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The misuse of prescription drugs is a pressing public health crisis in the United States that is fueled by high-risk prescribing. We show that high-risk prescribing comprises two distinct practices: (1) routinely overprescribing to patients whose prescription - fill patterns are consistent with misuse or abuse, which conforms to the definition of deviance in sociology, and (2) routinely overprescribing to patients whose prescription-fill patterns are within possible bounds of medical use, which does not. We call the second practice "liminal prescribing," a term that indicates it is legally and morally ambiguous. Using 213.9 million prescriptions to construct a four-year panel of the patient-sharing networks of 500,472 physicians, we find that deviant and liminal prescribers have starkly different social network structures and social influence processes; larger and more cohesive networks among prescribers are associated with more deviance but less liminality. Physicians' ties to liminal prescribers increase liminal prescribing but do not increase deviance. Our results suggest that liminal prescribing is distinct from deviant prescribing and is not a milder form of deviant prescribing. Liminal prescribing is far more prevalent than deviance and accounts for most of the oversupplied benzodiazepines in our dataset (55.8 versus 8.7 percent, respectively). Our study highlights that the social structures supporting liminal practices differ from those that support either rule-abiding practices or deviance. [ABSTRACT FROM AUTHOR]

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

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

The prevalence of autism has increased precipitously--roughly 10-fold in the past 40 years--yet no one knows exactly what caused this dramatic rise. Using a large and representative dataset that spans the California birth cohorts from 1992 through 2000, we examine individual and community resources associated with the likelihood of an autism diagnosis over time. This allows us to identify key social factors that have contributed to increased autism prevalence. While individual-level factors, such as birth weight and parental education, have had a fairly constant effect on likelihood of diagnosis over time, we find that community-level resources drive increased prevalence. This study suggests that neighborhoods dynamically interact with the people living in them in different ways at different times to shape health outcomes. By treating neighborhoods as dynamic, we can better understand the changing socioeconomic gradient of autism and the increase in prevalence. (Contains 7 figures, 11 notes, and 3 tables.)