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Objective: To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency–based primary care offices. Patients and Methods: A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency–based primary care office practices. Patients with an office visit at either of 2 IM residency–based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included. Results: During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident–associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing. Conclusion: For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.

Background and objective Increasing mortality and decreasing life expectancy in the USA are largely attributable to accidental overdose, alcohol-related disease and suicide. These ‘deaths of despair’ often follow years of morbidity, yet little is known about trends in the clinical recognition of ‘diseases of despair’. The objective of this study is to characterise rates of clinically documented diseases of despair over the last decade and identify sociodemographic risk factors.Design Retrospective study using a healthcare claims database with 10 years of follow-up.Setting Participants resided nationwide but were concentrated in US states disproportionately affected by deaths of despair, including Pennsylvania, West Virginia and Delaware.Participants Cohort included 12 144 252 participants, with no restriction by age or gender.Outcome measures Diseases of despair were defined as diagnoses related to alcohol misuse, substance misuse and suicide ideation/behaviours. A lookback period was used to identify incident diagnoses. Annual and all-time incidence/prevalence estimates were computed, along with risk for current diagnosis and patterns of comorbidity.Results 515 830 participants received a disease of despair diagnosis (58.5% male, median 36 years). From 2009 to 2018, the prevalence of alcohol-related, substance-related and suicide-related diagnoses respectively increased by 37%, 94%, and 170%. Ages 55–74 had the largest increase in alcohol/substance-related diagnoses (59% and 172%). Ages

When asked to estimate the outcome of arithmetic problems, participants overestimate for addition problems and underestimate for subtraction problems, both in symbolic and non-symbolic format. This bias is referred to as operational momentum effect (OM). The attentional shifts account holds that during computation of the outcome participants are propelled too far along a spatial number representation. OM was observed in non-symbolic multiplication and division while being absent in symbolic multiplication and division. Here, we investigate whether (a) the absence of the OM in symbolic multiplication and division was due to the presentation of the correct outcome amongst the response alternatives, putatively triggering verbally mediated fact retrieval, and whether (b) OM is correlated with attentional parameters, as stipulated by the attentional account. Participants were presented with symbolic and non-symbolic multiplication and division problems. Among seven incorrect response alternatives participants selected the most plausible result. Participants were also presented with a Posner task, with valid (70%), invalid (15%) and neutral (15%) cues pointing to the position at which a subsequent target would appear. While no OM was observed in symbolic format, non-symbolic problems were subject to OM. The non-symbolic OM was positively correlated with reorienting after invalid cues. These results provide further evidence for a functional association between spatial attention and approximate arithmetic, as stipulated by the attentional shifts account of OM. They also suggest that the cognitive processes underlying multiplication and division are less prone to spatial biases compared to addition and subtraction, further underlining the involvement of differential cognitive processes.

Biases are commonly seen in numerical cognition. The operational momentum (OM) effect shows that responses to addition and subtraction problems are biased in the whole-number direction of the operation. It is not known if this bias exists for other arithmetic operations. To determine whether OM exists in scalar operations, we measured response bias in adults performing symbolic (Arabic digits) and non-symbolic (dots) multiplication and division problems. After seeing two operands, with either a multiplication (×) or division (÷) sign, participants chose among five response choices. Both non-random performance profiles and the significant contribution of both operands in a multiple regression analysis predicting the chosen values, suggest that adults were able to use numerical information to approximate the outcomes in both notations, though they were more accurate on symbolic problems. Performance on non-symbolic problems was influenced by the size of the correct choice relative to alternatives. Reminiscent of the bias in addition and subtraction, we found a significant response bias for non-symbolic problems. Non-symbolic multiplication problems were overestimated and division problems were underestimated. These results indicate that operational momentum is present in non-symbolic multiplication and division. Given the influence of the size of the correct choice relative to alternatives, an interaction between heuristic bias and approximate calculation is possible.

Background: COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations., Methods: In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion., Results: The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD., Conclusions: This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.

Untreated patients with obstructive sleep apnea (OSA) are at increased risk for motor vehicle collisions; however, it is unclear how this should be translated into fitness-to-drive recommendations. Accordingly, the Canadian Thoracic Society (CTS) Sleep Disordered Breathing Clinical Assembly and the Canadian Sleep Society (CSS) assembled a CTS-CSS working group to propose recommendations with regard to driving in patients with OSA. Recommendations for assessing fitness to drive in noncommercial drivers: 1. Severity of OSA alone is not a reliable predictor of collision risk and, therefore, should not be used in isolation to assess fitness to drive; 2. The severity of sleep apnea should be considered in the context of other factors to assess fitness to drive; 3. The decision to restrict driving is ultimately made by the motor vehicle licensing authority; however, they should take into account the information and recommendations provided by the sleep medicine physician and should follow provincial guidelines; 4. For patients prescribed continuous positive airway pressure (CPAP) therapy, objective CPAP compliance should be documented. Efficacy should also be documented in terms of reversing the symptoms and improvement in sleep apnea based on physiological monitoring; 5. For patients treated with surgery or an oral appliance, verification of adequate sleep apnea treatment should be obtained; and 6. A driver diagnosed with OSA may be recertified as fit to drive based on assessment of symptoms and demonstrating compliance with treatment. The assessment should be aligned with the provincial driver's license renewal period. Commercial vehicles: Assessment of fitness to drive should be more stringent for patients operating commercial vehicles. In general, the CTS-CSS working group was in agreement with the Medical Expert Panel recommendations to the Federal Motor Carrier Safety Administration in the United States; these recommendations were adapted for Canadian practitioners.