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This cross-sectional study examines the trends in deaths due to fentanyl poisoning in the US pediatric population.

Early Intervention (EI) programs promote early childhood development but remain underutilized. Few studies have examined correlations with completion of EI referrals using a standardized referral system. Our study examined a minority, underserved population for characteristics that affect this critical step.Subjects were referred from an inner-city pediatric primary care clinic for EI evaluation from 3/1/15-5/31/18. Subjects were3 years of age at the time of referral, received pediatric care at the clinic, and were referred for EI. The dependent variable was completion of EI evaluation, verified by the medical record. Independent variables included demographic, maternal (eg, depression), child (eg, chronic illness), and referral characteristics. A multivariable logistic regression model was used to determine the predictors for completing an evaluation.Of 181 children referred to EI, 61.9% completed an EI evaluation; the average age was 18.9 (SD 7.4) months at first referral. For every additional month of age at the initial referral, a child was 5.0% less likely to complete an evaluation (adjusted odds ratio [aOR], 0.95; 95% confidence interval [CI], 0.90-0.99; P = .02). Two factors more than doubled the odds of completing an EI evaluation: having a chronic medical illness at the time of referral (aOR = 2.41, CI 1.21-4.79; P = .01), and being a child from a non-English speaking family (aOR = 2.22, CI 1.09-4.50; P = .03).The child's age and medical history, and language spoken at home affected the odds of successfully completing an EI evaluation. These findings can help clinicians target families at risk of failing to complete EI programs.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about their co-occurrence – termed a syndemic, defined as the synergistic effect of two or more conditions—on CVD risk in people with HIV (PWH). We used data from 5621 CVD-free participants (51% PWH) in the Veteran’s Aging Cohort Study-8, a prospective, observational study of veterans followed from 2002 to 2014 to assess the association between this syndemic and incident CVD by HIV status. Diagnostic codes identified cases of CVD (acute myocardial infarction, stroke, heart failure, peripheral artery disease, and coronary revascularization). Validated measures of alcohol use, smoking, and depressive symptoms were used. Baseline number of syndemic conditions was categorized (0, 1, ≥ 2 conditions). Multivariable Cox Proportional Hazards regressions estimated risk of the syndemic (≥ 2 conditions) on incident CVD by HIV-status. There were 1149 cases of incident CVD (52% PWH) during the follow-up (median 10.1 years). Of the total sample, 64% met our syndemic definition. The syndemic was associated with greater risk for incident CVD among PWH (Hazard Ratio [HR] 1.87 [1.47–2.38], p < 0.001) and HIV-negative veterans (HR 1.70 [1.35–2.13], p < 0.001), compared to HIV-negative with zero conditions. Among those with the syndemic, CVD risk was not statistically significantly higher among PWH vs. HIV-negative (HR 1.10 [0.89, 1.37], p = .38). Given the high prevalence of this syndemic combined with excess risk of CVD, these findings support linked-screening and treatment efforts.

Guidelines and pathways exist to help frontline providers evaluate injured children for suspected child abuse. Little, however, is known about whether the decision-making resulting from these interventions is correct. Therefore, in the absence of an available gold-standard test, we used experts' judgments to examine the appropriateness of these clinical decisions. We evaluated community emergency department (ED) providers' adherence to a guideline recommending a child protection team (CPT) consultation for infants with injuries associated with abuse. We then compared providers' decision-making to experts' recommendations before and after guideline implementation.Two experts conducted a blinded, retrospective review of injured infants from 3 community EDs (N = 175). Experts rated the likelihood that an injury was abusive, indeterminate, or accidental, and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation.Postguideline implementation, there was a significant increase in CPT consultations in indeterminate cases (14.3% vs 72.2%, P.001) and in SS testing when experts recommended SS (20.6% vs 56.8%, P = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, P = .02).Providers consulted the CPT most often for indeterminate cases. SS testing was in line with expert recommendations, but CPS reporting diverged from expert recommendations. Interventions linking community ED providers with a CPT may improve the evaluation of infants with injuries concerning for abuse.

OBJECTIVES Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children

BACKGROUND: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at eight US Veterans Health Administration (VA) sites. METHODS: Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported “prescription painkillers” and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS: Among 3,702 PWH, we identified four opioid use trajectories: 1) no lifetime use (25%); 2) stable, infrequent use (58%); 3) escalating use (7%); and 4) de-escalating use 11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION: Among PWH engaged in VA care, one in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.

Introduction Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status. Methods From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status. Results Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51–0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61–0.99; for uninfected: AOR 0.70, 95% CI 0.61–0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49–0.1.00; for uninfected: AOR 0.63, 95% CI 0.48–0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention. Conclusions For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).

Caregivers' substance use is associated with child maltreatment.Examine trends from 2005 to 2018 in percentages of three outcomes with caregivers' drug or alcohol use: child protective services (CPS) referrals, substantiated maltreatment reports, and foster care placements.22 U.S. states that contributed child-level maltreatment outcomes and caregivers' substance use data to the National Child Abuse and Neglect Data System from 2005 to 2018.Joinpoint regression was used to examine the average annual percent change (AAPC) in outcomes with caregivers' drug or alcohol use and to identify temporal changes.From 2005 to 2018, CPS referrals with caregivers' drug use increased (AAPC 2.33, p .001), while referrals with alcohol use remained unchanged (AAPC -0.11, p = .92) (trend difference p = .04). Substantiated reports with caregivers' drug and alcohol use increased (AAPC drug use 3.63, p .001, AAPC alcohol use 1.28, p = .03), with a greater increase observed with drug use (difference p = .03). Foster care placements with caregivers' drug use increased (AAPC 2.54, p .001), while placements with alcohol use did not change (AAPC -1.22, p = .29), (difference p = .005). Within the study period, changes in trends with caregivers' drug use included increased substantiated reports from 2010 to 2018 (p .001) and increased foster care placements from 2009 to 2018 (p .001). With caregivers' alcohol use, CPS referrals and foster care placements decreased from 2007 to 2018 (all p .001).Trends differed for outcomes with caregivers' drug versus alcohol use. Findings can inform policies to improve care for families affected by substance use.

Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings.To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences.Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants5-months with an oral injury or bruising,9-months with a non-skull fracture, and 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries.We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline.The median (IQR) age was 4 months (2-7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category.Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.

BACKGROUND: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practices and policies, we identified factors predictive of OAT initiation among patients with and without HIV. METHODS: In this longitudinal, cohort study, we identified 19,698 new clinical encounters of OUD occurring between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of initiation of any OAT within 30-days of a new OUD clinical encounter. We used a five-month break-in-care to ensure the identified OUD clinical encounter constituted a new opportunity for treatment. RESULTS: 4.9% of both PWH and uninfected patients initiated any OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (adjusted odds ration [aOR] = 0.54, 95% confidence interval [CI] 0.47 – 0.62), PWH (aOR=0.79, 95% CI 0.68–0.92), and rural residence (aOR=0.56, 95% CI 0.39–0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR=1.60, 95% CI 1.34 – 1.92), those with an alcohol related diagnosis (aOR=1.76, 95% CI 1.48–2.08), diagnosis year 2005–2008 relative to 2000–2004 (aOR=1.24, 95% CI 1.05–1.45), and patients with HCV (aOR=1.50, 95% CI 1.27–1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models. CONCLUSIONS: PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the known health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

Oral injuries in young children may indicate physical abuse. The prevalence of oral injuries in young children presenting to the emergency department is unknown. These data would assist providers in making decisions about the need for further abuse evaluation.To determine the prevalence of oral injuries, associated chief complaints and characteristics, and frequency of abuse evaluations in children younger than 24 months presenting to a pediatric emergency department (PED).Twelve pediatric emergency medicine physicians consecutively enrolled children younger than 24 months in a tertiary care PED.We performed a prospective observational study. Enrolled patients underwent a complete oral examination. Providers recorded patient demographics, type of chief complaint, oral injury details, developmental ability, and the presence of an abuse evaluation.Oral injuries occurred in 36/1303 (2.8%, 95% CI 1.9-3.8%) and were more common in patients with traumatic (26/200, 13%) versus medical chief complaints (10/1,103, 0.9%) (p .001). Of patients with oral injuries (36), 78% were mobile and 72% had traumatic chief complaints. Nine (25%) children with oral injuries were evaluated for abuse. Oral injuries in children 0-11 months old were more likely to be evaluated for abuse than children 12-24 months old (70.0% vs. 7.7%, p .001).The prevalence of oral injuries in children24 months old presenting to a PED was low. Most occurred in mobile children and in children with traumatic chief complaints. Younger, non-mobile children with oral injuries had a higher likelihood of having an abuse evaluation.

Although previous studies have examined differences in the characteristics of abusive versus non-abusive injuries, no study has focused on the differences in the circumstances surrounding these injuries, such as whether the event that caused the injury was witnessed or heard, or EMS was called.To determine predictors related to the circumstances of the injury (COI) for distinguishing abusive versus non-abusive injuries.Children younger than 3-years-old who were hospitalized with either a head injury or a fracture and evaluated by the child abuse consultation service between June 1, 2008 and June 30, 2017.In this case-control study, abusive (cases) and non-abusive (controls) injuries were determined by a consensus of two experts blinded to the COI. Multivariable logistic regression was used to identify COI predictors of abusive injuries.We identified 302 children: 80 cases (26.5%) and 222 controls (73.5%). Abused children were less likely to have a clear event described (p .001). Of the 251 with a clear event, we found that the significant variables for abuse were father's presence (adjusted odds ratio [aOR] 8.37; 95% CI 3.35-20.92), delay ≥24 h in seeking care (aOR 6.23; 95% CI 1.95-19.92) and calling EMS (aOR 3.21; 95% CI 1.10-9.36). In contrast, the event being heard (aOR 0.22; 95% CI 0.08-0.0.59) and the child being dropped (aOR 0.09; 95% CI 0.01-0.77) were less likely to be abusive.We identified five COI predictors that may help clinicians in determining whether a child's injuries are due to abuse.

BACKGROUND We aimed to investigate the impact of reducing drinking in patients with unhealthy alcohol use on improvement of chronic pain interference, substance use, and psychiatric symptoms. METHODS We analyzed longitudinal data from 2003 to 2015 in the Veterans Aging Cohort Study, a prospective, multisite observational study of US veterans, by emulating a hypothetical randomized trial (a target trial). Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and outcome conditions were assessed via validated survey items. Individuals were followed from the first time their AUDIT score was ≥ 8 (baseline), a threshold consistent with unhealthy alcohol use. We compared individuals who reduced drinking (AUDIT

Key Points Question Can alcohol use screening scores provide clinically meaningful information and facilitate identification of adverse mental health conditions and other substance use? Findings This cohort study using data from 6431 US patients collected from 2003 to 2012 found that high alcohol use scores (Alcohol Use Disorders Identification Test score ≥20) were associated with depression, anxiety, crack or cocaine use, and other stimulant use, with likelihood ratios greater than 3.5. Meaning These findings suggest that alcohol screening can inform decisions about further screening and diagnostic assessment for depression, anxiety, and some drug use outcomes., This cohort study examines whether alcohol screening provides information regarding alcohol-clustering conditions, including depression, anxiety, and use of tobacco, marijuana, and illicit drugs among US adults., Importance Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. Objective To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. Design, Setting, and Participants This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. Exposures The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. Main Outcomes and Measures Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. Results A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs

Although the opioid crisis began nearly three decades ago, it is only in recent years that we have begun to understand how the pediatric community has been affected by what remains a growing public health problem in the United States for Americans across the lifespan. The increased use of prescription and illicit opioids among women of child-bearing age has resulted in a three-fold increase in recent years in neonatal abstinence syndrome, a condition primarily affecting newborns exposed in utero to opioids. Moreover, millions of children and adolescents are now routinely exposed in their homes and communities to prescription and illicit opioids, which have taken a significant toll on the health and well-being of the pediatric community. For toddlers, school-aged children, and adolescents, calls to poison control centers and emergency department visits for opioid ingestions and overdose have increased markedly over the past two decades.

Few studies have examined the incidence of abusive fractures in children. Only one study to date, from a single pediatric trauma center,has reported on the incidence of abusive fractures over time. That study showed a decrease in abusive fractures over a 24-year period. Our objective for this current study was to compare these published data with recent data from this same trauma center, allowing for a detailed comparison of the incidence of abusive fractures over a 30-year period. We included children

Background: Child physical abuse causes significant morbidity. Previous research has established key physical examination and radiographic findings that are associated with abusive injury. A gap in the literature, however, is the role of additional injury circumstances and details, such as the context in which the injury occurred, in distinguishing abusive from accidental injuries. Hypothesis: Are there historical elements of the context in which a child’s injury occurs that are more likely associated with either abusive or accidental mechanisms? Methods: We performed a retrospective review of the medical records …

We assessed whether tobacco screening provides clinically meaningful information about other substance use, including alcohol and other drug use, potentially facilitating targeting of screening for substance use. Using data from the Veterans Aging Cohort Study survey sample (VACS; N = 7510), we calculated test performance characteristics of tobacco use screening results for identification of other substance use including sensitivity, specificity, positive-likelihood-ratio (+LR = [sensitivity/(1-specificity)]: increase in odds of substance use informed by a positive tobacco screen), and negative-likelihood-ratio (-LR: [(1-sensitivity)/specificity]: reduction in odds of substance use informed by a negative tobacco screen). The sample was 95% male, 75% minority, and 43% were current and 33% were former smokers. Never smoking, versus any history, indicated an approximate four-fold decrease in the odds of injection drug use (-LR = 0.26), an approximate 2.5-fold decrease in crack/cocaine (-LR = 0.35) and unhealthy alcohol use (-LR = 0.40), an approximate two-fold decrease in marijuana (-LR = 0.51) and illicit opioid use (-LR = 0.48), and an approximate 30% decrease in non-crack/cocaine stimulant use (-LR = 0.75). Never smoking yielded more information than current non-smoking (never/former smoking). Positive results on tobacco screening were less informative than negative results; current smoking, versus former/never smoking, provided more information than lifetime smoking and was associated with a 40% increase in the odds of non-crack/cocaine stimulant use (+LR = 1.40) and opioid use (+LR = 1.44), 50% increase in marijuana use (+LR = 1.52) and injection drug use (+LR = 1.55), and an 80–90% increase in crack/cocaine use (+LR = 1.93) and unhealthy alcohol use (+LR = 1.75). When comprehensive screening for substance use is not possible, tobacco screening may inform decisions about targeting substance use screening.

Questionnaires over a 9-year study period (2002-2010) were used to characterize cannabis, stimulant, and alcohol use among 3099 HIV-infected men participating in the Veterans Aging Cohort Study (VACS) to determine whether use of these substances is associated with changes in the VACS Index, a validated prognostic indicator for all-cause mortality. At baseline, 18% of participants reported no substance use in the past year, 24% lower risk alcohol use only, 18% unhealthy alcohol use only, 15% cannabis use (with or without alcohol), and 24% stimulant use (with or without alcohol or cannabis). In adjusted longitudinal analyses, cannabis use [β = -0.97 (95% CI -1.93, 0.00), p = 0.048] was not associated with mortality risk, while stimulant use [1.08 (0.16, 2.00), p = 0.021] was associated with an increased mortality risk, compared to lower risk alcohol use. Our findings show no evidence of a negative effect of cannabis use on mortality risk, while stimulant use was associated with increased mortality risk among HIV-infected men. Interventions to reduce stimulant use in this patient population may reduce mortality.

We examined the relationship between alcohol use trajectories and HIV disease severity among men and women participating in the Veterans Aging Cohort Study (VACS).Prospective cohort of HIV-infected persons in care at eight US Veterans Health Administration sites.Between 2002 and 2010, we assessed alcohol consumption annually using the alcohol use disorders identification test-consumption (AUDIT-C). HIV disease severity was ascertained using the VACS index, a validated measure of morbidity and all-cause mortality. We examined the relationship between alcohol use and HIV disease severity patterns using joint trajectory modeling. Alcohol use trajectories were validated using phosphatidylethanol - a biomarker of alcohol consumption - measured between 2005 and 2006 among a subset of participants. We examined associations between membership in alcohol use and VACS index trajectories using multinomial regression.Among eligible participants, we identified four alcohol consumption trajectories: abstainers (24% of the sample), lower risk (44%), moderate risk (24%), and higher risk drinkers (8%). Alcohol use trajectories were highly correlated with phosphatidylethanol (Cramér's V = 0.465, P 0.001): mean concentrations were 4.4, 17.8, 57.7, and 167.6 ng/ml in the abstainer, lower risk, moderate risk, and higher risk groups, respectively. Four VACS index trajectories were identified: low (2%), moderate (46%), high (36%), and extreme (16%). Higher risk drinkers were most common in the extreme VACS index group, and were absent in the low index group. In multivariable analysis, the association between alcohol use and VACS index trajectory membership remained significant (P = 0.002).Alcohol use trajectories characterized by persistent unhealthy drinking are associated with more advanced HIV disease severity among HIV-infected veterans in the United States.

Objective Patients with substance use disorders (SUDs) prescribed long-term opioid therapy (LtOT) are at risk for overdose and mortality. Prior research has shown that receipt of LtOT in accordance with clinical practice guidelines has the potential to mitigate these outcomes. Our objective was to determine whether the presence of a SUD modifies the association between guideline-concordant care and 1-year all-cause mortality among patients receiving LtOT for pain. Methods Among HIV+ and HIV- patients initiating LtOT (≥90 days opioids) between 2000 and 2010 as part of the Veterans Aging Cohort Study, we used time-updated Cox regression and propensity-score matching to examine-stratified by SUD status-the association between 1-year all-cause mortality and 3 quality indicators derived from national opioid-prescribing guidelines. Specifically, we examined whether patients received psychotherapeutic cointerventions (≥2 outpatient mental health visits), benzodiazepine coprescriptions (≥7 days), and SUD treatment (≥1 inpatient day or outpatient visit). These indicators were among those found in a previous study to have a strong association with mortality. Results Among 17,044 patients initiating LtOT, there were 1048 (6.1%) deaths during 1 year of follow-up. Receipt of psychotherapeutic cointerventions was associated with lower mortality in the overall sample and was more protective in patients with SUDs (adjusted hazard ratio [AHR] 0.43, 95% confidence interval [CI] 0.33-0.56 vs AHR 0.65, 95% CI 0.53-0.81; P for interaction = 0.002). Benzodiazepine coprescribing was associated with higher mortality in the overall sample (AHR 1.41, 95% CI 1.22-1.63), but we found no interaction by SUD status (P for interaction = 0.11). Among patients with SUDs, receipt of SUD treatment was associated with lower mortality (AHR 0.43, 95% CI 0.33-0.57). Conclusions For clinicians prescribing LtOT to patients with untreated SUDs, engaging patients with psychotherapeutic and SUD treatment services may reduce mortality. Clinicians should also avoid, when possible, prescribing opioids with benzodiazepines.

A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p

Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.

Background The prevalence and risk of concurrent unhealthy drinking, cigarette use, and depression on mortality among persons living with HIV (PLWH) is unclear. This study applied a syndemic framework to assess whether these co-occurring conditions increase mortality and whether such risk is differential by HIV status. Methods We evaluated 6721 participants (49.8% PLWH) without baseline cancer from the Veterans Aging Cohort Study, a prospective, observational cohort of PLWH and matched uninfected veterans enrolled in 2002 and followed through 2015. Multivariable Cox proportional hazards regressions estimated risk of a syndemic score (number of conditions: that is, unhealthy drinking, cigarette use, and depressive symptoms) on all-cause mortality by HIV status, adjusting for demographic, health status, and HIV-related factors. Results Fewer than 10% of participants had no conditions; 25.6% had 1, 51.0% had 2, and 15.0% had all 3. There were 1747 deaths (61.9% PLWH) during the median follow-up (11.4 years). Overall, age-adjusted mortality rates/1000 person-years increased with a greater number of conditions: (0: 12.0; 1: 21.2; 2: 30.4; 3: 36.3). For 3 conditions, the adjusted hazard ratio of mortality was 36% higher among PLWH compared with uninfected participants with 3 conditions (95% confidence interval, 1.07–1.72; P = .013), after adjusting for health status and HIV disease progression. Among PLWH and uninfected participants, mortality risk persisted after adjustment for time-updated health status. Conclusions Syndemic unhealthy drinking, cigarette use, and depression are common and are associated with higher mortality risk among PLWH, underscoring the need to screen for and treat these conditions.

Background Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department. Methods Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes. Results We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30). Conclusions Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.

What's New Fellows as Medical Educators (FAME) is the first department-wide curriculum for pediatric subspecialty fellows that includes experiential learning activities, faculty and peer coaching and self-reflection through journaling. Fellows who participated in the pilot curriculum demonstrated an improvement in objective teaching skills and self-efficacy.

Key Points Question How have US mortality rates for pediatric opioid poisonings changed over the past 2 decades? Findings In this cross-sectional study, 8986 children and adolescents died between 1999 and 2016 from prescription and illicit opioid poisonings. During this time, the mortality rate increased 268.2%. Meaning Pediatric-specific and family-centered interventions are needed to address pediatric opioid poisonings, a growing public health problem in the United States., Importance It is not yet known how many children and adolescents die each year from opioid poisonings and how mortality rates have changed over time. Objective To examine national trends in pediatric deaths from prescription and illicit opioids. Design, Setting, and Participants Cross-sectional in which serial mortality data from the Centers for Disease Control and Prevention were analyzed. The population included 8986 children and adolescents (age, This cross-sectional study evaluates the changes in the mortality rates among US children and adolescents who died from prescription and illicit opioid poisonings between 1999 and 2016.

Objectives Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. Methods Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). Results Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged. Conclusions Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.

Introduction Individuals with HIV and hepatitis C (HCV) infection, alcohol use disorder, or who are prescribed potentially hepatotoxic medications may be at increased risk for buprenorphine (BUP) associated hepatotoxicity. Materials and methods We examined a cohort of HIV-infected and uninfected patients receiving an initial BUP prescription between 2003 and 2012. We compared changes in alanine and aspartate aminotransferases (ALT and AST) and total bilirubin (TB) stratified by HIV status. We identified cases of liver enzyme elevation (LEE), TB elevation (TBE), and conducted chart review to assess for cases of drug induced liver injury (DILI) and death. We examined associations between age, sex, race, HIV-infection, HCV-infection, alcohol use disorder, and prescription of other potentially heptatotoxic medications with the composite endpoint of LEE, TBE, and DILI. Results Of 666 patients prescribed BUP, 36% were HIV-infected, 98% were male, 60% had RNA-confirmed HCV infection, 50% had a recent diagnosis of alcohol use disorder, and 64% were prescribed other potentially hepatotoxic medications. No clinically significant changes were observed in median ALT, AST and TB and these changes did not differ between HIV-infected and uninfected patients. Compared with uninfected patients, HIV-infected (OR 7.3, 95% CI 2.1–26.1, p = 0.002), HCV-infected (OR 4.9 95% CI 1.6–15.2, p = 0.007) or HIV/HCV co-infected patients (OR 6.9, 95%CI 2.1–22.2, p = 0.001) were more likely to have the composite endpoint of LEE, TB elevation or DILI, in analyses that excluded 60 patients with evidence of pre-existing liver injury. 31 patients had LEE, 14/187 HIV-infected and 17/340 uninfected (p = 0.25); 11 had TBE, including 9/186 HIV-infected and 2/329 uninfected (p = 0.002); 8 experienced DILI, 4/202 HIV-infected and 4/204 uninfected (p = 0.45). There were no significant associations with alcohol use disorder or prescription of other potentially hepatotoxic medications after adjustment for HIV/HCV status. Conclusions Liver enzymes and TB are rarely elevated in HIV-infected and uninfected patients receiving BUP. Risk of hepatotoxicity was greater in individuals infected with HIV, HCV, or HIV/HCV co-infection, who may benefit from increased monitoring.

Aims To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care. Design Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use. Setting Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC. Participants A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012. Measurements The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use. Findings Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35]. Conclusions New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.

For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes—notably mortality—is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51–0.75; P

Background Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans. Objectives This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling US veterans over time. Methods Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies sampling US veterans and reporting prevalence, distribution, and examining AUDs and DUDs. Results Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessment method, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time. Conclusion The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed. Scientific Significance These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans. (Am J Addict 2016;25:7-24) Language: en

Objective: We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use. Methods: Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use. Results: A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use. Conclusion: Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.

OBJECTIVES: Firearms are a leading cause of injury and death for children and adolescents in the United States. We examined how hospitalization rates for firearm injuries differ for rural and urban populations. METHODS: The Kids’ Inpatient Database was used to identify hospitalizations for firearm injuries in patients RESULTS: There were 21 581 hospitalizations for firearm injuries. The overall hospitalization rate was higher in urban versus rural areas (risk ratio [RR] = 1.95; 95% confidence interval [CI]: 1.81–2.10). Rates were highest for assaults in urban 15- to 19-year-olds (RR = 7.82; 95% CI: 6.48–9.44). Unintentional injuries were the leading cause of hospitalizations in younger age groups in all urban and rural locations. Rates for unintentional injuries were lower among urban versus rural 5- to 9-year-olds (RR = 0.47; 95% CI: 0.36–0.63) and 10- to 14-year-olds (RR = 0.44; 95% CI: 0.37–0.52). CONCLUSIONS: Hospitalizations for firearm assaults among urban 15- to 19-year-olds represent the highest injury rate. Notably, hospitalizations are lower for urban versus rural 5- to 9-year-olds and 10- to 14-year-olds, and unintentional firearm injuries are most common among these groups. Preventative public health approaches should address these differences in injury epidemiology.

BACKGROUND/AIMS: Although nonmedical use of prescription opioids (NMUPO) is a public health problem, few studies have examined the new-onset NMUPO in clinical populations. We estimated NMUPO incidence among veterans in medical care who had received prescription opioid medication and examined correlates of new-onset NMUPO. DESIGN: Prospective cohort study. SETTING: Veterans Health Administration primary care and infectious disease clinics in Atlanta, Baltimore, Bronx, Houston, Los Angeles, Manhattan, Pittsburgh, and Washington, DC. PARTICIPANTS: Patients enrolled in the Veterans Aging Cohort Study wave 3 (2005–2007) who received prescription opioids in the previous year and without lifetime NMUPO were followed at waves 4 and 5 (2008–2011). MEASUREMENTS: Cox proportional hazards regression was used to examine the relationship between duration of prescription opioid receipt and incident NMUPO, adjusting for demographics, alcohol and tobacco use, substance use disorders, psychiatric and medical diagnoses, and medication-related characteristics. FINDINGS: Among eligible participants (n = 815), the median age was 52 (IQR = 47–58) and 498 (59.8%) were Black; 122 (15.0%) reported new-onset NMUPO, for an incidence rate of 5.0 per 100 person-years. In a multivariable Cox model, compared to < 30 days, receipt of prescription opioids for 30–180 days (adjusted hazard ratio [AHR] = 1.65 95% CI: 1.06, 2.58) or > 180 days (AHR = 1.99, 95% CI: 1.21, 3.29) was associated with incident NMUPO. CONCLUSIONS: Duration of prescription opioid receipt is a risk factor for incident NMUPO among veterans receiving medical care. Providers who prescribe opioids should monitor for NMUPO, especially among those with a longer duration of opioid therapy.

BACKGROUND: Among patients prescribed long-term opioid therapy (LTOT) for chronic pain, no study has yet examined how clinicians respond to evidence of illicit drug use and whether the decision to discontinue opioids is influenced by a patient’s race. METHODS: Among outpatients of black and white race initiating LTOT through the VA between 2000 and 2010, we reviewed electronic medical records to determine whether opioids were discontinued within 60 days of a positive urine drug test. Logistic regression was used to examine differences by race. RESULTS: Among 15,366 patients of black (48.1%) or white (51.9%) race initiating LTOT from 2000–2010, 20.5% (25.5% of blacks vs. 15.8% of whites, P

BACKGROUND Unhealthy alcohol use may be particularly detrimental among individuals living with HIV and/or hepatitis C virus (HCV), and is often under-reported. Direct biomarkers of alcohol exposure may facilitate improved detection of alcohol use. METHODS We evaluated the association of alcohol exposure determined by both self-report [Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)] and a direct biomarker [phosphatidylethanol (PEth)], with mortality among HIV-infected and HIV-uninfected in the Veterans Aging Cohort Study-Biomarker Cohort. We considered PEth

BACKGROUND:The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates. METHODS:A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use. RESULTS:The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association. CONCLUSIONS:Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

Background Increased long-term prescription of opioids and/or benzodiazepines necessitates evaluating risks associated with their receipt. We sought to evaluate the association between long-term opioids and/or benzodiazepines and mortality in HIV-infected patients receiving antiretroviral therapy and uninfected patients. Methods Prospective analysis of all-cause mortality using multivariable methods and propensity score matching among HIV-infected patients receiving antiretroviral therapy and uninfected patients. Results Of 64,602 available patients (16,989 HIV-infected and 47,613 uninfected), 27,128 (exposed and unexposed to long-term opioids and/or benzodiazepines) were 1:1 matched by propensity score. The hazard ratio for death was 1.40 [95% confidence interval (CI): 1.22 to 1.61] for long-term opioid receipt, 1.26 (95% CI: 1.08 to 1.48) for long-term benzodiazepine receipt, and 1.56 (95% CI: 1.26 to 1.92) for long-term opioid and benzodiazepine receipt. There was an interaction (P = 0.01) between long-term opioid receipt and HIV status with mortality. For long-term opioid receipt, the hazard ratio was 1.46 (95% CI: 1.15 to 1.87) among HIV-infected patients, and 1.25 (95% CI: 1.05 to 1.49) among uninfected patients. Mortality risk was increased for patients receiving both long-term opioids and benzodiazepines when opioid doses were ≥ 20 mg morphine-equivalent daily dose and for patients receiving long-term opioids alone when doses were ≥ 50 mg morphine-equivalent daily dose. Conclusions Long-term opioid receipt was associated with an increased risk of death; especially with long-term benzodiazepine receipt, higher opioid doses, and among HIV-infected patients. Long-term benzodiazepine receipt was associated with an increased risk of death regardless of opioid receipt. Strategies to mitigate risks associated with these medications, and caution when they are coprescribed, are needed particularly in HIV-infected populations.

Prescription opioids, medications once largely reserved for the treatment of severe acute pain and end-of-life cancer pain, are now routinely used by primary care physicians for the treatment of moderate to severe chronic non-cancer pain,6, 8, 26, 41, 50 a trend that is increasingly controversial.25, 26, 31, 45, 48 Rates of opioid-related serious adverse events, including unprecedented rates of addiction to prescription opioids as well as deaths from unintentional overdose, have risen in parallel with opioid prescribing.5, 10, 11, 15, 17, 32, 40 Partly in response to these trends, the American Pain Society (APS)/American Academy of Pain Medicine (AAPM) and the Department of Veterans Affairs (VA)/Department of Defense (DoD) have published guidelines and consensus statements over the past 17 years to assist clinicians in managing chronic pain with opioid therapy (OT).1, 12, 39, 53, 54 These documents stipulate that initiation of long-term opioid therapy should be preceded by a risk assessment, followed by frequent monitoring. Adherence to clinical guidelines varies by medical specialty, provider expertise, and patient population.19, 24, 34, 43, 44 We hypothesize that HIV-infection, in particular, and its association with chronic pain and medical and psychiatric comorbidities, is likely to present obstacles to the receipt of guideline-concordant care for patients receiving long-term OT. Specifically, providers and patients must manage OT in the context of the competing demands of medical, psychiatric and substance use comorbidities, and accordingly, polypharmacy.7, 14, 18, 30, 38, 42, 46 Moreover, military veterans, in general, suffer from a high prevalence of chronic pain, particularly veterans returning from Afghanistan and Iraq (i.e., Operation Enduring Freedom and Operation Iraqi Freedom, respectively).46 To date, no studies have examined the provision of OT guideline-concordant care. The objective of this study is to examine the extent to which OT guideline-concordant care was provided in HIV-infected and uninfected veterans.

BACKGROUND AND OBJECTIVE Despite recent national attention on deaths from firearms, little information exists about children and adolescents who are hospitalized for firearm injuries. The objective was to determine the national frequency of firearm-related hospitalizations in the United States in children, compare rates by cause and demographics, and describe hospitalized cases. METHODS We used the 2009 Kids’ Inpatient Database to identify hospitalizations from firearm-related injuries in young people RESULTS In 2009, 7391 (95% confidence interval [CI]: 6523–8259) hospitalizations were due to firearm-related injuries. The hospitalization rate was 8.87 (95% CI: 7.83–9.92) per 100 000 persons CONCLUSIONS On average, 20 US children and adolescents were hospitalized each day in 2009 due to firearm injuries. Public health efforts are needed to reduce this common source of childhood injury.

BACKGROUND AND OBJECTIVE: Despite recent national attention on deaths from firearms, little information exists about children and adolescents who are hospitalized for firearm injuries. The objective was to determine the national frequency of firearm-related hospitalizations in the United States in children, compare rates by cause and demographics, and describe hospitalized cases. METHODS: We used the 2009 Kids’ Inpatient Database to identify hospitalizations from firearm-related injuries in young people RESULTS: In 2009, 7391 (95% confidence interval [CI]: 6523–8259) hospitalizations were due to firearm-related injuries. The hospitalization rate was 8.87 (95% CI: 7.83–9.92) per 100 000 persons CONCLUSIONS: On average, 20 US children and adolescents were hospitalized each day in 2009 due to firearm injuries. Public health efforts are needed to reduce this common source of childhood injury.

As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children