency of concomitant same-day administration of SIV with other target vaccines was also assessed. Results Among 41 112, 5482 and 3432 older adults who received ≥1 dose of COVID-19, pneumococcal and herpes zoster vaccines, missed opportunities for SIV accounted for 23.3%, 5.0% and 13.2%, respectively. Younger, male and foreign-born individuals were generally more prone to missing SIV. The co-administration of SIV with other recommended vaccines was relatively low, being 11.0%, 53.1% and 17.1% in COVID-19, pneumococcal and herpes zoster cohorts, respectively. Conclusions A sizeable proportion of older adults who received other recommended vaccines during the last influenza season did not receive SIV. This share of missed opportunities, which are subject to some social inequalities, may be addressed by increasing vaccine co-administration rates and implementing tailored health promotion interventions. [ABSTRACT FROM AUTHOR]

Adolescence is an essential stage of life for developing actions related to health promotion, especially in health education (HE). Public policies advocate for the expansion of participative technologies in this field, as well as different theoretical and methodological perspectives subsidize these. Among these, Paulo Freire's reference guide is practiced in Brazil and around the world. From the Freirean perspective, Thematic Investigation (TI) defines the content of the educational practice. This paper describes a methodological proposal of the Freirean Thematic Investigation for developing health educational practices and promoting health among adolescents. Initially, we describe the conception of the Freirean rationale that sets the grounds for the proposed method: human being, dialogical education and reality and their connections with HE with adolescents in a critical perspective. The methodological proposal is systematized into five stages: (i) Approaching adolescents and the field of educational practices; (ii) Reading reality; (iii) Seminars for analyzing reality reading and preparing the codifications; (iv) Critical analysis of reality; and (v) Planning educational practices. The TI confronts the adult-centric perspectives that characterize adolescent health care. Moreover, as a praxis, TI is a process of reflection and action with adolescents, allowing for not only the discovery of the themes that build educational practices but also for solutions (untested feasibility) for the individual and collective problems experienced by adolescents concerning their health. [ABSTRACT FROM AUTHOR]

Introduction: The Coronavirus Disease 2019 (COVID-19) has disrupted health services worldwide. The evidence on the impact of the pandemic on cancer care provision, however, is conflicting. We aimed to audit the management of patients diagnosed with early breast cancer (EBC) during the pandemic in a large, tertiary-level cancer center in Italy. Methods: We conducted a cross-sectional study to track the route to first treatment for patients diagnosed with EBC during 2019, 2020, and 2021. We abstracted data for all consecutive patients referred to the Veneto Institute of Oncology (Padua, Italy). We defined as point of contact (POC) the date of the first consultation with a breast cancer specialist of the breast unit. First treatment was defined as either upfront surgery or neoadjuvant chemotherapy (NACT). Results: We reviewed medical records for 878 patients for whom an MDT report during 2019-2021 (April through June) was available. Of these, 431 (49%) were eligible. The proportion of screen-detected tumors was larger in 2019 and 2021 than in 2020 (59%). Conversely, the proportion of screen-detected tumors was offset by the proportion of palpable tumors in 2020 (P = .004). Distribution of tumor and nodal stage was unchanged over time, but in situ tumors were slightly fewer in 2020 than in 2019 or 2021. The adjusted odds ratio for treatment delay (45 days or more) was 0.87 for 2020 versus 2019 (95% CI, 0.5-1.53) and 0.9 for 2021 versus 2019 (95% CI, 0.52-1.55). Conclusions: There was no evidence for major changes in the management of patients with EBC during 2019-2021 and no treatment delays were observed. Our findings suggest that more women presented with palpable nodules at diagnosis, but the stage distribution did not change over time. Validation on a larger cohort of patients is warranted to robustly assess the impact of the COVID-19 pandemic on treatment practices for patients with EBC. This article evaluates the impact on the distribution of disease parameters and time to care of patients with breast cancer during the SARS-CoV2 pandemic, using data from an audit of the management of patients diagnosed with early breast cancer during the pandemic in a large cancer center in Italy. [ABSTRACT FROM AUTHOR]

Background: The importance of clinical staging in breast cancer has increased owing to the wide use of neoadjuvant systemic therapy (NST). This study aimed to investigate the current practice patterns regarding clinical nodal staging in breast cancer in real-world settings. Materials and Methods: A web-based survey was administered to board-certified oncologists in Korea, including breast surgical, medical, and radiation oncologists, from January to April 2022. The survey included 19 general questions and 4 case-based questions. Results: In total, 122 oncologists (45 radiation, 44 surgical, and 33 medical oncologists) completed the survey. Among them, 108 (88%) responded that clinical staging before NST was primarily performed by breast surgeons. All the respondents referred to imaging studies during nodal staging. Overall, 64 (52.5%) responders determined the stage strictly based on the radiology reports, whereas 58 (47.5%) made their own decision while noting radiology reports. Of those who made their own decisions, 88% referred to the number or size of the suspicious node. Of the 75 respondents involved in prescribing regimens for neoadjuvant chemotherapy, 58 (77.3%) responded that the reimbursement regulations in the selection of NST regimens affected nodal staging in clinical practice. In the case-based questions, high variability was observed among the clinicians in the same cases. Conclusions: Diverse assessments by specialists owing to the lack of a clear, harmonized staging system for the clinical nodal staging of breast cancer can lead to diverse practice patterns. Thus, practical, harmonized, and objective methods for clinical nodal staging and for the outcomes of post-NST response are warranted for appropriate treatment decisions and accurate outcome evaluation. Nodal stage serves a pivotal role in making treatment decisions in breast cancer patients. This study investigated current practice patterns regarding clinical nodal staging in breast cancer in a real-world setting. [ABSTRACT FROM AUTHOR]

Objectives Current guidelines by the Canadian Paediatric Society on treating urinary tract infections (UTIs) exclude infants ≤ 60 days old. There is considerable practice variability in this age group, especially around the optimal duration of parenteral antibiotics. The study aimed to assess local practice patterns, and the safety of a short course (≤3 days) of parenteral antibiotics in young infants. Methods In this retrospective cohort study, 95 infants (≤60 days) with confirmed UTIs were identified at British Columbia Children's Hospital. Patients receiving short (≤3 days) and long (>3 days) duration of parenteral antibiotics were compared. Outcomes of interest included urinary tract infection recurrence within 30 days, hospital length of stay (LOS), representation, and readmission. Results Twenty infants (21%) received a short course of parenteral antibiotics. These infants were older (median 47 days versus 28 days) and non-bacteremic. Urinary tract infection recurrence was identified in 8 patients (8%), of which 7 were treated with a long duration (P = 1.0). Patients treated with a short duration had a significantly shorter LOS, with a mean difference of 4.21 days [95% CI: 3.37 to 5.05] (P < 0.001). All five (5%) bacteremic patients were treated exclusively with parenteral antibiotics. Conclusions In a Canadian setting, a short course of parenteral antibiotics is safe in young, non-bacteremic infants with UTIs. Despite substantial evidence, local practice patterns suggest a tendency towards prescription of long courses, providing an opportunity for quality improvement. [ABSTRACT FROM AUTHOR]

Background The effects of nirmatrelvir/ritonavir (NMV/r [Paxlovid]) on coronavirus disease 2019 (COVID-19) outcomes in younger vaccinated adults are unclear. The objective of this study was to assess if NMV/r use in vaccinated adults aged ≤50 years is associated with improved outcomes and to identify beneficial and nonbeneficial subgroups. Methods In this cohort study, we generated 2 propensity-matched cohorts of 2547 patients from an 86 119-person cohort assembled from the TriNetX database. Patients in 1 cohort received NMV/r, and patients in the matched control cohort did not. The main outcome was composite of all-cause emergency department visits, hospitalization, and mortality. Results The composite outcome was detected in 4.9% of the NMV/r cohort and 7.0% of the non-NMV/r cohort (odds ratio, 0.683 [95% confidence interval,.540–.864]; P =.001), indicating a 30% relative risk reduction. The number needed to treat (NNT) for the primary outcome was 47. Subgroup analyses found significant associations for patients with cancer (NNT = 45), cardiovascular disease (NNT = 30), and both conditions (NNT = 16). No benefit was found for patients with only chronic lower respiratory disorders (asthma/chronic obstructive pulmonary disease [COPD]) or without serious comorbidities. Thirty-two percent of NMV/r prescriptions in the overall database were for 18- to 50-year-olds. Conclusions NMV/r use in vaccinated adults aged 18–50 years, especially with serious comorbidities, was associated with reduced all-cause hospital visits, hospitalization, and mortality in the first 30 days of COVID-19 illness. However, NMV/r in patients without significant comorbidities or with only asthma/COPD had no association of benefit. Therefore, identifying high-risk patients should be a priority and overprescription should be avoided. [ABSTRACT FROM AUTHOR]

The article discusses the American Society of Health-System Pharmacists (ASHP) and Society of Infectious Diseases Pharmacists (SIDP) joint statement on the pharmacist's role in antimicrobial stewardship (AMS) in 2023. Topics covered includes establishing AMS programs as a priority with dedicated resources, promoting optimal use of antimicrobial agents, and education and training for pharmacists involved in AMS. Also noted is the need for all pharmacists to promote AMS efforts.

Alcohol use is a leading risk factor for premature death and disability. To tackle this issue, more systematic and accurate screening for at-risk consumption is needed in healthcare systems, especially by general practitioners (GPs). We assessed the frequency of at-risk consumption screening by GPs in France. We also identified characteristics associated with more frequent screening and greater use of validated screening tools by these healthcare providers. A cross-sectional survey was conducted among a representative sample of French GPs. Multinomial logistic regressions were used to identify factors associated with more frequent screening and greater use of validated screening tools. Response rate was of 73%. Of the 2412 participants, 42.8% screened all their patients systematically and repeatedly, while 48.0% never used standardized tools to screen potentially at-risk patients. Among other characteristics, being aware of and using the "early identification and brief intervention" screening strategy, and feeling absolutely comfortable talking with patients about reducing or stopping their alcohol use, were both associated with more frequent screening and use of standardized tools. Our results on at-risk alcohol use screening highlight an improvement over data from previous studies. Nevertheless, better training of French GPs in good alcohol screening practices—specifically, increased screening frequency and greater use of standardized tools—may improve identification of at-risk patients. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients with neck or low back pain in primary care settings. Methods Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6 months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients' predictor information collected both at point of consultation and 2 to 4 weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance. Results Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4 weeks after consultation (calibration slope = 0.848 [95% CI = 0.767 to 0.928] for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 [95% CI = 0.549 to 0.750]). Conclusion Model predictive accuracy was good when predictors were measured 2 to 4 weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance. Impact External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data on biomarker testing rates in rural populations with metastatic colorectal cancer (mCRC). To assess biomarker testing practices, oncologists in rural areas and urban clusters in the US were surveyed. Materials and Methods: A web-based survey was administered to oncologists spending ≥40% of their time practicing in rural areas or urban clusters and who had treated ≥2 patients with stage IV mCRC in the prior month. Results: Ninety-nine oncologists completed the quantitative survey and 17 the qualitative interview. Among respondents, 97% reported ordering biomarker tests. Oncologists reported testing for KRAS, NRAS, BRAF, HER2, and mismatch repair deficiency/microsatellite instability in 72%, 65%, 63%, 56%, and 66% of patients with metastatic disease, respectively. Forty-one percent reported performing reflex testing. The most cited testing barriers were lack of insurance coverage, insufficient tissue samples, and long turnaround times. Conclusion: Further assessment of rural testing practices is needed. In this study, oncologists in the US were surveyed to investigate practice patterns related to biomarker testing in rural areas and urban clusters, uncover obstacles to biomarker testing, and understand the role of telehealth in metastatic colorectal cancer. [ABSTRACT FROM AUTHOR]

Background Despite being the leading cause of mortality from bloodstream infections worldwide, little is known about regional variation in treatment practices for Staphylococcus aureus bacteremia (SAB). The aim of this study was to identify global variation in management, diagnostics, and definitions of SAB. Methods During a 20-day period in 2022, physicians throughout the world were surveyed on SAB treatment practices. The survey was distributed through listservs, e-mails, and social media. Results In total, 2031 physicians from 71 different countries on 6 continents (North America [701, 35%], Europe [573, 28%], Asia [409, 20%], Oceania [182, 9%], South America [124, 6%], and Africa [42, 2%]) completed the survey. Management-based responses differed significantly by continent for preferred treatment of methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) bacteremia, use of adjunctive rifampin for prosthetic material infection, and use of oral antibiotics (P <.01 for all comparisons). The 18F-FDG PET/CT scans were most commonly used in Europe (94%) and least frequently used in Africa (13%) and North America (51%; P <.01). Although most respondents defined persistent SAB as 3 – 4 days of positive blood cultures, responses ranged from 2 days in 31% of European respondents to 7 days in 38% of Asian respondents (P <.01). Conclusions Large practice variations for SAB exist throughout the world, reflecting the paucity of high-quality data and the absence of an international standard of care for the management of SAB. [ABSTRACT FROM AUTHOR]

Background Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. Methods We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. Results Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. Conclusions Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended. [ABSTRACT FROM AUTHOR]

Background Antibiotics are often overprescribed for pediatric conjunctivitis. We implemented a system-level quality improvement (QI) intervention to reduce unnecessary ophthalmic antibiotic use. Methods The multi-faceted intervention in Denver, CO comprised a clinical care pathway, nurse protocol modifications, electronic health record (EHR) changes, parent education materials, and clinician education. We evaluated children aged 6 months–17 years with conjunctivitis seen between November 2018 and December 2022. A multi-interrupted time series model evaluated the effectiveness of the intervention over three time periods: Pre-COVID, Pre-Intervention (November 2018–February 2020), COVID, Pre-Intervention (March 2020–March 2021), and Post-Intervention (April 2021–December 2022). Fisher's exact tests compared treatment failure and healthcare utilization rates between time periods and among children receiving or not receiving ophthalmic antibiotics. Results Among 6960 eligible encounters, ophthalmic antibiotic use was reduced by 18.8% (95% CI: 16.3, 21.3) from Pre-COVID, Pre-Intervention to Post-Intervention. During the Pre-Intervention period following the onset of COVID, a reduction of 16.1% (95% CI: 12.9, 19.3) was observed. Implementation of the intervention resulted in an additional 2.7% (95% CI: −0.4, 5.7) reduction in antibiotic prescribing, primarily in younger children (ages 6 months–5 years). The greatest reduction in prescribing occurred for nurse triage encounters with an 82.1% (95% CI: 76.8, 87.5) reduction in prescribing rates (92.6%–10.5%). Treatment failure occurred in 1301 (18.7%) children and was more common among children that received an ophthalmic antibiotic than those that did not (20.0 vs 17.9%; P  = .03). Conclusion The QI intervention significantly reduced ophthalmic antibiotic prescribing for pediatric conjunctivitis without increasing treatment failure rates or health care utilization. [ABSTRACT FROM AUTHOR]