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OBJECTIVE: We sought to estimate rates of progression and regression of grade 1 cervical intraepithelial neoplasia (CIN 1) among women with human immunodeficiency virus (HIV). METHODS: In a multicenter prospective cohort study, HIV-seropositive and HIV-seronegative women were evaluated colposcopically after receiving an abnormal cytology test result between November 1994 and September 2002. Women with CIN 1 were included, except those who had undergone hysterectomy, cervical therapy, or had CIN 2-3 or cervical cancer. Those women who were included were followed cytologically twice yearly, with colposcopy repeated for atypia or worse. RESULTS: We followed 223 women with CIN 1 (202 HIV seropositive and 21 HIV seronegative) for a mean of 3.3 person-years. Progression occurred in 8 HIV-seropositive women (incidence density, 1.2/100 person-years; 95% confidence interval [CI] 0.5-2.4/100 person-years) and in no HIV seronegative women. Regression occurred in 66 (33%) HIV-seropositive women (13/100 person-years, 95% CI 10-16/100 person-years) versus 14 (67%) seronegative women (32/100 person-years, relative risk 0.40, 95% CI 0.25-0.66; P < .001). In multivariate analysis, regression was associated with human papillomavirus (HPV) detection (hazard ratio [HR] for low risk 0.28, 95% CI 0.13-0.61, P = .001; and for high-risk 0.34, 95% CI 0.20-0.55, P < .001 versus no HPV detected) and Hispanic ethnicity (HR 0.48, 95% CI 0.230.98; P = .04); HIV serostatus was only marginally linked to regression (HR 0.52, 95% CI 0.27-1.03; P = .06), but seropositive women were less likely to regress when analysis was limited to 146 women with HPV detected at CIN 1 diagnosis (HR 0.18, 95% CI 0.05-0.62; P = .006). CONCLUSION: Grade 1 cervical intraepithelial neoplasia infrequently progresses in women with HIV. Thus, observation appears safe absent other indications for treatment. LEVEL OF EVIDENCE: II-1. [ABSTRACT FROM AUTHOR]

Monitoring vaccination activity requires regular access to information about patient vaccination status. This report describes our experience using multiple Department of Veterans Affairs (VA) data sources to determine availability and completeness of vaccination information for veterans with spinal cord injuries and disorders (SCI&D). Administrative and clinical databases were limited to coding vaccine administration, undercounted vaccinations, and were unable to account for whether the vaccine was offered and the reasons for nonreceipt. Medical record review provided more detail but was labor intensive and costly. Patient surveys provided the richest information but were costly, time-consuming, and based on a sample of patients. Agreement was poor between data sources. This report suggests that while VA is well positioned to use national databases for clinical care decisions and to inform policy, vaccination data were incomplete. Electronic records must include data that are consistently entered and validated before they can be useful for care management and decision making. [ABSTRACT FROM AUTHOR]

Context: Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D)., Objective: The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies., Method: SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders)., Results: AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation., Conclusion: Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Context: Veterans Health Administration (VHA) maintained a registry of identified and verified cases of US Veterans with spinal cord injuries and disorders (SCI/D) since 1994: VHA SCI/D Registry (VHA SCIDR). Data elements, capture, and storage methods varied over time., Objective: Describe the consolidation and harmonization of historical VHA SCIDR data spanning three decades during its evolution to an automated platform and report population characteristics., Methods: The VHA SCIDR captured data using four distinct acquisition methods over 28 years, including cases of Veterans with SCI/D receiving SCI/D System of Care services, via 25 SCI/D Centers and 122 Spoke Sites throughout the VHA healthcare system. Foundational elements of VHA SCIDR data capture methods, harmonization of data elements with the current automated algorithm, access protocol, and governance structure are described., Results: From Fiscal Years (FYs) 1994 to 2022, VHA SCIDR identified 52,407 Veterans with traumatic or non-traumatic SCI/D, and 96.95% were male, 56.09% White, 16.57% were Black, 1.23% Asian and Pacific Islander, 0.75% Native American, and 25.36% unknown. Traumatic etiology comprised 53.39% of the sample, while 31.75% were non-traumatic, with 14.87% missing etiology classification. Injury category proportions were 5.19% high tetraplegia, 5.83% low tetraplegia, 5.85% high paraplegia, 7.53% low paraplegia, and 23.35% AIS D, with 52.25% missing or unable to be calculated., Conclusions: VHA SCIDR is one of the three largest SCI/D registries in North America and is the case-identification platform for VHA SCI/D operations, program evaluation, and research studies. VHA SCIDR is connected to each Veteran's VHA healthcare data, facilitating big data research.

Objectives: We aimed to evaluate the association between antibiotic prophylaxis and adverse outcomes following tooth extraction within the Veterans Affairs Healthcare System., Methods: We conducted a retrospective cohort study of patients undergoing dental extractions in 2015-2019. The primary exposure was antibiotic prophylaxis. The primary outcome was post-extraction complication within 7 days (e.g., alveolar osteitis and surgical site infection); the secondary outcome was subsequent medical care relating to a post-extraction oral complication within 7 days. Multivariable logistic regression models assessed the independent effect of antibiotic prophylaxis on each outcome., Results: Of 385,880 visits with a dental extraction, 122,810 (31.8%) received antibiotic prophylaxis. Overall, 3387 (0.9%) experienced a post-extraction complication and 350 (0.09%) received medical care relating to a post-extraction oral complication within 7 days. In multivariable regression, diabetes was a statistically significant (p = 0.01) effect modifier of the association between antibiotic prophylaxis and post-extraction complication. Among visits for patients without diabetes, antibiotic prophylaxis was significantly associated with an increased odds of post-extraction complication (odds ratio [OR] = 1.25, 95% confidence interval [CI]: 1.13-1.38), but among visits for patients with diabetes no significant effect was observed (OR = 1.03, 95% CI: 0.92-1.15). Antibiotic prophylaxis was not significantly associated with post-extraction medical care (OR = 1.04; 95% CI: 0.83-1.30)., Conclusions: In this large retrospective cohort, we observed no significant protective effect of antibiotic prophylaxis on post-extraction complications or subsequent medical care utilization in a setting with low complication rates. These data suggest that use of antibiotic prophylaxis in similar settings may need to be re-evaluated to minimize unnecessary antibiotic use., (© 2024 The Author(s). Journal of Public Health Dentistry published by Wiley Periodicals LLC on behalf of American Association of Public Health Dentistry. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Control of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa spread in healthcare settings begins with timely and accurate laboratory testing practices. Survey results show most Veterans Affairs facilities are performing recommended tests to identify these organisms. Most facilities report sufficient resources to perform testing, though medium-complexity facilities report some perceived barriers., Competing Interests: None., (© The Author(s) 2024.)

Background: Ceftazidime/avibactam is one of the preferred treatment options for carbapenem-resistant Enterobacterales (CRE). However, the benefit of combining ceftazidime/avibactam with another antibiotic remains unclear., Objectives: To identify variables associated with treatment failure during the use of ceftazidime/avibactam for CRE infections and assess the effect of combining an aminoglycoside with ceftazidime/avibactam., Methods: This was a retrospective cohort study of patients with a positive CRE culture treated with ceftazidime/avibactam between 2015 and 2021 in 134 Veterans Affairs (VA) facilities. The primary outcome was 30-day mortality and the secondary outcome was in-hospital mortality. A subanalysis in patients who received an aminoglycoside was also performed., Results: A total of 303 patients were included. The overall 30-day and in-hospital mortality rates were 12.5% and 24.1%, respectively. Age (aOR 1.052, 95% CI 1.013-1.093), presence in the ICU (aOR 2.704, 95% CI 1.071-6.830), and receipt of an aminoglycoside prior to initiation of ceftazidime/avibactam (aOR 4.512, 95% CI 1.797-11.327) were independently associated with 30-day mortality. In the subgroup of patients that received an aminoglycoside (n = 77), their use in combination with ceftazidime/avibactam had a 30-day mortality aOR of 0.321 (95% CI, 0.089-1.155)., Conclusion: In veterans treated with ceftazidime/avibactam for CRE infections, increased age, receipt of an empiric aminoglycoside, and presence in the ICU at the time of index culture were associated with higher 30-day mortality. Among patients who received an aminoglycoside, their use in combination with ceftazidime/avibactam trended toward protectiveness of 30-day mortality, suggesting a potential role for this combination to treat CRE infections in patients who are more severely ill., Competing Interests: Declaration of competing interests None declared., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Abstract: Inappropriate urinary tract infection diagnosis in patients with neurogenic bladder may result from ambiguous symptoms experienced by these patients and contributes to antibiotic overuse. Characterization of patient-reported signs and symptoms may help providers more appropriately diagnose urinary tract infections. A previous study collected signs and symptoms recorded in electronic medical records of patients with neurogenic bladder due to spinal cord injury/disorder, multiple sclerosis, and Parkinson's disease with at least one urinary tract infection diagnosis between 2017-2018 at four medical centers. In this study, 23 veterans from this cohort with urinary tract infection diagnoses in the previous year participated in focus groups conducted May 2021-May 2022. Transcripts were coded using mixed deductive and inductive coding. Qualitative data were compared to electronic medical records data to give a comprehensive picture of signs and symptoms. Both providers and patients attributed nonspecific symptoms like urine changes to urinary tract infection, but there was discordance between patients and providers in the identification of other signs and symptoms. Several patients described providers disregarding symptoms other than fever or chills. Optimizing urinary tract infection care for patients with neurogenic bladder could involve improving patient-provider communication about urinary tract infection signs and symptoms and emphasizing thorough elicitation and evaluation of all signs and symptoms., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Besides race, little is known about how other social determinants of health (SDOH) affect quality of diabetic eye care., Objective: To evaluate the association between multiple SDOH and monitoring for diabetic retinopathy (DR) in accordance with clinical practice guidelines (CPGs)., Design, Setting, and Participants: This cohort study was conducted in 11 US medical centers and included adult patients (18-75 years old) with diabetes. Patients received care from 2012 to 2023 and had 18 months or more of follow-up., Exposures: Multiple SDOH and associated factors, including ethnicity, urbanicity of residence, health insurance type, and diabetes type., Main Outcomes and Measures: Adjusted odds ratio (aOR) of receiving 1 or more eye-care visits and 1 or more dilated fundus examinations in accordance with CPGs., Results: The study cohort included 37 397 adults with diabetes: 10 157 Black patients and 27 240 White patients. The mean (SD) age was 58 (11) years for Black patients and 59 (11) years for White patients. Of the Black patients, 6422 (63.2%) were female and 3735 (36.8%) male; of the White patients, 13 120 (48.1) were female and 14 120 (51.8) were male. Compared with those of the same race in urban communities, Black patients (aOR, 0.12; 95% CI, 0.04-0.31) and White patients (aOR, 0.75; 95% CI, 0.62-0.91) with diabetes living in rural communities had 88% and 25% lower odds of having eye-care visits, respectively. Sicker Black and White patients, defined by the Charlson Comorbidity Index, had 4% (aOR, 1.04; 95% CI, 1.02-1.06) and 5% (aOR, 1.05, CI 1.04-1.06) higher odds of having an eye-care visit, respectively. Black patients with preexisting DR had 15% lower odds of visits (aOR, 0.85, CI 0.73-0.99) compared with those without preexisting DR while White patients with preexisting DR had 16% higher odds of eye-care visits (aOR, 1.16; 95% CI, 1.05-1.28). White patients with Medicare (aOR, 0.85; 95% CI, 0.80-0.91) and Medicaid (aOR, 0.81; 95% CI, 0.68-0.96) had lower odds of eye-care visits vs patients with commercial health insurance. Hispanic White patients had 15% lower odds of eye-care visits (aOR, 0.85; 95% CI, 0.74-0.98) vs non-Hispanic White patients. White patients with type 1 diabetes had 17% lower odds of eye-care visits (aOR, 0.83; 95% CI, 0.76-0.90) vs those with type 2 diabetes. Among patients who had eye-care visits, those with preexisting DR (Black: aOR, 1.68; 95% CI, 1.11-2.53; White: aOR, 1.51; 95% CI, 1.16-1.96) were more likely to undergo dilated fundus examinations., Conclusions and Relevance: This study found that certain SDOH affected monitoring for DR similarly for Black and White patients with diabetes while others affected them differently. Patients living in rural communities, Black patients with preexisting DR, and Hispanic White patients were not receiving eye care in accordance with CPGs, which may contribute to worse outcomes.

Objective: Stenotrophomonas maltophilia is a multidrug-resistant gram-negative bacillus that can cause serious infections but has limited treatment options. This study aims to establish trends in the treatment of S. maltophilia bloodstream infections (BSI) across the United States in Department of Veterans Affairs (VA) facilities., Methods: Data was evaluated over a 10-year timeframe (2012 to 2021) in this retrospective cohort study. Veterans with ≥ 1 blood culture with S. maltophilia within a VA medical encounter were included. Microbiology, pharmacy, and patient information were collected through national VA data sources and chart review. Descriptive statistics and Poisson regression were used to summarize patient demographics, facility characteristics, microbiologic data, and treatment trends., Results: A total of 374 blood cultures positive for S. maltophilia were identified across 75 VA facilities. Of 282 unique patients with BSI, the majority were male (93.6%), white (67.4%), with a mean age of 64 ± 13.1 years. Of those patients, 78% received treatment, 12.8% had a polymicrobial blood culture, and 5.3% had a documented sulfa allergy. Susceptibility results were most reported for trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, and ceftazidime, with 4.5%, 4.3%, and 44.4% resistant isolates, respectively. Antibiotics most prescribed included TMP-SMX (41.5%) and levofloxacin (39.4%), followed by ciprofloxacin (13.8%) and ceftazidime (12.4%). Combination therapy was prescribed in 33% of patients. No significant trends were found with antibiotic utilization over time., Conclusions: TMP-SMX and levofloxacin were the most prescribed antibiotics for S. maltophilia BSI treatment. No significant changes were seen with antibiotic prescribing trends in Veterans from 2012 to 2021., Competing Interests: All authors report no conflicts of interest or financial disclosures relevant to this article. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government., (© The Author(s) 2024.)

Introduction: Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket)., Methods: Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction., Results: Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88)., Conclusion: Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted., (2024 Special Care Dentistry Association and Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objectives: While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing., Methods: Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions., Results: 73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians., Conclusions: The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics., (© 2024 American Association of Public Health Dentistry.)

Objective: Develop and implement a system in the Veterans Health Administration (VA) to alert local medical center personnel in real time when an acute- or long-term care patient/resident is admitted to their facility with a history of colonization or infection with a multidrug-resistant organism (MDRO) previously identified at any VA facility across the nation., Methods: An algorithm was developed to extract clinical microbiology and local facility census data from the VA Corporate Data Warehouse initially targeting carbapenem-resistant Enterobacterales (CRE) and methicillin-resistant Staphylococcus aureus (MRSA). The algorithm was validated with chart review of CRE cases from 2010-2018, trialed and refined in 24 VA healthcare systems over two years, expanded to other MDROs and implemented nationwide on 4/2022 as "VA Bug Alert" (VABA). Use through 8/2023 was assessed., Results: VABA performed well for CRE with recall of 96.3%, precision of 99.8%, and F1 score of 98.0%. At the 24 trial sites, feedback was recorded for 1,011 admissions with a history of CRE (130), MRSA (814), or both (67). Among Infection Preventionists and MDRO Prevention Coordinators, 338 (33%) reported being previously unaware of the information, and of these, 271 (80%) reported they would not have otherwise known this information. By fourteen months after nationwide implementation, 113/130 (87%) VA healthcare systems had at least one VABA subscriber., Conclusions: A national system for alerting facilities in real-time of patients admitted with an MDRO history was successfully developed and implemented in VA. Next steps include understanding facilitators and barriers to use and coordination with non-VA facilities nationwide.

Decreasing the time to contact precautions (CP) is critical to carbapenem-resistant Enterobacterales (CRE) prevention. Identifying factors associated with delayed CP can decrease the spread from patients with CRE. In this study, a shorter length of stay was associated with being placed in CP within 3 days., Competing Interests: The authors have no conflicts of interest to disclose., (© The Author(s) 2024.)

Study Design: Qualitative study., Objectives: To explore how knowledge, perceptions, and beliefs about urinary tract infections (UTIs) among persons with neurogenic bladder (NB) may impact health behaviors and provider management and enhance person-centeredness of interventions to improve UTI management., Setting: Three Veterans Affairs (VA) medical centers., Methods: Adults with NB due to spinal cord injury/disorder (SCI/D) or multiple sclerosis (MS) with UTI diagnoses in the prior year participated in focus groups. Transcripts were coded using deductive codes linked to the Health Belief Model and inductive codes informed by grounded theory., Results: Twenty-three Veterans (SCI/D, 78%; MS: 18.5%) participated in discussions. Three themes emerged: (1) UTI knowledge; (2) factors affecting the intervention environment; and (3) factors affecting modes of delivery. Knowledge gaps included UTI prevention, specific symptoms most indicative of UTI, and antibiotic side effects. Poor perceptions of providers lacking knowledge about NB and ineffective patient-provider communication were common in the Emergency Department and non-VA facilities, whereas participants had positive perceptions of home-based care. Participants perceived lower severity and frequency of antibiotic risks compared to UTI risks. Participant preferences for education included caregiver involvement, verbal and written materials, and diverse settings like peer groups., Conclusions: Identifying patient perspectives enhances person-centeredness and allows for novel interventions improving patient knowledge and behaviors about UTIs. Partnering with trusted providers and home-based caregivers and improving NB knowledge and communication in certain care settings were important. Patient education should address mental risk representations and incorporate preferences for content delivery to optimize self-efficacy and strengthen cues to action., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To describe utilization of at-home coronavirus disease 2019 (COVID-19) testing among healthcare workers (HCW)., Design: Serial cross-sectional study., Setting and Participants: HCWs in the Chicago area., Methods: Serial surveys were conducted from the Northwestern Medicine (NM HCW SARS-CoV-2) Serology Cohort Study. In April 2022, participants reflected on the past 30 days to complete an online survey regarding COVID-19 home testing. Surveys were repeated in June and November 2022. The percentage of completed home tests and ever-positive tests were reported. Multivariable Poisson regression was used to calculate prevalence rate ratios (PRR) and univariate analysis was used for association between participant characteristics with home testing and positivity., Results: Overall, 2,226 (62.4%) of 3,569 responded to the survey in April. Home testing was reported by 26.6% of respondents and 5.9% reported having at least one positive home test. Testing was highest among those 30-39 years old (35.9%) and nurses (28.3%). A positive test was associated ( P < .001) with exposure to people, other than patients with known or suspected COVID-19. Home testing increased in June to 36.4% (positivity 19.9%) and decreased to 25% (positivity 13.5%) by November., Conclusion: Our cohort findings show the overall increase in both home testing and ever positivity from April to November - a period where changes in variants of concern of SARS-CoV-2 were reported nationwide. Having an exposure to people, other than patients with known or suspected COVID-19 was significantly associated with both, higher home testing frequency and ever-test positivity., Competing Interests: The author(s) declare none.All authors on this manuscript declare no conflicts of interests or financial disclosures relevant to this article., (© The Author(s) 2024.)

Background: Antibiotics prescribed as infection prophylaxis prior to dental procedures have the potential for serious adverse drug events (ADEs). However, the extent to which guideline concordance and different dental settings are associated with ADEs from antibiotic prophylaxis is unknown. Aim: The purpose was to assess guideline concordance and antibiotic-associated ADEs and whether it differs by VA and non-VA settings. Methods: Retrospective cohort study of antibiotic prophylaxis prescribed to adults with cardiac conditions or prosthetic joints from 2015 to 2017. Multivariable logistic regression models were fit to assess the impact of ADEs, guideline concordance and dental setting. An interaction term of concordance and dental setting evaluated whether the relationship between ADEs and concordance differed by setting. Results: From 2015 to 2017, 61,124 patients with antibiotic prophylaxis were identified with 62 (0.1%) having an ADE. Of those with guideline concordance, 18 (0.09%) had an ADE while 44 (0.1%) of those with a discordant antibiotic had an ADE (unadjusted OR: 0.84, 95% CI: 0.49-1.45). Adjusted analyses showed that guideline concordance was not associated with ADEs (OR: 0.78, 95% CI: 0.25-2.46), and this relationship did not differ by dental setting (Wald χ^2 p -value for interaction = 0.601). Conclusion: Antibiotic-associated ADEs did not differ by setting or guideline concordance., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ramanathan, Evans, Hershow, Calip, Rowan, Hubbard and Suda.)

Objective: Inappropriate diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are leading causes of antibiotic overuse but have not been well-studied in patients with risks for complicated UTI such as neurogenic bladder (NB). Our aim was to describe ASB and UTI management in patients with NB and assess factors associated with inappropriate management., Design: Retrospective cohort study., Setting: Four Department of Veteran's Affairs (VA) medical centers., Participants: Adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson disease (PD) and encounters with an ASB or UTI diagnosis between 2017 and 2018. Clinical and encounter data were extracted from the VA Corporate Data Warehouse and medical record reviews for a stratified sample of 300 encounters from N=291 patients., Interventions: None., Main Outcome Measures: Prevalence of appropriate and inappropriate ASB and UTI diagnosis and treatment was summarized. Multivariable logistic regression models assessed factors associated with inappropriate management., Results: N=200 UTI and N=100 ASB encounters were included for the 291 unique patients (SCI/D, 39.9%; MS, 36.4%; PD, 23.7%). Most patients were men (83.3%), >65 years (62%), and used indwelling or intermittent catheterization (68.3%). Nearly all ASB encounters had appropriate diagnosis (98%). 70 (35%) UTI encounters had inappropriate diagnosis, including 55 (27.5%) with true ASB, all with inappropriate treatment. Among the remaining 145 UTI encounters, 54 (27%) had inappropriate treatment. Peripheral vascular disease, chronic kidney disease, and cerebrovascular disease were associated with increased odds of inappropriate management; indwelling catheter (aOR 0.35, P=.01) and Physical Medicine & Rehabilitation provider (aOR 0.29, P<.01) were associated with decreased odds., Conclusion: Up to half of UTI encounters for patients with NB had inappropriate management, largely due to inappropriate UTI diagnosis in patients with true ASB. Interventions to improve ASB and UTI management in patients with NB should target complex patients with comorbidities being seen by non-rehabilitation providers., (Published by Elsevier Inc.)

Objective: To describe antimicrobial therapy used for multidrug-resistant (MDR) Acinetobacter spp. bacteremia in Veterans and impacts on mortality., Methods: This was a retrospective cohort study of hospitalized Veterans Affairs patients from 2012 to 2018 with a positive MDR Acinetobacter spp. blood culture who received antimicrobial treatment 2 days prior to through 5 days after the culture date. Only the first culture per patient was used. The association between treatment and patient characteristics was assessed using bivariate analyses. Multivariable logistic regression models examined the relationship between antibiotic regimen and in-hospital, 30-day, and 1-year mortality. Generalized linear models were used to assess cost outcomes., Results: MDR Acinetobacter spp. was identified in 184 patients. Most cultures identified were Acinetobacter baumannii (90%) , 3% were Acinetobacter lwoffii, and 7% were other Acinetobacter species. Penicillins-β-lactamase inhibitor combinations (51.1%) and carbapenems (51.6%)-were the most prescribed antibiotics. In unadjusted analysis, extended spectrum cephalosporins and penicillins-β-lactamase inhibitor combinations-were associated with a decreased odds of 30-day mortality but were insignificant after adjustment (adjusted odds ratio (aOR) = 0.47, 95% CI, 0.21-1.05, aOR = 0.75, 95% CI, 0.37-1.53). There was no association between combination therapy vs monotherapy and 30-day mortality (aOR = 1.55, 95% CI, 0.72-3.32)., Conclusion: In hospitalized Veterans with MDR Acinetobacter spp ., none of the treatments were shown to be associated with in-hospital, 30-day, and 1-year mortality. Combination therapy was not associated with decreased mortality for MDR Acinetobacter spp. bacteremia., Competing Interests: All authors report no conflicts of interest or financial disclosures relevant to this article.The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government., (© The Author(s) 2023.)

Objective: The Veterans Health Administration (VHA), the largest single provider of spinal cord injury and disorder (SCI/D) care in the United States, currently mandates that every patient receives a screening urine culture during the annual evaluation, a yearly comprehensive history and physical examination. This testing has shown in a small subset of patients to overidentify asymptomatic bacteriuria that is then inappropriately treated with antibiotics. The objective of the current analysis was to assess the association of the annual evaluation on urine testing and antibiotic treatment in a national sample of Veterans with SCI/D., Design/method: A retrospective cohort study using national VHA electronic health record data of Veterans with SCI/D seen between October 1, 2017-September 30, 2019 for their annual evaluation., Results: There were 9447 Veterans with SCI/D who received an annual evaluation; 5088 (54%) had a urine culture obtained. 2910 cultures (57%) were positive; E. coli was the most common organism obtained (12.9% of total urine cultures). Of the patients with positive urine cultures, 386 were prescribed antibiotics within the 7 days after that encounter (13%); of the patients with negative cultures (n = 2178), 121 (6%) were prescribed antibiotics; thus, a positive urine culture was a significant driver of antibiotic use (p < 0.001)., Conclusion: The urine cultures ordered at the annual exam are often followed by antibiotics; this practice may be an important target for antibiotic stewardship programs in SCI., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: During the coronavirus disease 2019 pandemic, high levels of burnout were reported among healthcare workers. This study examines the association of work absenteeism and frequency of thoughts in leaving current job with burnout among a cohort of healthcare workers during the COVID-19 pandemic., Methods: A cross-sectional survey of healthcare workers was conducted from April-May, 2022 on healthcare workers from 10 hospitals, 18 immediate care centers, and 325 outpatient practices in the Chicago area and surrounding Illinois suburbs. Logistic regression models were used to assess the association of burnout scores (Oldenburg Burnout Inventory-OLBI) and its sub-scores (exhaustion and disengagement scores) with work absenteeism and thoughts of leaving work., Results: One-fifth and 60% of respondents ( n  = 1,825) reported unplanned absenteeism and thoughts of leaving their job, respectively. After adjusting for covariates, higher burnout scores, especially exhaustion scores, were associated with increased odds of unplanned absenteeism (OR = 1.04, 95% CI: 1.01-1.08). Burnout scores and both sub-scores were also positively associated with the frequency of thoughts of leaving work, e.g., each unit increase in the OLBI burnout score was associated with 1.39 (95% CI: 1.34-1.43) times higher odds of thinking about leaving work "a lot/constantly" vs. "never"., Discussion: Overall, this study cohort showed a positive association between burnout scores and unplanned work absenteeism (and frequency of thoughts in leaving job) during the COVID-19 pandemic. More research is needed to support healthcare worker well-being during times of stress and direct solutions to addressing unplanned absenteeism in the light of a pandemic., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Lee, Vu, Fuller, Freedman, Bannon, Wilkins, Moskowitz, Hirschhorn, Wallia and Evans.)

Although urinary tract infections (UTIs) are common in patients with neurogenic bladder (NB), limited data exist on UTI perceptions, experiences, and beliefs in these patients. We recruited adults with NB due to spinal cord injury/disorder (SCI/D) or multiple sclerosis (MS) at three Veterans Affairs (VA) medical centers to participate in 11 virtual focus groups. Audio transcripts were coded using a mixed approach with primary deductive codes linked to the Health Belief Model, and secondary inductive codes informed by grounded theory. Twenty-three Veterans (SCI/D, 78%; MS, 18.5%) participated between May 2021 and May 2022. Participants' perspectives, experiences, and beliefs about UTI were reflected in three major themes: 1) influence of caregivers; 2) influence of the healthcare environment and provider characteristics; and 3) barriers and facilitators to care. Caregivers promoted care-seeking behavior, enabled in-home care, and enhanced participants' self-efficacy to understand educational material. Participants had poor perceptions of providers who were not knowledgeable about NB or ineffectively communicated. Good relationships with providers who knew the participant well improved self-efficacy to follow provider recommendations. These results suggest that patient-centered interventions to improve UTI management in this population should expand caregiver involvement, enhance patient-provider communication, and target provider types and care settings that lack familiarity with NB., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objectives: Dentists prescribe 10% of all outpatient antibiotics in the United States and are the top specialty prescriber. Data on current antibiotic prescribing trends are scarce. Therefore, we evaluated trends in antibiotic prescribing rates by dentists, and we further assessed whether these trends differed by agent, specialty, and by patient characteristics., Design: Retrospective study of dental antibiotic prescribing included data from the IQVIA Longitudinal Prescription Data set from January 1, 2012 to December 31, 2019., Methods: The change in the dentist prescribing rate and mean days' supply were evaluated using linear regression models., Results: Dentists wrote >216 million antibiotic prescriptions between 2012 and 2019. The annual dental antibiotic prescribing rate remained steady over time ( P = .5915). However, the dental prescribing rate (antibiotic prescriptions per 1,000 dentists) increased in the Northeast (by 1,313 antibiotics per 1,000 dentists per year), among oral and maxillofacial surgeons (n = 13,054), prosthodontists (n = 2,381), endodontists (n = 2,255), periodontists (n = 1,961), and for amoxicillin (n = 2,562; P < .04 for all). The mean days' supply significantly decreased over the study period by 0.023 days per 1,000 dentists per year ( P < .001)., Conclusions: From 2012 to 2019, dental prescribing rates for antibiotics remained unchanged, despite decreases in antibiotic prescribing nationally and changes in guidelines during the study period. However, mean days' supply decreased over time. Dental specialties, such as oral and maxillofacial surgeons, had the highest prescribing rate with increases over time. Antibiotic stewardship efforts to improve unnecessary prescribing by dentists and targeting dental specialists may decrease overall antibiotic prescribing rates by dentists.

This project surveyed Veterans' COVID-19 vaccination beliefs and status. 1,080 (30.8%) Veterans responded. Factors associated with being unvaccinated, identified using binomial logistic regression, included negative feelings about vaccines (OR = 3.88, 95%CI = 1.52, 9.90) and logistical difficulties such as finding transportation (OR = 1.95, 95%CI = 1.01, 3.45). This highlights the need for education about and access to vaccination., Competing Interests: The authors have no conflicts of interest to disclose., (© The Author(s) 2023.)

Objective: Many children with chronic musculoskeletal pain conditions experience stigma which can have negative downstream consequences. This study compares ratings of clinical pain (current pain intensity and pain interference), experimental pain (temporal summation, cold water tolerance, and cold pain intensity), and pain-related stigma among three groups of youth with rheumatic conditions. The relations among ratings of pain-related stigma and pain variables were explored., Methods: Eighty-eight youth aged 8-17 years with a diagnosis of juvenile idiopathic arthritis (JIA = 32), juvenile fibromyalgia (JFM = 31), or non-specific chronic pain (NSCP = 25) completed measures of clinical pain ratings (average 7-day pain intensity, day of assessment pain (DoA), and pain interference), experimental pain (cold pain tolerance, cold pain intensity, and temporal summation of mechanical pain), and pain-related stigma. Data analysis compared pain-related stigma and pain ratings across the three groups and examined the relations among pain-related stigma and pain ratings., Results: Youth with JFM reported higher ratings of clinical pain and pain-related stigma than their counterparts with NSCP or JIA. However, there were no differences in experimental pain. Pain-related stigma was associated with greater ratings of pain interference, particularly for those with JIA and NSCP. Pain-related stigma was also associated with greater average daily pain intensity but not DoA., Conclusion: Youth with medically unexplained pain report greater stigma and worse pain than their peers; thus, robust assessment of pain in this population is necessary. Future work should longitudinally explore the impact of pain-related stigma on pain outcomes and treatment responses., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids., Objective: The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States., Methods: This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation., Results: Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period., Conclusion: Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain., Knowledge Transfer Statement: The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.

Acceptance of the COVID-19 vaccination becomes more critical as new variants continue to evolve and the United States (US) attempts to move from pandemic response to management and control. COVID-19 stands out in the unique way it has polarized patients and generated sustained vaccine hesitancy over time. We sought to understand differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant patients, with the goal of informing communication and implementation strategies to increase uptake of COVID-19 vaccines in Veteran and non-Veteran communities. This qualitative study used interview data from focus groups conducted by the Department of Veterans Affairs (VA) and the University of Utah; all focus groups were conducted using the same script March-July 2021. Groups included forty-six United States Veterans receiving care at 28 VA facilities across the country and 166 non-Veterans across Utah for a total of 36 one-hour focus groups. We identified perceptions and attitudes toward COVID-19 vaccination through qualitative analysis of focus group participant remarks, grouping connections with identified themes within domains developed based on the questions asked in the focus group guide. Responses suggest participant attitudes toward the COVID-19 vaccine were shaped primarily by vaccine attitude changes over time, impacted by perceived vaccine benefits, risks, differing sources of vaccine information and political ideology. Veterans appeared more polarized, being either largely non-hesitant, or hesitant, whereas non-Veterans had a wider range of hesitancy, with more participants identifying minor doubts and concerns about receiving the vaccine, or simply being altogether unsure about receiving it. Development of COVID-19 vaccine communication strategies in Veteran and non-Veteran communities should anticipate incongruous sources of information and explicitly target community differences in perceptions of risks and benefits associated with the vaccine to generate candid discussions and repair individuals' trust. We believe this could accelerate vaccine acceptance over time., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objectives: Twelve percent of the U.S. population has a dental implant. Although rare, implant loss/complications can impact quality of life. This study evaluated indicators for implant loss/complications., Methods: Veterans with dental implants placed between 2015 and 2019 were included. Implant loss/complications were defined as implant removal or peri-implant defect treatment within 90 days. Binomial logistic regression identified factors associated with implant loss/complications., Results: From 2015 to 2019, 48,811 dental implants were placed in 38,246 Veterans. Implant loss/complications was identified for 202 (0.4%) implants. In adjusted analyses, Veterans aged 50-64 years (OR = 1.92 (95% confidence interval (CI): 1.06, 3.46)) and ≥65 (OR = 2.01 (95% CI: 1.14, 3.53)) were more likely to have implant loss/complications. History of oral infection, tooth location, and number of implants placed all significantly increased the odds of loss/complications., Conclusion: Dental implant loss/complications are rare outcomes. Older age, location of implant, and the number of implants placed during a visit were significant predictors of loss/complication., (© 2023 American Association of Public Health Dentistry. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objective: The aim of the study is to characterize patient-reported signs and symptoms of urinary tract infections in patients with neurogenic bladder to inform development of an intervention to improve the accuracy of urinary tract infection diagnosis., Design: This is a retrospective cohort study of adults with neurogenic bladder due to spinal cord injury/disorder, multiple sclerosis, and/or Parkinson disease and urinary tract infection encounters at four medical centers between 2017 and 2018. Data were collected through medical record review and analyzed using descriptive statistics and unadjusted logistic regression., Results: Of 199 patients with neurogenic bladder and urinary tract infections, 37% were diagnosed with multiple sclerosis, 36% spinal cord injury/disorder, and 27% Parkinson disease. Most patients were men (88%) in inpatient or long-term care settings (60%) with bladder catheters (67%). Fever was the most frequent symptom (32%). Only 38% of patients had a urinary tract-specific symptom; 48% had only nonspecific to the urinary tract symptoms. Inpatient encounter setting (odds ratio, 2.5; 95% confidence interval, 1.2-5.2) was associated with greater odds of only having nonspecific urinary tract symptoms., Conclusions: In patients with neurogenic bladder and urinary tract infection encounters, nonspecific signs and symptoms are most frequently reported. These results can inform interventions to help providers better elicit and document urinary tract-specific symptoms in patients with neurogenic bladder presenting with possible urinary tract infection, particularly among hospitalized patients., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Describe patient-reported signs and symptoms of urinary tract infection (UTI) in adults with neurogenic bladder (NB) due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), and Parkinson disease (PD); (2) Differentiate urinary tract specific symptoms and nonspecific symptoms reported by adults with NB for suspected UTI and recognize how this may impact UTI diagnosis in this population; and (3) Recognize differences in UTI signs and symptoms reported by patients with NB based on patient and encounter characteristics., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: No research has been conducted to assess whether antibiotic prophylaxis prescribing differs by dental setting. Therefore, the goal of this study was to compare the prescribing of antibiotic prophylaxis in Veterans Affairs (VA) and non-Veterans Affairs settings., Methods: This was a retrospective study of veteran and non-veteran dental patients with cardiac conditions or prosthetic joints between 2015-2017. Multivariable log binomial regression analysis was conducted to compare concordant prescribing by setting with a sub-analysis for errors of dosing based on antibiotic duration (i.e., days prescribed)., Results: A total of 61,124 dental visits that received a prophylactic antibiotic were included. Most were male (61.0%), and 55 years of age or older (76.2%). Nearly a third (32.7%) received guideline concordant prophylaxis. VA dental settings had a lower prevalence of guideline concordant prescribing compared to non-VA settings in unadjusted results (unadjusted prevalence ratio [uPR] = 0.92, 95% CI: 0.90-0.95). After adjustment, prevalence of guideline concordant prescribing was higher in those with prosthetic joints in the VA setting (adjusted prevalence ratio [aPR] = 1.73, 95% CI: 1.59-1.88), with no difference identified in those without a prosthetic joint (aPR = 0.99, 95% CI: 0.96-1.01). Concordance of dosing was higher in VA compared to non-VA settings (aPR = 1.11, 95% CI: 1.07-1.15)., Conclusions: VA has a higher prevalence of guideline concordant prescribing among those with prosthetic joints and when assessing dosing errors. Though the presence of an integrated electronic health record (EHR) may be contributing to these differences, other system or prescriber-related factors may be responsible. Future studies should focus on to what extent the integrated EHR may be responsible for increased guideline concordant prescribing in the VA setting., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Purpose: Opioids, benzodiazepines and sedatives can manage dental pain, fear and anxiety but have a narrow margin of safety in children. General dentists may inappropriately prescribe gabapentin and stimulants. National evidence on dispensing rates of these high-alert medicines by dentists to children is limited., Methods: We utilize join-point regression to identify changes in fills for opioids, sedatives, benzodiazepines, gabapentin, and stimulants to children <18 years from 2012 to 2019 in a national dataset comprising 92% of dispensed outpatient prescriptions by dentists., Results: From 2012 to 2019, 3.8 million children filled prescriptions for high-alert drugs from general dentists. National quarterly dispensing of high-alert drugs decreased 63.1%, from 10456.0 to 3858.8 days per million. Opioids accounted for 69.4% of high-alert prescriptions. From 2012 to 2019, fills for opioids, sedatives, benzodiazepines, and stimulants decreased by 65.2% (7651.8 to 2662.7), 43.4% (810.9 to 458.7), 43.6% (785.7 to 442.7) and 89.3% (825.6 to 88.6 days per million), respectively. Gabapentin increased 8.1% (121.8 to 131.7 days per million). A significant decrease in high-alert fills occurred in 2016, (-6.0% per quarter vs. -1.6% pre-2016, P-value<0.001), especially for opioids (-7.0% vs. -1.2%, P-value<0.001). Older teenagers (15-17 years) received 42.5% of high-alert prescriptions. Low-income counties in the South were overrepresented among top-prescribing areas in 2019., Conclusions: We found promising national decreases in fills for high-alert medicines to children by general dentists from 2012 to 2019. However, older teenagers and children in some counties continued to receive dental opioids at high rates. Future efforts should address non-evidence-based pain management in these groups., (© 2022 John Wiley & Sons Ltd.)

Objectives: Opioids prescribed by dentists have been associated with serious adverse events, including opioid-related overdose and mortality. However, the downstream outcomes of opioids prescribed by dentists to Veterans who are at high risk for opioid misuse and overdose have yet to be determined., Methods: This was a national cross-sectional analysis of opioids associated with dental visits within the Veterans Health Administration from 2015 to 2018. Overprescribing was defined per guidelines as >120 morphine milligram equivalents (MME) or >3 days supply. The association of dental visit and patient characteristics was modeled separately for opioid-related poisoning and all-cause mortality using logistic regression., Results: Of 137,273 Veterans prescribed an opioid by a dentist, 0.1% and 1.1% were associated with opioid-related poisoning and mortality, respectively. There was no difference in opioid poisoning within 6 months for Veterans with opioid prescriptions >120 MME (aOR = 1.25 [CI: 0.89-1.78]), but poisoning decreased in Veterans prescribed opioids >3-days supply (aOR = 0.68 [CI: 0.49-0.96]). However, Veterans with opioids >120 MME were associated with higher odds of mortality within 6 months (aOR = 1.17 [95% CI: 1.05-1.32]) while there was no difference in prescriptions >3-days supply (aOR = 1.12 [CI: 0.99-1.25])., Conclusion: Serious opioid-related adverse events were rare in Veterans and lower than other reports in the literature. Since nonopioid analgesics have superior efficacy for the treatment of acute dental pain, prescribing opioid alternatives may decrease opioid-related poisoning. Strategies for dentists to identify patients at high risk should be incorporated into the dental record., (© 2023 American Association of Public Health Dentistry.)

We assessed trends in treatment of patients with CRE from 2012 through 2018. We detected decreased utilization of aminoglycosides and colistin and increased utilization in extended-spectrum cephalosporins and ceftazidime-avibactam. We found significant uptake of ceftazidime-avibactam, a newly approved antibiotic, to treat CRE infections.

Abstract: The U.S. Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and provides dental care to approximately one-half million veterans annually. In response to the opioid crisis, the VA released several opioid risk mitigation strategies. Although opioid prescribing by VA dentists has decreased on the whole, the implementation experiences at the level of dentists remains unclear. Our objective was to explore the barriers and facilitators that affect opioid decision making for management of acute dental pain among VA dentists. Dentists practicing in the VA facilities with the highest and lowest volume of opioid prescriptions were recruited. Standardized qualitative interviews by telephone followed a semistructured guide designed around the Capability (C), Opportunity (O), Motivation (M), and Behaviour (B) model. Audio recordings were transcribed and independently double-coded using NVivo to identify potential targets for future guideline-based opioid interventions. Of 395 eligible general and specialty dentists, 90 (24.8%) completed an interview representing 33 VA facilities. Opportunities for prescribing opioids included 1) completion of dental procedures associated with acute dental pain, 2) caring for patients who presented with existing dental pain, and 3) responding to patient opioid requests. Capabilities included using resources (eg, electronic medical records), clinical judgement (eg, evaluation of medical history including medication use), communication skills, and ability to screen for opioid misuse. Motivation themes focused on alleviating patients' acute dental pain. Barriers and facilitators of opioid prescribing varied across facilities. The results can offer intervention targets for continued opioid risk mitigation efforts., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Among 108 (0.05% of cohort) US veterans with a Clostridioides difficile infection (CDI) within 30 days of a dental antibiotic prescription, 80% of patients received guideline-discordant antibiotics. Half had chronic gastrointestinal illness potentially exacerbating their CDI risk. More efforts are needed to improve antibiotic stewardship.

Objective: Obesity is associated with executive function (EF) deficits across the lifespan. Higher body mass index (BMI), obesity severity, and poorer adherence and weight outcomes in obesity treatment have all been associated with EF deficits. Adult literature has begun to emphasize neuroinflammation in obesity as a possible pathway to later cognitive impairment in EF. However, pediatric obesity literature has yet to establish associations between peripheral inflammation and EF. Thus, the present study examined associations and variability in inflammation, EF, and adiposity in children with or at risk for obesity. Additionally, inflammation was examined as a mediator of the relationship between adiposity and EF., Methods: Children (N = 39) aged 8-12 years with BMI ≥ 50th percentile were recruited. The NIH Toolbox Cognitive Battery was used to assess performance-based EF. Peripheral inflammation was assessed in fasted sera. Dual-energy X-ray absorptiometry scans were conducted to assess body composition. Linear regression and Hayes' PROCESS Model 4 (Hayes, 2017) were used to evaluate associations between adiposity and inflammation, inflammation and EF, and whether adiposity effects EF through its effect on inflammation., Results: Positive associations were identified between adiposity and inflammation, and negative to null associations were identified between inflammation and EF. Medium indirect effects of adiposity on EF through inflammation were detected., Conclusion: Pilot evidence suggests greater adiposity is linked with greater inflammation, which in turn is associated with less EF in some domains. Directionality and causality cannot yet be established, but with replication, findings may inform efforts to target EF in pediatric obesity., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship., Objectives: The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry., Methods: We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes., Results: Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05)., Conclusion: The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign., (Published by Elsevier Inc.)

Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2022.)

Objective: To compare clinical outcomes associated with appropriate and inappropriate management of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) among inpatients with neurogenic bladder (NB)., Design: Multicenter, retrospective cohort., Setting: The study was conducted across 4 Veterans' Affairs hospitals., Participants: The study included veterans with NB due to spinal cord injury or disorder (SCI/D), multiple sclerosis (MS), or Parkinson's disease (PD) hospitalized between January 1, 2017, and December 31, 2018, with diagnosis of ASB or UTI., Interventions: In a medical record review, we classified ASB and UTI diagnoses and treatments as appropriate or inappropriate based on national guidelines., Main Outcome Measures: Frequencies of Clostridioides difficile infection, acute kidney injury, 90-day hospital readmission, postculture length-of-stay (LOS), and multidrug-resistant organisms in subsequent urine cultures were compared between those who received appropriate and inappropriate management., Results: We included 170 encounters with ASB (30%) or UTI (70%) diagnoses occurring for 166 patients. Overall, 86.1% patients were male, 47.6% had SCI/D and 77.6% used bladder catheters. All ASB encounters had appropriate diagnoses, and 96.1% had appropriate treatment. In contrast, 37 UTI encounters (31.1%) had inappropriate diagnoses and 61 (51.3%) had inappropriate treatment, including 30 encounters with true ASB. Among patients with SCI/D or MS, appropriate ASB or UTI diagnosis was associated with a longer postculture LOS (median, 14 vs 7.5 days; P = .02). We did not detect any significant associations between appropriate versus inappropriate diagnosis and treatment and other outcomes., Conclusions: Almost one-third of UTI diagnoses and half of treatments in hospitalized patients with NB are inappropriate. Opportunities exist to improve ASB and UTI management in patients with NB to minimize inappropriate antibiotic use., (© The Author(s) 2022.)

Objectives: Healthcare workers (HCWs) are a high-priority group for coronavirus disease 2019 (COVID-19) vaccination and serve as sources for public information. In this analysis, we assessed vaccine intentions, factors associated with intentions, and change in uptake over time in HCWs., Methods: A prospective cohort study of COVID-19 seroprevalence was conducted with HCWs in a large healthcare system in the Chicago area. Participants completed surveys from November 25, 2020, to January 9, 2021, and from April 24 to July 12, 2021, on COVID-19 exposures, diagnosis and symptoms, demographics, and vaccination status., Results: Of 4,180 HCWs who responded to a survey, 77.1% indicated that they intended to get the vaccine. In this group, 23.2% had already received at least 1 dose of the vaccine, 17.4% were unsure, and 5.5% reported that they would not get the vaccine. Factors associated with intention or vaccination were being exposed to clinical procedures (vs no procedures: adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.16-1.65) and having a negative serology test for COVID-19 (vs no test: AOR, 1.46; 95% CI, 1.24-1.73). Nurses (vs physicians: AOR, 0.24; 95% CI, 0.17-0.33), non-Hispanic Black (vs Asians: AOR, 0.35; 95% CI, 0.21-0.59), and women (vs men: AOR, 0.38; 95% CI, 0.30-0.50) had lower odds of intention to get vaccinated. By 6-months follow-up, >90% of those who had previously been unsure were vaccinated, whereas 59.7% of those who previously reported no intention of getting vaccinated, were vaccinated., Conclusions: COVID-19 vaccination in HCWs was high, but variability in vaccination intention exists. Targeted messaging coupled with vaccine mandates can support uptake.

Objective: To determine prophylaxis appropriateness by Veterans' Affairs (VA) dentists., Design: A cross-sectional study of dental visits, 2015-2019., Methods: Antibiotics within 7 days before a visit in the absence of an oral infection were included. Appropriate antibiotic prophylaxis was defined as visits with gingival manipulation and further delineated into narrow and broad definitions based on comorbidities. The primary analysis applied a narrow definition of appropriate prophylaxis: cardiac conditions at the highest risk of an adverse outcome from endocarditis. The secondary analysis included a broader definition: cardiac or immunocompromising condition or tooth extractions and/or implants. Multivariable log-linear Poisson generalized estimating equation regression was used to assess the association between covariates and unnecessary prophylaxis prescriptions., Results: In total, 358,078 visits were associated with 369,102 antibiotics. The median prescription duration was 7 days (IQR, 7-10); only 6.5% were prescribed for 1 day. With the narrow definition, 15% of prophylaxis prescriptions were appropriate, which increased to 72% with the broader definition. Prophylaxis inconsistent with guidelines increased over time. For the narrow definition, Black (vs White) race, Latine (vs non-Latine) ethnicity, and visits located in the West census region were associated with unnecessary prophylaxis. Variables associated with a lower risk were older age, prosthetic joints, immunocompromising condition, and rural location., Conclusions: Of every 6 antibiotic prophylaxis prescriptions, 5 were inconsistent with guidelines. Improving prophylaxis appropriateness and shortening duration may have substantial implications for stewardship. Guidelines should state whether antibiotic prophylaxis is indicated for extractions, implants, and immunocompromised patients.

Background: Carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSI) increase mortality three-fold compared with carbapenem-susceptible bloodstream infections. Because these infections are rare, there is a paucity of information on mortality associated with different treatment regimens. This study examines treatment regimens and association with in-hospital, 30 day and 1 year mortality risk for patients with CRE-BSI., Methods: This retrospective cohort study identified hospitalized patients within the Veteran Affairs (VA) from 2013 to 2018 with a positive CRE blood culture and started antibiotic treatment within 5 days of culture. Primary outcomes were in-hospital, 30 day and 1 year all-cause mortality. Secondary outcomes were healthcare costs at 30 days and 1 year and Clostridioides difficile infection 6 weeks post culture date. The propensity for receiving each treatment regimen was determined. Multivariable regression assessed the association between treatment and outcomes., Results: There were 393 hospitalized patients from 2013 to 2018 included in the study. The cohort was male (97%) and elderly (mean age 71.0 years). Carbapenems were the most prescribed antibiotics (47%). In unadjusted analysis, ceftazidime/avibactam was associated with a lower likelihood of 30 day and 1 year mortality. After adjusting, ceftazidime/avibactam had a 30 day mortality OR of 0.42 (95% CI 0.17-1.02). No difference was found in C. difficile incidence at 6 weeks post-infection or total costs at 30 days or 1 year post culture date by any treatments., Conclusions: In hospitalized veterans with CRE-BSI, none of the treatments were shown to be associated with all-cause mortality. Ceftazidime/avibactam trended towards protectiveness against 30 day and 1 year all-cause mortality. Use of ceftazidime/avibactam should be encouraged for treatment of CRE-BSI., (Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy 2022.)

Burnout, depression, and anxiety are prevalent among healthcare workers (HCWs) during the COVID-19 pandemic and have been previously shown to contribute to poor health outcomes and reduced quality of care. Positive psychological constructs such as positive affect and meaning and purpose are related to resilience in the face of significant stress. No studies have examined these associations among a cohort of HCWs during this pandemic. The purpose of this study was to examine the association of depression, anxiety, positive affect, and meaning and purpose with burnout among HCWs during the COVID-19 pandemic. We utilized data from a cross-sectional survey conducted between September 29-December 8, 2021, among a cohort of 2,411 HCWs from a large, tertiary academic health care system in the Chicago area. We employed the Patient-Reported Outcomes Measurement Information System (PROMIS) measures for depression, anxiety, positive affect, and meaning and purpose and burnout was measured by the Oldenburg Burnout Inventory (OLBI). The majority (80.88%) of HCWs in this study identified as White, Non-Hispanic race/ethnicity, female sex (82.37%), and roughly one third were between ages 30-39 years old (30.98%). Registered nurses (26.96%) accounted for the largest single occupation group. The mean burnout score was 36.87 (SD = 7.65), with 53.38% of participants classified as having burnout, and registered nurses demonstrating the highest proportions of burnout (63.54%). Higher depression (coef = 0.15, SE = 0.03, p < 0.001) and anxiety (coef = 0.25, SE = 0.02, p < 0.001) scores were associated with higher burnout in multivariable linear regression models. Increased positive affect (coef= -0.19, SE= 0.02, p < 0.001) and meaning and purpose (coef= -0.12, SE= 0.01, p < 0.001) scores were significantly associated with reduced burnout. Positive affect and meaning and purpose were inversely associated with burnout among a cohort of HCWs during the COVID-19 pandemic. Previous studies of positive affect and meaning and purpose suggest the potential buffering effect that these indices may have on burnout. Future research is needed to examine the effect of positive affect and meaning and purpose on mitigating the negative impacts of burnout, depression, and anxiety among HCWs as they cope with the stress of the COVID-19 pandemic and beyond., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bannon, Evans, Freedman, Lee, Vu, Wallia, Wilkins, Moskowitz and Hirschhorn.)

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Background: Dentists in the United States frequently prescribe opioids for dental-related pain, although evidence shows superior efficacy of nonopioids for pain management. A national sample of US dentists was interviewed to understand the barriers and facilitators to opioid prescribing., Methods: Semistructured one-on-one telephone interviews were conducted with dentists sampled from the 6 regions of The National Dental Practice-Based Research Network. Responses were coded into the domains of the Capability, Opportunity and Motivation Model of Behavior. Potential behavior change interventions were identified for targeted themes., Results: Seventy-three interviews were qualitatively analyzed. Most of those interviewed were general dentists (86.3%) and on average (SD) were in practice for 24.3 (13.0) years. Ten themes were identified within the Capability, Opportunity and Motivation Model of Behavior. Dentists' knowledge of opioid risk, ability to identify substance use disorder behavior, and capability of communicating pain management plans to patients or following clinic policies or state and federal regulations were linked with judicious opioid prescribing. Dentists reported prescribing opioids if they determined clinical necessity or feared negative consequences for refusing to prescribe opioids., Conclusions: Dentists' opioid decision making is influenced by a range of real-world practice experiences and patient and clinic factors. Education and training that target dentists' knowledge gaps and changes in dentists' practice environment can encourage effective communication of pain management strategies with patients and prescribing of nonopioids as first-line analgesics while conserving opioid use., Practical Implications: Identified knowledge gaps in dentistry can be targets for education, clinical guidelines, and policy interventions to ensure safe and appropriate prescribing of opioids., (Copyright © 2022 American Dental Association. Published by Elsevier Inc. All rights reserved.)