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Introduction: Substance use disorders (SUDs) are complex interactions between various genetic, environmental, developmental, and social factors. Yoga is recommended as a nonmainstream treatment for many health conditions, including SUDs. Methods: Five databases were searched for randomized controlled trials (RCTs) that evaluated yoga as an intervention in adults with any type of substance use disorder. The interventions being studied included Hatha yoga, Sudarshan Kriya yoga, breathing yoga exercises, and meditation. Studies, where yoga was combined with other interventions were excluded. The effect of yoga as an intervention was analyzed using primary outcomes such as anxiety, pain, and craving. Eight RCTs met the eligibility criteria, and quality analysis was conducted using the Cochrane criteria. Results: Among the 8 final studies eligible for quality analysis, 2 had undefined substance use, while the others were focused on tobacco, alcohol, or opioids. Seven out of 8 studies showed significant results and improved primary outcomes such as anxiety, pain, or substance use. Seven out of the 8 studies showed significant positive outcomes using yoga in conjunction with other pharmacological treatment modalities like opioid substitution therapy. Conclusions: Six out of 8 studies showed low concerns, while 2 studies showed some concerns about the risk of bias judgment. Although the results look encouraging, RCTs with larger sample size are needed to better evaluate the effectiveness of yoga as a treatment modality for substance use.

Professor Sir Richard Doll, in collaboration with Professor Sir Austin Bradford Hill, were the first to quantitate the relationship of cigarette smoking with lung cancer.1 Later, Doll aptly stated, “Death in old age is inevitable, but death before old age is not.”1 The Richard Doll Building at the University of Oxford in Oxford, England, is inscribed with one of Doll's many impactful statements about cigarette smoking: In previous centuries, 70 years used to be regarded as humanity's allotted span of life, and only about one in five lived to such an age. Nowadays, however, for non-smokers in Western countries, the situation is reversed: only about one in five will die before 70, and the non-smoker death rates are still decreasing, offering the promise, at least in developed countries, of a world where death before 70 is uncommon.1 Despite this evidence-based optimism, cigarette smoking and the emerging clinical and public health challenges of overweight and obesity and physical inactivity are the leading avoidable causes of premature death in most industrialized nations. These risk factors are also emerging in the rest of the world, so that smoking, overweight and obesity, and physical inactivity are the major contributors to the reason that cardiovascular disease (CVD) has increased from number 5 to number 1 as the cause of mortality worldwide.2 In the United States during the past several decades (since 1965), the prevalence of cigarette smoking has decreased markedly.3 Nonetheless, in 2018, approximately 34.2 million Americans aged 18 years and older, or 13.7% of the population, were current cigarette smokers.3 Thus, the impact of cigarette smoking on avoidable and premature mortality remains alarmingly high. In the United States alone, smoking causes more than 480,000 deaths each year.3 These sobering statistics reflect, in major ways, the approximate 2-fold increased risk of CVD among current smokers and the approximate 20-fold increased risk of lung cancer among long-term smokers. Specifically, these relative increases translate to absolute increases of more than 150,000 deaths per year from CVD and 130,000 deaths per year from lung cancer among persons ≥35 years of age.4 Quitting smoking before age 40 years reduces the risk of dying from cigarette-related disease by approximately 90%.5 Specifically, smoking cessation significantly reduces the risks of CVD—beginning within a matter of months—and the risk of CVD among those who quit smoking equals that of lifelong nonsmokers within a few years, even among older adults.6 In contrast, reductions in mortality risk from lung cancer only begin to appear several years after quitting, and even by 10 years, the risk has been reduced to only approximately midway between continuing smokers and lifelong nonsmokers.7 In the United States in 2016, approximately 30 million hospital admissions occurred among persons 18+ years of age, with an average length of stay of 4.6 days.8 A 2009 study in San Francisco reported the prevalence of cigarette smoking among hospitalized patients to be 40%9 in contrast to the prevalence in the general population of 13.7%.3,10 This prevalence implies that up to 12 million inpatients in US hospitals are smokers. In this paper, we discuss effective and safe counseling and drug therapies that have the potential to prevent numerous premature deaths in the United States caused by cigarettes in hospitalized smokers.

The 2nd annual Health Equity Summer Research Summit organized by the Center of Excellence (COE) in Health Equity, Training and Research, Baylor College of Medicine (BCM), was a forum to catalyze the fertilization and exchange of cutting-edge ideas in the area of disparity research in medicine. The summit fosters understanding of current health equity research, training, clinical care, and outreach initiatives, in addition to offering an opportunity for connecting with allies and partners working in the field of health equity and health disparities. The summit provides opportunities for our COE Scholars (undergraduate/post-baccalaureate students and Baylor medical students, clinical fellows and junior faculty) to showcase their research findings which are reflective of their past year's endeavor as scholars at the center. Abstracts in this Book of Abstracts represent a summary of these research efforts. With this summit, BCM continues to build on its long history of educational outreach initiatives to promote diversity in medicine by focusing on programs aimed at increasing the number of diverse and highly qualified medical professionals ready to introduce effective and innovative approaches to reduce or eliminate health disparities. These programs will improve information resources, clinical education, curricula, research and cultural competence as they relate to minority health issues and social determinants of health.

St. John’s wort (SJW) has been researched and clinically used for treating various psychiatric disorders, including depression. Few clinical trials have studied its use in smoking cessation. This systematic review provides comprehensive evidence of the studies conducted to date. Five databases were searched for randomized controlled trials (RCTs) that evaluated the effectiveness of SJW for smoking cessation in adults. The trials included the use of SJW alone, or along with nicotine replacement therapy, chromium, or behavioral therapies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to report this systematic review. Overall, four RCTs met the eligibility criteria, and the risk of bias analysis was conducted using the Cochrane criteria. Abstinence, along with other physical symptoms, were measured as outcomes at the end of the follow-up period. Studies reported variable abstinence rates and a decrease in cravings at the end of 12-14 weeks. However, there was minimal to no difference reported between the intervention and placebo groups in all of the clinical trials. One of the studies reported minimal physical side effects. Overall, SJW was well tolerated. Quality analysis of the included studies showed low concerns in two studies while the other two studies showed high concerns in the risk of bias judgment. More clinical trials with larger sample sizes should be conducted in the future to evaluate the effectiveness of the use of SJW for smoking cessation.

ObjectivesThe objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment.DesignA preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration.SettingTwo family medicine clinics (one intervention and one control) were included.ParticipantsAll female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019.ResultsOur sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001.ConclusionA multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.

Introduction: Despite near-universal utilization of electronic health records (EHRs) by physicians in practice, medical students in most ambulatory settings gain limited experience with placing EHR orders. In this study, an individual preceptor site investigated the usefulness of a targeted curriculum in improving students’ EHR confidence and clinical reasoning skills. Methods: Family medicine clerkship students assigned to one community health center were invited to participate in this prospective, survey-based study. In their first week, students observed a preceptor performing EHR tasks. For the remainder of the 4-week clerkship, students utilized decision support tools, assigned a working diagnosis, entered unsigned orders in the EHR, proposed an assessment, and discussed a plan with a preceptor. Students completed weekly questionnaires to self-report confidence across several EHR domains while preceptors synchronously evaluated students’ accuracy with entering orders correctly. Results: From February 2017 to March 2020, all 49 eligible students completed the study. One hundred percent of students reported that placing EHR orders was beneficial to their medical education. The difference over time in learner confidence with placing EHR orders was statistically significant across every domain (eg, writing prescriptions, ordering labs and imaging). Preceptors’ evaluations of students’ accuracy with placing orders also showed significant improvement between each week. Conclusion: Clerkship-wide EHR training may be limited by multiple sites with multiple EHR products. This pilot study suggests that committed faculty at an individual preceptor site can offer a targeted curriculum to help students develop EHR confidence. We propose other preceptors similarly offer students this opportunity to maximize clerkship education.

Objective: To validate the use of electronic algorithms based on International Classification of Diseases (ICD)-10 codes to identify outpatient visits for urinary tract infections (UTI), one of the most common reasons for antibiotic prescriptions. Methods: ICD-10 symptom codes (e.g., dysuria) alone or in addition to UTI diagnosis codes plus prescription of a UTI-relevant antibiotic were used to identify outpatient UTI visits. Chart review (gold standard) was performed by two reviewers to confirm diagnosis of UTI. The positive predictive value (PPV) that the visit was for UTI (based on chart review) was calculated for three different ICD-10 code algorithms using (1) symptoms only, (2) diagnosis only, or (3) both. Results: Of the 1087 visits analyzed, symptom codes only had the lowest PPV for UTI (PPV = 55.4%, 95%CI: 49.3&ndash, 61.5%). Diagnosis codes alone resulted in a PPV of 85% (PPV = 84.9%, 95%CI: 81.1&ndash, 88.2%). The highest PPV was obtained by using both symptom and diagnosis codes together to identify visits with UTI (PPV = 96.3%, 95%CI: 94.5&ndash, 97.9%). Conclusions: ICD-10 diagnosis codes with or without symptom codes reliably identify UTI visits, symptom codes alone are not reliable. ICD-10 based algorithms are a valid method to study UTIs in primary care settings.

BACKGROUND Cancer among infants (

The U.S. Preventive Services Task Force recommends that clinicians adopt universal alcohol screening and brief intervention as a routine preventive service for adults, and efforts are underway to support its widespread dissemination. The likelihood that healthcare systems will sustain this change, once implemented, is under-reported in the literature. This article identifies factors that were important to postimplementation sustainability of an evidence-based practice change to address alcohol misuse that was piloted within three diverse primary care organizations. The Centers for Disease Control and Prevention funded three academic teams to pilot and evaluate implementation of alcohol screening and brief intervention within multiclinic healthcare systems in their respective regions. Following the completion of the pilots, teams used the Program Sustainability Assessment Tool to retrospectively describe and compare differences across eight sustainability domains, identify strengths and potential threats to sustainability, and make recommendations for improvement. Health systems varied across all domains, with greatest differences noted for Program Evaluation, Strategic Planning, and Funding Stability. Lack of funding to sustain practice change, or data monitoring to promote fit and fidelity, was an indication of diminished Organizational Capacity in systems that discontinued the service after the pilot. Early assessment of sustainability factors may identify potential threats that could be addressed prior to, or during implementation to enhance Organizational Capacity. Although this study provides a retrospective assessment conducted by external academic teams, it identifies factors that may be relevant for translating evidence-based behavioral interventions in a way that assures that they are sustained within healthcare systems.

Background: Studies of antibiotic prescribing choice and duration have typically excluded women with recurrent UTI (rUTI), yet the Infectious Disease Society of America (IDSA) UTI treatment guidelines are applicable to recurrent and sporadic cystitis. We sought to better understand prescribing practices among uncomplicated rUTI patients in terms of choice of drug, duration of therapy, and the risk factors for receiving guideline-discordant therapy. Methods: We performed a retrospective database study by extracting electronic health record data from adults seen at academic primary care, internal medicine, or urology practices between November 2016 and December 2018. Inclusion criteria included having ≥2 or ≥3 International Classification of Diseases Tenth Edition (ICD-10) cystitis codes recorded within a 6- or 12-month period, respectively. We excluded patients with ICD-10 codes indicating any structural or functional genitourinary comorbidities, interstitial cystitis, vaginosis, compromised immune systems, or pregnancy in the prior year. Patients were also excluded if they had signs or symptoms of pyelonephritis at presentation. Results: Overall, 232 patients presented for 597 outpatient visits. Most were married (52.2%), non-Hispanic white (62.9%), and female (92.2%), with a median age of 58 years (IQR, 41–68). Only 21% of visits with an antibiotic prescribed for treatment consisted of a first-line therapy agent prescribed for the recommended duration. In terms of antibiotic choice, these agents were prescribed in 58.4% of scenarios, which primarily included nitrofurantoin (37.8%) and trimethoprim-sulfamethoxazole (TMP-SMX) (20.3%). Guideline-discordant choices of fluoroquinolones (28.8%), and β-lactams (11.2%) were the second and third most commonly prescribed drug categories, respectively. Multinomial logistic regression identified age (OR, 1.02; 95% CI, 1.002–1.04) or having a telephone visit (OR, 3.17; 95% CI, 1.54–6.52) as independent risk factors for receiving a β-lactam. The duration exceeded the 3-day guideline recommendation in 87.6% of fluoroquinolones and 73% of TMP-SMX (73%) prescriptions, and 61% of nitrofurantoin prescriptions exceeded the recommended 5-day duration. Multiple logistic regression analysis revealed that seeking care at a urology clinic (OR, 2.81; 95% CI, 1.59–5.17) served as an independent factor for therapy duration exceeding guideline recommendations. Conclusions: This retrospective study revealed shortcomings in prescribing practices in the type and duration of therapy for rUTI. rUTI as well as sporadic UTI are important targets for outpatient antibiotic stewardship interventions.Funding: This investigator-initiated research study was funded by Rebiotix Inc, a Ferring Company.Disclosures: None

Objective To describe the rates and temporal trends of inpatient end-of-life care among patients hospitalized with metastatic cancer in the United States. Methods We used data from the Nationwide Inpatient Sample to conduct a cross-sectional analysis of unplanned inpatient hospitalizations of patients aged 18 years or older with metastatic cancer from 2002 to 2011. Multivariable logistic regression was used to assess patient-and hospital-level predictors of discharge to hospice care, palliative care, and in-hospital mortality. Temporal trends in outcomes were characterized with use of joinpoint regression. Results There were an estimated 350,241 unplanned hospitalizations per year of patients with a diagnosis of metastatic cancer. During their inpatient stay, 5.8% of patients received palliative care, and among those discharged alive, 12.2% were referred to hospice care. The rate of inpatient palliative care increased from 2.3% to 13.6%, the rate of discharge to hospice care increased from 4.1% to 15.6%, and the in-hospital mortality rate decreased from more than 14.0% to 9.8%. These patterns were consistent across cancer subtypes, and were most pronounced among patients with extreme risk of mortality. Conclusion Despite increases in the provision of comfort-oriented care to patients with metastatic cancer, few receive such services. We recommend screening protocols in hospitals to identify patients who are good candidates for palliative care consultation and hospice referral.

Objective: To investigate the incidence and trends in colorectal cancer (CRC) among Asian American populations in the United States. Methods: CRC incidence data from 1994 through 2013 were obtained from 13 Surveillance, Epidemiology, and End Results registries. SEER*Stat and IBM SPSS Statistics were used. Results: The age-adjusted incidence of CRC among Asian Americans decreased from 45.6 per 100,000 in 1994 to 33.0 per 100,000 in 2013, with the annual percent change being −1.8% (P

Objective To describe differences in preferred roles in cancer treatment decision-making and identify associated sociodemographic and health-related factors among adults in the United States. Methods We conducted a cross-sectional analysis of nationally representative data from the 2014 Health Information National Trends Survey. Descriptive statistics were calculated and multivariable logistic regression was conducted to examine associations. Results Half (48.3%) of respondents preferred a collaborative role in decision-making under the supposition of a moderate chance of survival; while 53.4% preferred a more active role when the chance of survival was low. Approximately 7%–8% indicated a preference for a passive role in decision-making, for both low and moderate chances of survival. Several predictors of role preference for cancer treatment decision-making emerged, including age, sex, education, race/ethnicity, and having a regular health care provider. At both low and moderate chances of survival, the college educated were less likely to prefer a passive role, whereas Hispanics were two to three times more likely than whites to indicate a preference for a passive role. Conclusion Adults’ role preference for cancer treatment decision-making may be influenced by sociodemographic and health-related factors. Increased awareness of these factors, paired with enhanced patient–provider communication, may assist health care professionals in providing individualized and high-quality, patient-centered cancer care.

Background The American Cancer Society estimates that about 25% of all US cancer deaths will be due to lung cancer – more than from cancers of the colon, breast, and prostate combined. Methods We ascertained county-level age-adjusted and age-specific death rates and 95% confidence intervals from the Centers for Disease Control and Prevention Compressed Mortality File. Multiple regression analyses were used to estimate the strength and direction of relationships between county poverty, smoking, fine particulate matter (PM2.5) air pollution, and US Census divisions and race- and sex-specific lung cancer deaths. Results Poverty, smoking, and particulate matter air pollution were positively and significantly related to lung cancer deaths among white men, but of these, only poverty and smoking were significantly associated with lung cancer deaths among white women. Residence in the South Atlantic, East South Central, and West South Central US Census divisions at the time of death was significantly associated with lung cancer deaths for both white men and white women. As with white men, poverty and smoking were associated with lung cancer deaths among black men, but of these, only adult smoking had a statistically significant association among black women. Conclusions The results support the need for further research, particularly in high-risk areas, to better differentiate factors specific to race and sex and to understand the impact of local risk factors.

Objective The main objective of this initiative was to present evaluation results from an innovative adaptation of the Advanced Life Support in Obstetrics (ALSO) training course. We modified the traditional ALSO curriculum in our institution by adding hands-on training in laceration repairs and simulation scenarios on acute maternity care. Methods The modified ALSO provider course was designed to enhance cognitive and procedural skills of health care professionals in managing obstetric emergencies. Forty-nine participants attended this course and completed a posttraining survey. Descriptive statistics were used to describe the participant-reported assessment scores for the ALSO course on three domains (subject knowledge, organization and clarity, and teaching effectiveness) for each of 12 course topics. Results Evaluation of the results showed a high rate of trainee satisfaction as evidenced by the mean assessment scores across all topics ranging from 4.80 to 4.98 (out of 5.00). All trainees said they would refer others to the course. Our modified ALSO course effectively addressed the important needs of primary care physicians involved in maternity care, especially in underserved communities where specialized obstetric care is not readily available. Both simulation scenarios and workshops using simulated human tissue provide a better foundation before formal training. Conclusion Given the changing legal and regulatory climate, we expect that learning to treat complex obstetric situations on the job will become increasingly risky. With this in mind, both simulation scenarios and workshops using simulated human tissue will provide a better foundation before formal training.

Adherence to 2011 Infectious Diseases Society of America (IDSA) guidelines for urinary tract infections (UTIs) remains low in primary care. Fluoroquinolones are commonly prescribed to treat uncomplicated cystitis, and most antibiotic prescriptions have durations that exceed current recommendations. We performed a difference-in-differences study to assess the effectiveness of a stewardship intervention in a family medicine clinic at an academic outpatient center from August 2016 to March 2019. During our intervention period, the FDA released 2 additional warnings about the side effects of fluoroquinolones. Methods: The study had 2 sites (intervention and comparison) and 3 periods: baseline, before the intervention, and the intervention. During the first 2 years, we obtained baseline data and performed interviews (preintervention period) exploring provider prescribing decisions for cystitis at both sites. During the intervention period at the intervention site only, we presented an educational lecture including an overview of the IDSA guidelines, definitions for various UTI syndromes and actual clinical examples, and instruction on use of a decision aid. During the audit and feedback phase, providers were contacted once per month in person or by phone to provide follow-up on whether their treatment decision adhered to the IDSA guidelines. We performed a log-binomial regression analysis of the primary outcome, adherence to the IDSA guidelines for management of uncomplicated cystitis, both to antibiotic choice and duration of therapy. Results: We performed 156 audit-and-feedback sessions with 13 providers during the intervention period (March 2018–2019). Patients in both sites were similar in terms of age and Charlson comorbidity index. Adherence to the guidelines for antibiotic choice and duration increased in the intervention period at both sites (Fig. 1). The treatment of cystitis in the intervention period of the intervention site was 11.5 times (95% CI, 6.1–21.6) as likely to be guideline-adherent as the treatment in the baseline period of the comparison site (Fig. 2). Conclusions: Adherence to IDSA guidelines for the choice of antibiotic and duration increased in both intervention and comparison sites. Even though the intervention site started with higher compliance, improvement was also greater in the intervention site. FDA warnings about the side effects of fluoroquinolones released during the intervention period may have contributed to the avoidance of fluoroquinolones at both sites. Our intervention was effective at improving antibiotic choice and duration, so our future plans include incorporating our decision-support algorithm into the electronic medical record.Funding: This study was supported by Zambon Pharmaceuticals.Disclosures: None

Rose's Strategy of Preventive Medicine is critical reading for students and teachers in public health as well as practitioners of family and preventive medicine. In his classic, Geoffrey Rose outlines the prevention paradox that led to a discussion of two main preventive approaches to a disease, the individual- and population-based. This commentary briefly provides historical perspectives and viewpoints on the message of fundamental importance that when the population moves as a whole, the relative differences are the characteristics not of individuals but of populations. The "population as a whole" has been adopted in the lexicon of public health, enriched by Hippocrates' treatise on air, water, and places; Durkheim's collective consciousness; Pickering's continuous unimodal distribution; and Keys' charts of contrasting distributions. These readings should provide the public health professionals with a critical understanding of prevention paradox when they tend to focus only on the expression of the root cause above ground but fail to at the roots beneath the ground.

Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs&rsquo, knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.

Background The optimal approach for treating outpatient male urinary tract infections (UTIs) is unclear. We studied the current management of male UTI in private outpatient clinics, and we evaluated antibiotic choice, treatment duration, and the outcome of recurrence of UTI. Methods Visits for all male patients 18 years of age and older during 2011–2015 with International Classification of Diseases, Ninth Revision, Clinical Modification codes for UTI or associated symptoms were extracted from the EPIC Clarity Database of 2 family medicine, 2 urology, and 1 internal medicine clinics. For eligible visits in which an antibiotic was prescribed, we extracted data on the antibiotic used, treatment duration, recurrent UTI episodes, and patient medical and surgical history. Results A total of 637 visits were included for 573 unique patients (mean age 53.7 [±16.7 years]). Fluoroquinolones were the most commonly prescribed antibiotics (69.7%), followed by trimethoprim-sulfamethoxazole (21.2%), nitrofurantoin (5.3%), and beta-lactams (3.8%). Antibiotic choice was not associated with UTI recurrence. In the overall cohort, longer treatment duration was not significantly associated with UTI recurrence (odds ratio [OR] = 1.95; 95% confidence interval [CI], 0.91–4.21). Longer treatment was associated with increased recurrence after excluding men with urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, and benign prostatic hyperplasia (OR = 2.62; 95% CI, 1.04–6.61). Conclusions Our study adds evidence that men with UTI without evidence of complicating conditions do not need to be treated for longer than 7 days. Shorter duration of treatment was not associated with increased risk of recurrence. Shorter treatment durations for many infections, including UTI, are becoming more attractive to reduce the risk of resistance, adverse events, and costs.

Background: Diabetes distress (DD), a type of psychological distress specific to people with diabetes, is strongly associated with difficulties in performing self-care and inability to meet glycemic targets. Despite increased recognition of the need to manage DD, interventions that are both feasible and effective for reducing DD in routine care settings are not yet known. A pilot study showed that health coaching (HC) has some efficacy in addressing DD, but no adequately powered study has implemented a pragmatic research design capable of assessing the real-world effectiveness of HC in reducing DD. Objective: The aim of this study is to describe the rationale and design of an ongoing clinical trial, Coaching and Education for Diabetes Distress trial, that seeks to assess whether HC effectively reduces DD among primary care patients with diabetes and whether HC is more effective than an educational program targeting DD. Methods: The 2-arm randomized controlled trial is taking place at an academic family medicine practice in Houston, Texas. Both arms will receive usual care, which includes education about DD. In addition, the intervention arm will receive 8 HC sessions over a 5-month period. The primary outcome measure is reduction in DD over a 6-month period. Additional outcome measures include changes in hemoglobin A1c and self-care practices (medication-taking, dietary, and physical activity behaviors). Results: As of March 2019, screening and recruitment are ongoing, and the results are expected by July 2020. Conclusions: HC is feasible in primary care and has been successfully applied to improving chronic disease self-management and outcomes. This study will provide evidence as to whether it has significant value in addressing important unmet psychological and behavioral needs of patients with diabetes. Trial Registration: ClinicalTrials.gov NCT03617146; https://clinicaltrials.gov/ct2/show/NCT03617146 (Archived by WebCite at http://www.webcitation.org/76Va37dbO) International Registered Report Identifier (IRRID): DERR1-10.2196/12166

Background Obesity prevalence is disproportionately high among Hispanic children. Objectives The Healthy Families Study assessed the efficacy of a culturally targeted, family-based weight gain prevention intervention for Hispanic immigrant families with children ages 5-7 years. Methods The study used a two-group, cluster randomized trial design, assigning 136 families (clusters) to the active intervention (weight gain prevention) and 136 families to attention control (oral health). The active intervention included a 4-month intensive phase (eight classes) and an 8-month reinforcement phase (monthly mail/telephone contact). Children's body mass index z-score (BMI-Z) was the primary outcome. Results The BMI-Z growth rate of the active intervention group did not differ from the attention control group at short-term follow-up (median 6 months; 168 families, 206 children) or long-term follow-up (median 16 months; 142 families, 169 children). Dose response analyses indicated a slower increase in BMI-Z at short term among overweight/obese children who attended more intervention classes. Moderate physical activity on weekends increased at short term. Weekend screen time decreased at short term among those attending at least one class session. Conclusion Low class attendance likely impacted intention-to-treat results. Future interventions targeting this population should test innovative strategies to maximize intervention engagement to produce and sustain effects on weight gain prevention.

Community antimicrobial resistance rates are high in communities with frequent use of nonprescription antibiotics. Studies addressing nonprescription antibiotic use in the United States have been restricted to Latin American immigrants. We estimated the prevalence of nonprescription antibiotic use in the previous 12 months as well as intended use (intention to use antibiotics without a prescription) and storage of antibiotics and examined patient characteristics associated with nonprescription use in a random sample of adults. We selected private and public primary care clinics that serve ethnically and socioeconomically diverse patients. Within the clinics, we used race/ethnicity-stratified systematic random sampling to choose a random sample of primary care patients. We used a self-administered standardized questionnaire on antibiotic use. Multivariate regression analysis was used to identify independent predictors of nonprescription use. The response rate was 94%. Of 400 respondents, 20 (5%) reported nonprescription use of systemic antibiotics in the last 12 months, 102 (25.4%) reported intended use, and 57 (14.2%) stored antibiotics at home. These rates were similar across race/ethnicity groups. Sources of antibiotics used without prescriptions or stored for future use were stores or pharmacies in the United States, “leftover” antibiotics from previous prescriptions, antibiotics obtained abroad, or antibiotics obtained from a relative or friend. Respiratory symptoms were common reasons for the use of nonprescription antibiotics. In multivariate analyses, public clinic patients, those with less education, and younger patients were more likely to endorse intended use. The problem of nonprescription use is not confined to Latino communities. Community antimicrobial stewardship must include a focus on nonprescription antibiotics.

Background Use of antibiotics without a prescription (non-prescription use) contributes to antimicrobial resistance. Non-prescription use includes obtaining and taking antibiotics without a prescription, taking another person’s antibiotics, or taking one’s own stored antibiotics. We conducted a quantitative survey focusing on the factors that impact patients’ decisions to use non-prescription antibiotics. Methods We surveyed patients visiting public safety net primary care clinics and private emergency departments in a racially/ethnically diverse urban area. Surveys were read aloud to patients in Spanish and English. Survey domains included patients’ perspectives on which syndromes require antibiotic treatment, their perceptions of health care, and their access to antibiotics without a prescription. Results We interviewed 190 patients, 122 from emergency departments (64%), and 68 from primary care clinics (36%). Overall, 44% reported non-prescription antibiotic use within the past 12 months. Non-prescription use was higher among primary care clinic patients (63%) than the emergency department patients (39%, p = 0.002). The majority felt that antibiotics would be needed for bronchitis (78%) while few felt antibiotics would be needed for diarrhea (30%) (Figure 1). The most common situation identified “in which respondents would consider taking antibiotics without contacting a healthcare provider was “got better by taking this antibiotic before” (Figure 2). Primary care patients were more likely to obtain antibiotics without prescription from another country than emergency department patients (27% vs. 13%, P=0.03). Also, primary care patients were more likely to report obstacles to seeking a doctor’s care, such as the inability to take time off from work or transportation difficulties, but these comparisons were not statistically significant. Figure 1. Patients’ agreement that antibiotics would be needed varied by symptom/syndrome. Figure 2. Situations that lead to non-prescription antibiotic use impacted the two clinical populations differently Conclusion Non-prescription antibiotic use is a widespread problem in the two very different healthcare systems we included in this study, although factors underlying this practice differ by patient population. Better understanding of the factors driving non-prescription antibiotic use is essential to designing patient-focused interventions to decrease this unsafe practice. Disclosures All Authors: No reported disclosures

Background Since 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US. Methods The US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations. Findings From 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes. Interpretation These descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

Opioid misuse, including the use of heroin and the overprescribing, misuse, and diversion of opioid pain medications, has reached epidemic proportions in the United States. As a result, there has been a dramatic increase in opioid use disorder and associated overdoses and deaths. Addiction is a chronic brain disease with a genetic component that affects motivation, inhibition, and cognition. Patient characteristics associated with successful buprenorphine maintenance treatment include stable or controlled medical or psychiatric comorbidities and a safe, substance-free environment. As a partial opioid agonist, buprenorphine has a ceiling effect that limits respiratory depression and adds to its safety in accidental or intentional overdose. Buprenorphine and combinations of buprenorphine and naloxone are generally well tolerated; adverse effects include anxiety, constipation, dizziness, drowsiness, headache, nausea, and sedation. Family physicians who meet specific requirements can obtain a Drug Addiction Treatment Act of 2000 waiver by notifying the Substance Abuse and Mental Health Services Administration of their intent to begin dispensing and/or prescribing buprenorphine. Medication-assisted treatment with buprenorphine is as effective as methadone in terms of treatment retention and decreased opioid use when prescribed at fixed dosages of at least 7 mg per day; dosages of 16 mg per day are clearly superior to placebo. Sporadic opioid use is not uncommon in the first few months of medication-assisted treatment and should be addressed by increased visit frequency and more intensive engagement with behavioral therapies. Follow-up visits should include documentation of any relapses, reemergence of cravings or withdrawal, random urine drug testing, pill or wrapper counts, and checks of state prescription drug database records.

Objective Pre-pregnancy obesity and gestational diabetes mellitus (GDM) are increasingly prevalent independent risk factors for maternal and infant morbidities. However, there is a paucity of information on their joint effects on health outcomes and healthcare costs. Methods A population-based retrospective cohort study was conducted in Florida using a validated statewide database covering 1,057,647 infants born between 2004 and 2009. Using generalized linear modeling, joint associations between levels of pre-pregnancy body mass index (BMI) and GDM and maternal complications of pregnancy, adverse birth outcomes, and healthcare costs were examined. The relative excess risk due to interaction was used to describe the direction and magnitude of the BMI–GDM interaction on the additive scale. Results Increasing pre-pregnancy BMI conferred increasing odds of adverse consequences, as did GDM, and the BMI–GDM interaction was greater than additive for 9 of 14 outcomes. The cost for infants born to women with GDM/obesity-III was 34% higher during the first year compared with those born to women with normal BMI and without GDM. The costs of maternal and infant inpatient care associated with overweight/obesity and GDM totaled over $351 million. Conclusions These findings provide further evidence of the importance of lifestyle modifications to decrease rates of obesity and risk factors from GDM.

The reciprocal relationship between mental and physical health is well established. Undiagnosed, untreated, and poorly managed mental health conditions are associated with numerous physical health complications, poor treatment adherence, and decreased quality of life. Despite growing evidence regarding the importance of effectively addressing these conditions in primary care, the rates of identification remain low and follow-up and management by primary care providers has been criticized. The objective of this review was to demonstrate the role of Patient-Centered Medical Home (PCMH) and mental health integration in addressing comprehensive health care needs in primary care patients, and to describe common barriers and facilitators to the implementation of these types of programs.

Objective This quality improvement project evaluated the impact of a point-of-care (POC) HbA1c stat lab intervention and a nurse-assisted expanded visit implemented among patients with uncontrolled type 2 diabetes (T2D) at a community health center in Houston, TX. Methods This was a before-and-after POC intervention among adult patients who received primary care services between 1 July 2014 and 31 December 2014 (baseline visit) and who had at least one 3-month follow-up visit. Results Three hundred eighty-seven patients were included in the study. The majority were 9%) at baseline, with the highest average levels among Hispanic (10.9%) and black (10.7%) patients. There was a significant difference in the HbA1c level before (mean=10.65, SD=1.9291) and after (mean=9.25, SD=1.8187) intervention. The absolute reduction in the level of HbA1c was 1.4% (t=12.834, p Conclusion There is a distinct advantage in using a stat HbA1c lab when combined with shared POC visits to assist patients with uncontrolled T2D in lowering the HbA1c, improving self-management, and reducing long-term costs.

Objective Vaccines prevent many cases of infectious disease, yet immunization campaigns are hindered by various barriers. This work presents the results of a quality improvement project addressing barriers to vaccine compliance in an underserved teaching practice by reducing missed opportunities and increasing provider and patient compliance rates for pneumococcal, Tdap, influenza, and zoster vaccines in adults. Methods The study intervention aimed to address patient knowledge, provider knowledge and skills, proactive care coordination, and outreach and counselling of high-risk groups. Aggregate patient data from intervention at year-end were compared to the prior year. Outcome targets were as follows: improved vaccination rates by one-half of the difference between baseline and Healthy People 2020 goals; reduced patient refusals by 10%; and reduced missed opportunities by 50%. Results All of the vaccination rates improved, but with mixed results regarding the target outcomes. The rates of vaccine refusal were mixed in terms of the direction of the change, the significance, and achieving targets. Missed opportunities all improved, but the significance was mixed and none reached targets. Conclusion This project has helped to identify patient and provider knowledge of vaccination as a key to increasing compliance, and missed opportunities as the greatest challenge in achieving targets. The burden of documentation is significant on providers, and future work should focus on methods to improve the ease of documentation. Clinical outcomes and improvements were encouraging; however, it is clear that there remain challenges to reaching Healthy People 2020 goals within the study population and nationally.

Fetal alcohol spectrum disorders (FASD) occur as a result of prenatal alcohol exposure and are commonly associated with intellectual disability. Maternal alcohol consumption affects fetal development resulting in numerous lifelong physical, mental, and neurobehavioral abnormalities. To promote prevention of prenatal alcohol exposure and intervention to mitigate alcohol’s postnatal effects, the Centers for Disease Control and Prevention (CDC) provides continuing education to healthcare providers through their FASD Regional Training Centers (RTCs). An online survey evaluated healthcare providers’ perceived competency after training. Cover letters with the survey link were electronically mailed to healthcare providers, who received training between 2002 and 2009 from the Midwest and Southeast RTCs. Eighty-two providers who treated women or children responded to the survey (7.5% response rate). Approximately 86% of providers who treated women have identified women ‘at risk’ for alcohol abuse with 90% indicating they would refer to Substance Abuse or Mental Health Services. However, over 25% perceived lack of training and limited time as barriers in treating women of childbearing age for at-risk drinking. Over 90% of providers who treated children reported feeling competent in recognizing FAS and other alcohol-related effects. Yet, only 23% of providers for children reported using FASD diagnostic schema and were more apt to use growth charts (70%) rather than lip philtrum guides (58%) or palpebral fissure length measurements (50%), tools typically used in FAS determination. These results suggest a need for training to focus on methodology that assists providers to easily incorporate screening, diagnostic, and treatment procedures into their daily practice.

A community-based intervention is described that targets oral health self-care practices among Hispanic children in the United States and is being tested in an ongoing trial. Descriptive results of baseline oral health variables are presented. As of January 2013, 284 Hispanic children of ages 5–7 enrolled in the Healthy Families Study in Nashville, TN, USA. Families are randomized to one of two culturally appropriate interventions. At baseline, 69.6 % of children brushed at least twice daily, and 40.6 % brushed before bed daily. One-third of parents did not know if their children’s toothpaste contained fluoride. This intervention fills the need for community-based interventions to improve oral health self-care practices that are culturally appropriate in Hispanic families.

Objective To describe the national frequency, prevalence, and trends of discharge against medical advice (DAMA) among inpatient hospitalizations in the United States and identify differences across patient- and hospital-level characteristics, overall and in clinically distinct diagnostic subgroups. Patients and Methods We conducted a retrospective, cross-sectional analysis of inpatient hospitalizations (≥18 years), discharged between January 1, 2002, and December 31, 2011, using the Nationwide Inpatient Sample. Descriptive statistics, multivariable logistic, and joinpoint regression were used for statistical analyses. Results Between January 1, 2002, and December 31, 2011, more than 338,000 inpatient hospitalizations were discharged against medical advice each year, with a 1.9% average annual increase in prevalence over the decade (95% CI, 0.8%-3.0%). Temporal trends in DAMA varied by principal diagnosis. Among patients hospitalized for mental health- or substance abuse-related disorders, there was a −2.3% (95% CI, −3.8% to −0.8%) average annual decrease in the rate of DAMA. A statistically significant temporal rate change was not observed among hospitalizations for pregnancy-related disorders. Multivariable regression revealed several patient and hospital characteristics as predictors of DAMA, including lack of health insurance (odds ratio [OR], 3.78; 95% CI, 3.62-3.94), male sex (OR, 2.40; 95% CI, 2.36-2.45), and northeast region (OR, 1.91; 95% CI, 1.72-2.11). Other predictors included age, race/ethnicity, income, primary diagnosis, severity of illness, and hospital location/type and size. Conclusion Rates for DAMA have increased in the United States, and key differences exist across patient and hospital characteristics. Early identification of vulnerable patients and preventive measures such as improved patient-provider communication may reduce DAMA.

Objective: Health-related Internet use and eHealth technologies, including online patient-provider communication (PPC), are continually being integrated into health care environments. This study aimed to describe sociodemographic and health- and Internet-related correlates that influence adult patients’ interest in and electronic exchange of medical information with health care providers in the United States. Methods: Nationally representative cross-sectional data from the 2014 Health Information National Trends Survey (N = 3677) were analyzed. Descriptive statistics and multivariable regression analyses were performed to examine associations between patient-level characteristics and online PPC behavior and interests. Results: Most respondents were Internet users (82.8%), and 61.5% of information seekers designated the Internet as their first source for health information. Younger respondents ( Conclusion: Patients’ interest in and display of online PPC-related behaviors vary by age, race/ethnicity, education, income, Internet access/behaviors, and information type. These findings can inform efforts aimed at improving the use and adoption of eHealth technologies, which may contribute to a reduction in communication inequalities and health care disparities.