Introduction and hypothesis
Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of ...asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population.
Methods
We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care.
Results
We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment.
Conclusions
The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.
•3-digit ZIP codes (“ZIP3s”) were classified into quintiles by % of White residents.•We examined trends in buprenorphine distribution by ZIP3 quintiles across 2007–2017.•Growth was disproportionately ...greater for ZIP3s with higher % White residents.•The magnitude of the observed racial/ethnic differences increased over time.•Increasing the waivered prescriber rate had smaller effect in ZIP3s with lower % White residents.
To assess whether per capita buprenorphine distribution varies by regional racial/ethnic composition, Medicaid expansion status, and time period.
Our unit of analysis -- three-digit ZIP codes (“ZIP3s”) -- was classified into quintiles based on percentage of White residents. A weighted linear regression model of buprenorphine distribution -- including White resident quintile, waivered prescriber rate, overdose rate, sociodemographic factors, and year fixed effects -- was estimated using national buprenorphine distribution data from 2007 to 2017. We report predictive margins of the buprenorphine distribution rate by quintile, as well as average marginal effects of waivered prescriber rate on buprenorphine distribution rate for each quintile. Analyses were stratified by Medicaid expansion status and time period (2007−2010, 2011−2014, 2015−2017).
Buprenorphine distribution increased nationally during 2007–2017, yet growth was disproportionately greater for ZIP3s with higher percentages of White residents. Medicaid expansion states exhibited significant differences in buprenorphine distribution across ZIP3 quintiles during 2007−2010, the magnitude of which increased across time periods. Non-expansion states exhibited significant quintile differences during 2011−2014 and 2015−2017. The average marginal effect of increasing the waivered prescriber rate on the distribution rate was consistently smaller in ZIP3s with lower percentages of White residents, particularly in expansion states.
We find ecological evidence consistent with racial/ethnic disparities in buprenorphine distribution. Our finding that increasing the waivered prescriber rate had differential effects by ZIP3 racial/ethnic composition suggest that broad initiatives to increase the number of waivered prescribers are likely insufficient to achieve equitable buprenorphine access. Rather, targeted and tailored policy efforts are warranted.
Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian ...anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.
We performed a systematic review and meta-analysis to determine whether D-mannose reduces urinary tract infection recurrence (ie, cumulative incidence) in adult women with recurrent urinary tract ...infection compared with other prevention agents. Secondary outcomes included side effects and compliance with D-mannose use.
Ovid Medline 1946-, Embase 1947-, Scopus 1823-, Cochrane Library, Web of Science 1900-, and ClinicalTrials.gov were searched through 4/15/2020.
Systematic review inclusion: randomized controlled trials, prospective cohorts, and retrospective cohorts written in English of women ≥18 years old with recurrent urinary tract infection in which D-mannose was utilized as an outpatient prevention regimen. Systematic review exclusion: lab or animal-based research, study protocols only, and conference abstracts. Meta-analysis inclusion: stated D-mannose dose, follow-up time ≥6 months, a comparison arm to D-mannose, and data available from women ≥18 years of age.
Two independent reviewers made abstract, full text, and data extraction decisions. Study methodologic quality was assessed using the Cochrane Risk of Bias tool. Relative risks, confidence intervals, and heterogeneity were computed.
Searches identified 776 unique citations. Eight publications met eligibility: 2 using D-mannose only; 6 using D-mannose combined with another treatment. Seven studies were prospective: 2 randomized controlled trials, 1 randomized cross-over trial, and 4 prospective cohort studies. One retrospective cohort study was included. Three studies met meta-analysis eligibility (1 randomized controlled trial, 1 randomized cross-over trial, and 1 prospective cohort). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to placebo was 0.23 (95% confidence interval, 0.14–0.37; heterogeneity=0%; D-mannose n=125, placebo n=123). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to preventative antibiotics was 0.39 (95% confidence interval, 0.12–1.25; heterogeneity=88%; D-mannose n=163, antibiotics n=163). Adverse side effects were reported in 2 studies assessing D-mannose only (1 study (n=10) reported none; the other reported a low incidence (8/103 participants) of diarrhea). Two studies reported compliance, which was high.
D-mannose appears protective for recurrent urinary tract infection (vs placebo) with possibly similar effectiveness as antibiotics. Overall, D-mannose appears well tolerated with minimal side effects—only a small percentage experiencing diarrhea. Meta-analysis interpretation must consider the small number of studies with varied study design and quality and the overall small sample size.
•LGB opioid disparities varied significantly by sexual identity and gender.•LGB women and gay men had elevated rates of past-year opioid misuse.•Lifetime heroin use was elevated among LGB women and ...bisexual men.•LGB women reported lower perceived risk of trying heroin and greater heroin access.•Bisexual women uniquely had elevated OUD rates and lifetime injection heroin use.
Lesbian, gay and bisexual (LGB) adults have elevated use of many substances compared to heterosexual adults, yet LGB disparities in specific types of opioid misuse and perceived opioid risk have not been fully characterized.
Data on 126,463 adults (including 8241 LGB adults) were from the 2015–2017 National Survey of Drug Use and Health. Logistic regression was used to estimate lesbian/gay (L/G) and bisexual disparities (relative to same-gender heterosexuals) for: lifetime prescription pain reliever misuse, heroin use and injection heroin use; past-year opioid misuse and opioid use disorder (OUD); and perceived risk of and access to heroin.
All LGB subgroups had elevated lifetime pain reliever misuse rates relative to same-gender heterosexuals. Lifetime heroin use was elevated among LGB women and bisexual men; bisexual women had 4 times the odds of injection heroin use. LGB women and gay men had 1.4–2.4 times the odds of past-year opioid misuse; bisexual women had 2.5 times the odds of OUD. LGB women reported both lower perceived risk of trying heroin and greater perceived heroin access.
Lifetime and past-year opioid misuse is elevated among LGB adults. Bisexual women are particularly at-risk, uniquely exhibiting disparities on high-risk injection use and OUD. Lower perceived risk of and greater access to heroin among LGB women may play a role in the onset or continuation of opioid misuse. Opioid misuse disparities among LGB adults are of substantial concern given the resultant elevated risk for fatal and non-fatal opioid overdose.
To test the hypothesis that dysregulated wound healing is associated with Urogynecologic mesh complications, we collected vaginal cell secretions using vaginal swabs after polypropylene mesh ...implantation in patients with (N = 39) and without (N = 40) complication. A customized multiplex immunoassay measured markers of inflammation (MCP-1, IGFBP-1, IL-2, IL-10, IL-17, PDGF-BB, bFGF, IL-1b, IL-6, IL-12p70, TNF-α), neuroinflammation (IL-1RA, TGF-β, IL-15, IL-18, IL-3, M-CSF), angiogenesis (VEGF), and matrix proteins (fibronectin, tenasin c, thrombospondin-2, lumican) between groups. Patients with complications were younger, heavier, implanted with mesh longer, and more likely to be ever smokers. A 5 kg/m
BMI increase and ever-smoking were associated with a 2.4-fold and sixfold increased risk of complication, respectively. Patients with the highest tertile of bFGF, fibronectin, thrombospondin-2, TNF-β, or VEGF had an odds ratio (OR) of 11.8 for having a mesh complication while ≥ 3 elevated had an OR of 237 while controlling for age, BMI, and smoking. The highest tertile of bFGF, thrombospondin-2, and fibronectin together perfectly indicated a complication (P < 0.0001). A receiver-operator curve for high bFGF, thrombospondin-2, and fibronectin showed excellent discrimination between complications and controls (AUC 0.87). These data provide evidence of dysregulated wound healing in mesh complications. Modifiable factors provide potential targets for patient counseling and interventions.
Background
Prescription opioid misuse among older adults has received little attention to date. Potential age variation in characteristics of and motivations for prescription opioid misuse has not ...been fully characterized yet has important implications for preventing diversion and misuse.
Objective
To examine (1) age-specific patterns of source of misused prescription opioid pain relievers and motives for misuse and (2) age-specific and source-specific associations with opioid use disorder (OUD), heroin use, benzodiazepine misuse, and OUD treatment utilization.
Design
Cross-sectional study using 3 waves (2015–2017) of the National Survey on Drug Use and Health (68% average response rate)
Participants
Respondents aged 12 and older with past-year prescription opioid pain reliever misuse (
n
= 8228)
Main Measures
Source for the most-recently misused prescription pain reliever (categorized as medical, social, or illicit/other), motive for last episode of misuse, OUD, heroin use, benzodiazepine misuse, and OUD treatment.
Key Results
Adults 50 and older comprised approximately 25% of all individuals reporting past-year prescription opioid misuse. A social source was most common for individuals under age 50 while a medical source was most common for individuals 50 and older. The most commonly reported motive for misuse was to “relieve physical pain”; the frequency of this response increased across age groups (47% aged 12–17 to 87% aged 65+). Among adults age 50 and older with prescription opioid misuse, 17% met criteria for OUD, 15% reported past-year benzodiazepine misuse, and 3% reported past-year heroin use.
Conclusions
Physicians continue to be a direct source of prescription opioids for misuse, particularly for older adults. Ongoing clinical initiatives regarding optimal opioid prescribing practices are needed in addition to effective non-opioid strategies for pain management. Clinical initiatives should also include screening adult and adolescent patients for non-medical use of prescription opioids as well as improving access to OUD treatment for individuals of all ages.
Introduction and hypothesis
Our primary aim was to describe the incidence of the diagnosis of urosepsis or pyelonephritis during the 60 days following initial evaluation of an uncomplicated urinary ...tract infection (UTI) among female Medicare beneficiaries ≥ 65 years of age.
Study design
This was a retrospective cohort study of women ≥ 65 years of age undergoing evaluation for an incident, uncomplicated urinary tract infection (UTI) between the years 2011–2018 included in the Medicare 5% Limited Data Set (LDS). We grouped women into age categories of 65–74 years, 75–84 years, or > 84 years old. We excluded women with possible complicated UTI, those hospitalized within 60 days prior to index UTI evaluation, and those residing in a nursing home and place of service consistent with an inpatient setting/facility. The association between age and risk of each outcome was estimated with Cox proportional hazards models, controlling for relevant comorbidities.
Results
Between 2011–2018, 169,958 women met our inclusion/exclusion criteria and were evaluated for uncomplicated UTI. In total, 2935 (1.7%) had a subsequent diagnosis of either urosepsis (
n
= 2848, 1.6%) or pyelonephritis (
n
= 145, 0.08%). In adjusted analysis, the hazard of urosepsis was significantly higher for women > 84 years (aHR 1.49, 95% CI 1.38, 1.65;
p
< 0.01) and those aged 75–84 (aHR 1.24, 95% CI 1.13, 1.37;
p
< 0.01) compared to those aged 65–74 years. In contrast, age group was not significantly associated with the hazard for pyelonephritis.
Conclusions
Urosepsis and pyelonephritis are very uncommon after evaluation of incident uncomplicated UTI in female medical beneficiaries ≥ 65 years of age.
Reliable evaluations of state-level policies are essential for identifying effective policies and informing policymakers' decisions. State-level policy evaluations commonly use a ...difference-in-differences (DID) study design; yet within this framework, statistical model specification varies notably across studies. More guidance is needed about which set of statistical models perform best when estimating how state-level policies affect outcomes.
Motivated by applied state-level opioid policy evaluations, we implemented an extensive simulation study to compare the statistical performance of multiple variations of the two-way fixed effect models traditionally used for DID under a range of simulation conditions. We also explored the performance of autoregressive (AR) and GEE models. We simulated policy effects on annual state-level opioid mortality rates and assessed statistical performance using various metrics, including directional bias, magnitude bias, and root mean squared error. We also reported Type I error rates and the rate of correctly rejecting the null hypothesis (e.g., power), given the prevalence of frequentist null hypothesis significance testing in the applied literature.
Most linear models resulted in minimal bias. However, non-linear models and population-weighted versions of classic linear two-way fixed effect and linear GEE models yielded considerable bias (60 to 160%). Further, root mean square error was minimized by linear AR models when we examined crude mortality rates and by negative binomial models when we examined raw death counts. In the context of frequentist hypothesis testing, many models yielded high Type I error rates and very low rates of correctly rejecting the null hypothesis (< 10%), raising concerns of spurious conclusions about policy effectiveness in the opioid literature. When considering performance across models, the linear AR models were optimal in terms of directional bias, root mean squared error, Type I error, and correct rejection rates.
The findings highlight notable limitations of commonly used statistical models for DID designs, which are widely used in opioid policy studies and in state policy evaluations more broadly. In contrast, the optimal model we identified--the AR model--is rarely used in state policy evaluation. We urge applied researchers to move beyond the classic DID paradigm and adopt use of AR models.
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