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The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs.We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) using propensity scores to balance covariates and generalized estimating equation models.Overall, laboratory-based process measures occurred more frequently (range, 65.7%-76.6%) than measures requiring specialty referrals (retinal examinations, 33.3%; diabetes education, 3.4%). Compared with non-FQHC patients, FQHC patients had about 3 percentage point lower rates of each process measure, except for higher rates of diabetes education [relative risk=1.09, 95% confidence interval (CI): 1.03-1.16]. FQHC patients had fewer overall [incident rate ratio (IRR)=0.87, 95% CI: 0.86-0.88] and diabetes-related hospitalizations (IRR=0.79, 95% CI: 0.77-0.81), but more overall (IRR=1.06, 95% CI: 1.05-1.07) and diabetes-related emergency department visits (IRR=1.10, 95% CI: 1.08-1.13).This national analysis identified opportunities to improve diabetes management among Medicaid enrollees with type 2 diabetes, especially for retinal examinations or diabetes education. Overall, we found slightly lower rates of most diabetes care process measures for FQHC patients versus non-FQHC patients. Despite having higher rates of emergency department visits, FQHC patients were significantly less likely to be hospitalized than non-FQHC patients. These findings emphasize the need to identify innovative, effective approaches to improve diabetes care for Medicaid enrollees, especially in FQHC settings.

Emerging pathogens can have devastating effects on naïve hosts, but disease outcomes often vary among host species. Comparing the cellular response of different hosts to infection can provide insight into mechanisms of host defence. Here, we used RNA-seq to characterize the transcriptomic response of Darwin's finches to avian poxvirus, a disease of concern in the Galápagos Islands. We tested whether gene expression differs between infected and uninfected birds, and whether transcriptomic differences were related either to known antiviral mechanisms and/or the co-option of the host cellular environment by the virus. We compared two species, the medium ground finch (Geospiza fortis) and the vegetarian finch (Platyspiza crassirostris), to determine whether endemic Galápagos species differ in their response to pox. We found that medium ground finches had a strong transcriptomic response to infection, upregulating genes involved in the innate immune response including interferon production, inflammation, and other immune signalling pathways. In contrast, vegetarian finches had a more limited response, and some changes in this species were consistent with viral manipulation of the host's cellular function and metabolism. Many of the transcriptomic changes mirrored responses documented in model and in vitro studies of poxviruses. Our results thus indicate that many pathways of host defence against poxviruses are conserved among vertebrates and present even in hosts without a long evolutionary history with the virus. At the same time, the differences we observed between closely related species suggests that some endemic species of Galápagos finch could be more susceptible to avian pox than others.Resumen Los patógenos emergentes pueden generar efectos devastadores en huéspedes nuevos, sin embargo, los efectos de la enfermedad varían según el tipo de huésped. Al comparar la respuesta celular de las diferentes especies afectadas se puede determinar el mecanismo de defensa del huésped, y la base de susceptibilidad a la enfermedad. A través de la secuenciación de ARN, se caracterizó la respuesta de transcripción de viruela aviar, un virus introducido, en los pinzones de Darwin. Probamos si una expresión genética difiere entre aves infectadas y no infectadas, y si la diferencia de transcripción estaba relacionada con mecanismos antivirales conocidos y/o con la co-opción del entorno celular del hospedero por parte del virus. Comparamos dos especies, pinzón mediano de tierra (Geospiza fortis) y pinzón vegetariano (Platyspiza crassirostris), para determinar si estas especies tienen variación en sus respuestas al mismo patógeno nuevo. Encontramos que el pinzón mediano de tierra presenta una fuerte respuesta de transcripción a la infección, involucrando a la regulación de genes inmunes que incluyen la producción de interferón, inflamación y otras vías de respuesta inmunológica. A diferencia del pinzón vegetariano que presenta una respuesta más limitada a la infección. Nuestros resultados revelaron evidencia de manipulación viral en la función celular del hospedador y en el metabolismo del huésped, proporcionando información sobre como la viruela aviar afecta al huésped. Varias de las respuestas de transcripción a la infección se ven reflejadas en estudios in vitro y en modelos animales, lo cual indica que muchas vías de defensa del huésped contra la viruela son conservadas en vertebrados incluso en huéspedes sin una historia evolutiva larga del virus. Al mismo tiempo, la variación que observamos entre especies estrechamente relacionadas indica que algunas especies endémicas de pinzones de Galápagos podrían ser más susceptibles a la viruela aviar que otras especies.

Purpose Rising cancer care expenditures and technological advancement of shorter radiation therapy regimens have drawn significant attention to the use of hypofractionated radiation therapy in clinical care. We examine the costs of hypofractionated whole breast irradiation (HF-WBI) compared with conventional whole breast irradiation (CF-WBI) in the United States and investigate the influences of patient characteristics and commercial insurance on HF-WBI use. Methods and Materials In a retrospective study using private employer-sponsored insurance claims, a pooled cross-sectional evaluation of radiation therapy in patients with commercial insurance was performed from 2008 to 2017. The study population included female patients with early-stage breast cancer treated with lumpectomy and whole breast irradiation. Results A total of 15,869 women received HF-WBI, and 59,328 received CF-WBI. HF-WBI use increased from 2008 to 2017. Community-level factors such as a higher proportion of college graduates and greater mixed racial composition were associated with increased HF-WBI use. Mean insurer-paid radiation therapy expenditures were significantly lower for HF-WBI versus CF-WBI (adjusted difference, $6375; 95% confidence interval, $6147–$6603). Mean patient out-of-pocket expenditure for HF-WBI was $139 less than that for CF-WBI. Geographic variation existed across the United States in HF-WBI use (range, 9.6%-36.2%), with no consistent relationship between HF-WBI use and corresponding average cost differences between HF-WBI and CF-WBI. Conclusions If trends continue, HF-WBI will soon become the dominant form of radiation treatment in the United States. Although HF-WBI represents significant savings to the health care system and individual patients, no evidence indicated that a financial disincentive had slowed adoption of HF-WBI. Therefore, multilevel approaches, including individuals, the community, and health policy, should be used to promote cost-effective cancer care. Innovations to policies on cost-effective radiation therapy treatment might consider non-financial incentives to promote HF-WBI use.

Background: Rising cancer care expenditures and technological advancement of shorter radiotherapy regimens have drawn significant attention to the use of hypofractionated radiotherapy in clinical care. We examine the costs of hypofractionated (HF-WBI) compared to conventional whole breast irradiation (CF-WBI) in the U.S. through 2017 and investigate the influences of patient characteristics and commercial insurance on HF-WBI use. Methods: In a retrospective study using private employer-sponsored insurance claims, a pooled cross-sectional evaluation of radiotherapy in patients with commercial insurance was performed from 2008-2017. The study population included female patients with early-stage breast cancer treated with lumpectomy and whole-breast irradiation. HF-WBI is defined as receipt of 15-24 radiation fractions and/or radiation fractions delivered between 21-31 days. CF-WBI is defined as receipt of 25-40 fractions and/or radiation fractions delivered between 39-120 days. The primary outcomes and measures were the use of HF-WBI and CF-WBI and total radiotherapy expenditures, including costs incurred by insurers and patient out-of-pocket expenses. Results: A total of 15,869 women received HF-WBI and 59,328 received CF-WBI. HF-WBI use increased from 2008 to 2017. Community-level factors like a higher proportion of college graduates and greater mixed racial composition were associated with increased HF-WBI use. No association was observed between insurance plan characteristics and the likelihood of receiving HF-WBI. The mean insurer-paid radiotherapy expenditures were significantly lower for HF-WBI vs. CF-WBI (adjusted difference $6,375, 95% CI $6,147-$6,603). The mean patient out-of-pocket expenditure for HF-WBI was $139 less than that of CF-WBI (Table 1). Geographic variation existed across U.S. states in HF-WBI use (range: 9.6%-36.2%). There was no consistent relationship across states between the utilization of HF-WBI and the corresponding average cost differences for HF-WBI relative to CF-WBI. Conclusions: If trends continue, HF-WBI will soon become the dominant form of radiation treatment in the U.S. Although HF-WBI represents significant savings to the health care system and individual patients, no evidence indicated that a financial disincentive slowed the adoption of HF-WBI. Therefore, multi-level approaches, including individuals, the community, and health policy, should be utilized to promote cost-effective cancer care. Table 1.Radiotherapy-related expenditures for breast cancer patients aged Citation Format: Loren Saulsberry, Chuanhong Liao, Dezheng Huo. Hypofractionated and conventional whole-breast radiotherapy for breast cancer patients: Financial risk and expenditures in the U.S. 2008-2017 [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-07.

Medicare beneficiaries of color used more home health care services than white beneficiaries overall and were more likely to rely on unpaid informal caregivers.

Background: Latent tuberculosis infection (LTBI) treatment is an effective strategy to eliminate TB in low-incidence settings. Shorter LTBI regimens incorporating the antimicrobial class of rifamycins are designed to improve treatment completion rates. Recent evidence suggests that the rifamycins could induce irreversible gut microbiota changes that impact future anti-TB immunity. Methods: To document the immediate effect of the rifamycins on the gut microbiota, we followed six patients with LTBI initiating four months of monotherapy with rifampin (4R; n=4) or three months of rifapentine in combination with isoniazid (3HP; n=2) and tracked recovery to baseline two months posttreatment completion. We collected stool samples parallel to the LTBI group from healthy volunteers (N=6) unexposed to the rifamycins. We used a questionnaire to collect diet, antibiotics, and lifestyle changes during follow-up. We profiled the gut microbiota using 16S rRNA amplicon sequencing (V1-V2 region). Results: Rifamycin exposure resulted in a 4.24% decrease in alpha diversity, compared to a 3.27% decrease in the controls. While the change in alpha diversity was small and not statistically different from changes observed in controls, significant bacterial community dissimilarity correlated with treatment duration (R2 = 0.269, P=0.041) and dose (R2 =0.201, P = 0.001) were observed. This rifamycin-associated dysbiosis was characterized by a depletion of butyrate-producing taxa (Clostridium-XIVa and Roseburia) and expansion of potentially pathogenic taxa within the Firmicutes and Proteobacteria phyla. Recovery of the gut microbial composition was incomplete two months after treatment ended. Conclusion: TB prophylaxis with the rifamycins induced minimal changes in the overall gut microbiota diversity but a significant shift in gut microbial composition. A larger clinical study with a longer follow-up time is necessary to confirm the extent to which the gut microbiota can recover from this rifamycin-induced dysbiosis to inform strategies to mitigate potential LTBI treatment sequelae.

To derive and validate a new ecological measure of the social determinants of health (SDoH), calculable at the zip code or county level.The most recent releases of secondary, publicly available data were collected from national U.S. health agencies as well as state and city public health departments.The Social Vulnerability Metric (SVM) was constructed from U.S. zip-code level measures (2018) from survey data using multidimensional Item Response Theory and validated using outcomes including all-cause mortality (2016), COVID-19 vaccination (2021), and emergency department visits for asthma (2018). The SVM was also compared with the existing Centers for Disease Control and Prevention's Social Vulnerability Index (SVI) to determine convergent validity and differential predictive validity.The data were collected directly from published files available to the public online from national U.S. health agencies as well as state and city public health departments.The correlation between SVM scores and national age-adjusted county all-cause mortality was r = 0.68. This correlation demonstrated the SVM's robust validity and outperformed the SVI with an almost four-fold increase in explained variance (46% vs. 12%). The SVM was also highly correlated (r ≥ 0.60) to zip-code level health outcomes for the state of California and city of Chicago.The SVM offers a measurement tool improving upon the performance of existing SDoH composite measures and has broad applicability to public health that may help in directing future policies and interventions. The SVM provides a single measure of SDoH that better quantifies associations with health outcomes.

ImportanceThere were over 45 000 suicides in the US in 2020, making suicide the 12th leading cause of death. If social vulnerability is associated with suicide rates, targeted interventions for at-risk segments of the population may reduce US suicide rates.ObjectiveTo determine the association between social vulnerability and suicide in adults.Design, Setting, and ParticipantsThis cohort study analyzed 2 county-level social vulnerability measures (the Social Vulnerability Index [SVI] and the Social Vulnerability Metric [SVM]) and US Centers for Disease Control and Prevention–reported county-level suicides from 2016 to 2020. Data were analyzed November and December 2022.ExposuresCounty-level variability in social vulnerability.Main Outcomes and MeasuresThe primary outcome measure was number of county-level adult suicides from 2016 to 2020, offset by county adult population during those years. The association between social vulnerability (measured using the SVI and the newly created SVM for 2018) and suicide was modeled using a bayesian-censored Poisson regression model to account for the CDC’s suppression of county-level suicide counts of less than 10, adjusted for age, racial and ethnic minority, and urban-rural county characteristics.ResultsFrom 2016 to 2020, there were a total of 222 018 suicides in 3141 counties. Comparing the least socially vulnerable (0% to 10%) to the most socially vulnerable (90% to 100%) counties, there was a 56% increase in suicide rate (17.3 per 100 000 persons to 27.0 per 100 000 persons) as measured by the SVI (incidence rate ratio, 1.56; 95% credible interval, 1.51-1.60) and an 82% increase in suicide rate (13.8 per 100 000 persons to 25.1 per 100 000 persons) as measured by the SVM (incidence rate ratio, 1.82; 95% credible interval, 1.72-1.92).Conclusions and RelevanceThis cohort study found that social vulnerability had a direct association with risk for adult suicide. Reducing social vulnerability may lead to life-saving reduction in the rate of suicide.

Introduction. Despite its importance, pathologic nodal (pN) staging of lung cancer remains poor. We evaluated the quality and survival impact of two interventions to improve pN staging. Methods. Using a non-randomized stepped-wedge design, we implemented use of a lymph node (LN) specimen collection kit to improve intraoperative LN collection (surgical intervention) and a novel gross dissection method for intrapulmonary LN retrieval (pathology intervention) in 12 hospitals in five contiguous Hospital Referral Regions in AR, MS and TN (2009-2021). With appropriate statistical methods we compared surgical quality and survival of patients among: neither (Group 1), pathology only (Group 2), surgical only (Group 3), and both (Group 4) interventions. Results. Of 4,019 patients, 50%, 5%, 21% and 24%, were in Groups 1-4 respectively. Rates of non-examination of LNs and non-examination of mediastinal LNs: 11%, 9%, 0% and 0%; 29%, 35%, 2% and 2% respectively in Groups 1-4 (p Discussion. Combining a LN collection kit and novel gross dissection method significantly improved pN evaluation and survival in a population-based cohort. Citation Format: Meredith A. Ray, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha Matthews, Amal Anga, Christopher Giampapa, Elizabeth Sales, Sherry Okun, Edward T. Robbins, Bradley Wolf, Paul Levy, Horace L. Wiggins, Thomas Ng, Vishal Sachdev, Ganpat Valaulikar, Hetal D. Patel, Nicholas R. Faris, Matthew Smeltzer, Raymond U. Osarogiagbon. Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4359.

Background. Most patients die within 5 years of curative-intent lung cancer surgery Differences in surgical quality and cancer biology drive long-term overall survival (OS) differences after curative-intent resection. From 2009 onward, we implemented a sequence of interventions to improve surgical quality and pathologic evaluation in a regional population. We evaluated population-level surgical quality and OS in the MS-QSR cohort. Methods. We categorized the MS-QSR into 4 (approximately) 5-year eras: 1) 2004-08, baseline; 2) 2009-13 (quality feedback and pilot intervention studies); 3) 2014-18 (surgical intervention with a lymph node collection kit); 4) 2019-22 (dual surgical and pathology intervention with novel gross dissection method). We compared surgical quality and OS across eras using standard statistical methods. Results. Of 6,701 resections, 15%, 33%, 32%, and 20% were in Eras 1-4, respectively. American College of Surgeons Operative Standard 5.8 quality was attained in 4%, 22%, 45%, and 65% of resections in Eras 1-4, respectively; the International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’ was achieved in 0%, 9%, 20%, and 31%, respectively; 120-Day mortality rates were 10%, 9%, 7%, and 4%; 3-year OS rates were 49%, 64%, 71%, and 84%; 5-year OS, 34%, 52%, and 61%, in Eras 1-3 (too early for Era 4); p Conclusion. Population-level surgical quality and OS have improved sequentially in parallel with implementation of interventions to surgical and pathology practices. The higher OS threshold in the MS-QSR creates a platform to interrogate the biologic drivers of surgical outcomes differences. Citation Format: Olawale Akinbobola, Meredith A. Ray, Carrie Fehnel, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Caroline M. Godfrey, Matthew Smeltzer, Raymond U. Osarogiagbon. Evolution of curative-intent lung cancer surgery in a 4 eras in the population-based mid-south quality of surgical resection (MS-QSR) cohort. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4382.

Introduction. Poor quality NSCLC resection impairs survival, but some patients survive irrespective. We explored characteristics of patients in 4 cohorts defined by surgery quality and survival. Methods. We analyzed stage I resections in a population-based cohort surviving >120 days post-op from 2009-2018. Using the International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’ and 3-year survival as ‘good’, we categorized patients into 4 dyads: 1) Good surgery/good survival; 2) Good surgery/poor survival; 3) Poor surgery/good survival (reference); 4) Poor surgery/poor survival. We used Chi-square and Kruskal-Wallis test for description, multivariable multinomial logistic regression to estimate Odds Ratio (OR) of surgery quality and survival. Results. Of 1,515 patients, 31%, 7%, 51%, and 12% were in Groups 1-4, respectively. In the ‘mis-match dyads’ (Groups 2 and 3), Group 2 was more likely to be elderly (70 vs. 66, p Older (OR=1.06), male (OR=1.78), Medicaid patients (OR=2.16) with smoking history (OR=3.25) had poorer survival despite good surgery rather than survival despite bad surgery. With poor surgery, male (OR=2.01) patients tumor 2-3 and >3 cm (OR=1.77 and 1.64) had poorer survival; commercially insured patients had 36% reduced risk of poor survival. Compared to open thoracotomy, patients with robotic-assisted surgery were >4-fold more likely to have good surgery rather than poor surgery but good survival. Conclusion. Differentiating characteristics associated with good/bad survival after good/bad quality lung cancer surgery provide opportunity to compare biomarker profiles between dyads. Citation Format: Huibo Shao, Yu-Sheng Lee, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Matthew Smeltzer, Meredith A. Ray, Raymond U. Osarogiagbon. Comparative characteristics of stage I non-small cell lung cancer (NSCLC) patients segregated by quality of surgery and survival in a population-based cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3216.

Introduction. 5-year disease-free survival after curative-intent resection of stage IA NSCLC approximates 65%. The quality of resection and differences in cancer biology probably account for most curative-intent treatment failure. We evaluated the hazard associated with markers of surgical quality. Methods. Using the population-based Mid-South Quality of Surgical Resection cohort, we compared outcomes of pathologic IA NSCLC resections from 2009 to 2021. With the stringent International Association for the Study of Lung Cancer complete (R0) resection for reference, we evaluated eight quality benchmarks: wedge resection; resections with positive margins; non-examination of lymph nodes (LN) from anywhere (pNX), mediastinal (pNXmed), intrapulmonary, hilar, low paratracheal and subcarinal stations. We evaluated hazard ratios (HR), adjusted for age, sex, insurance, histology, comorbidity, preoperative staging and technique of resection (95% CI) from Proportional Hazards models. Results. Of 2,243 resections, 906 (41%) were R0; 1,333 were non-R0, including 3% R1/R2, 13% pNX, 15% wedge resections, 15% pNXmed, 45% without subcarinal, 41% without hilar, 47% without low paratracheal, and 36% without intrapulmonary LNs.Compared to IASLC-R0, adjusted HRs were: 2.04 (1.21-3.44) for R1/R2; 1.75 (1.33-2.31) for pNX; 1.64 (1.26-2.14) for wedge resections; 1.35 (1.12-1.63) for non-examination of intrapulmonary LN; 1.33 (1.03-1.72), pNXmed; 1.25 (1.02-1.53), non-examination of hilar LN; 1.15 (0.95 - 1.39) missing station 4; and 1.11 (0.90-1.37) missing station 7 LNs. Conclusion. Surgical quality, indicated by markers of LN evaluation, have significant impact on long-term survival and should be required selection criteria or stratification factors in lung cancer surgery trials. Citation Format: Huibo Shao, Yu-Sheng Lee, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Meredith A. Ray, Matthew Smeltzer, Raymond U. Osarogiagbon. Hierarchy of prognostic quality markers after curative-intent resection of stage IA non-small cell lung cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4372.

The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45–10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61–4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77–3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88–2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47–3.07) (p < 0.0001), median household income (OR = 1.63, 1.03–2.58) (p = 0.035), male gender (OR = 1.47, 1.21–1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18–1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08–1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Background: Although overwhelming results of randomized controlled trials have demonstrated that hypofractionated whole breast radiation therapy (HF-WBI) has similar recurrence rates and disease-free survival as compared to conventional fractionated whole breast radiation (CF-WBI), we and others have shown that the adoption of HF-WBI remained low in the United States by 2013. It is unknown whether the utilization of HF-WBI has changed after 2013 in the United States. Methods: Among the patients who underwent a lumpectomy, we identified 688,079 patients with early stage invasive breast cancer and 248,218 patients with ductal carcinoma in situ (DCIS) in the National Cancer Database from 2004-2016. We defined HF-WBI as 2.5-3.33 Gy/fraction to the breast, while CF-WBI as 1.8-2.0 Gy/fraction. We evaluated the trend of HF-WBI utilization and examined factors associated with HF-WBI utilization using logistic regression models. Results: Among invasive cancer patients, the usage of HF-WBI increased significantly from 0.7% in 2004 to 15.6% in 2013 and then to 38.1% in 2016. Among DCIS patients, the usage of HF-WBI has increased significantly from 0.4% in 2004 to 13.4% in 2013 and then to 34.3% in 2016. The upsurge of HF-WBI therapy did not affect the overall use of radiotherapy as there was a corresponding decrease in CF-WBI use over these years. In the analysis of factors related to HF-WBI among invasive breast cancer patients, we found that age is strongly correlated with HF-WBI utilization and it is more likely for older patients to receive HF-WBI than younger patients. The proportion of HF-WBI use was 9.3% among women younger than age 50 while 21.8% of women older than 50 years were treated with HF-WBI. Another factor found was race/ethnicity; we found that among African American women with invasive breast cancer, 12.7% used HF-WBI and among Asian women with invasive breast cancer, 23.6% used HF-WBI, while 15.6% of white women used HF-WBI. Among the invasive breast cancer patients, HF-WBI use varied widely across geographical location with the highest uptake in the Mountain census region (25.3%) and least uptake in the West South Central region (10.5%). Other factors associated with HF-WBI use for invasive breast cancer patients included nodal status, tumor size, treating facility type, treating facility volume, and distance from home to treating facility. We found that large academic facilities were more likely to administer HF-WBI (24.4%) than small community treating facilities (11.2%). Our results for DCIS patients were similar to that of the invasive breast cancer patients. Conclusions: HF-WBI utilization in the United States has more than doubled from 2013 to 2016. Although its use is close to that of conventional WBI, HF-WBI is still far from preferred standard of care in the United States. We identified several patient and facility factors that can impact the uptake of HF-WBI treatment. Citation Format: Dezheng Huo, Minji Kang, Loren Saulsberry, Yasmin Hasan. Has hypofractionated whole breast radiation therapy become standard of care in the United States? An updated report from national cancer database [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-14.

BACKGROUND/OBJECTIVES: Care continuity prevents increased health care utilization and mortality during transition from pediatric to adult care. Our program employs a co-located care delivery model, in which pediatric provider involvement continues during young adulthood. We tested the hypothesis that individuals who participated in the co-located model have greater retention in adult care compared to those who only received pediatric transition services. METHODS: This study consisted of 311 youth with SCD (51.4 % male; 63.0% HbSS/HbSβ(0)-thalassemia) who transferred to adult care from 2007–2017. Retention was defined as continuation with an adult provider for ≥12 or ≥24 months post-pediatric care. Logistic regression estimated the association between co-location status and retention at 12 and 24 months. Logistic regression and t-tests were used to evaluate potential predictors of retention in adult care. RESULTS: Individuals who participated in the co-location model were 1.9 times more likely to remain in adult care 12 (95%CI: 1.01, 3.47) and 24 (95%CI: 1.01, 3.70) months post pediatric care compared to those who did not participate. Individuals with HbSS/HbSβ(0)-thalassemia were 1.9 times more likely to be retained at 12 months compared to those with HbSC/HbSβ(+)-thalassemia/HbS/HPFH (95%CI: 1.12, 3.09). For every clinic encounter in the last 2 years of pediatric care, the odds of being retained at least 24 months after initiating adult care increased 1.1 times (95%CI: 1.02, 1.13). CONCLUSIONS: Continuity of providers from pediatric to adult care may increase long-term retention in adult care. Longitudinal monitoring of adult outcomes is critical to identifying the efficacy of transition services.

Most children with sickle cell disease (SCD) today survive into adulthood. Among emerging adults, there is a marked increase in acute care utilization and a rise in mortality, which can be exacerbated by not establishing or remaining in adult care. Health care transition programs are therefore essential to prepare, transfer, and integrate emerging adults in the adult care setting. The Six Core Elements of Health Care Transition, created by the Center for Health Care Transition Improvement, define the basic components of health care transition support as follows: (1) transition policy, (2) tracking and monitoring progress, (3) assessing transition readiness, (4) planning for adult care, (5) transferring to adult care, and (6) integrating into adult care. Programs that implement the Six Core Elements have experienced significant declines in care abandonment during adolescence and young adulthood and higher early adult care engagement. Most of the core transition activities are not currently reimbursable, however, posing a challenge to sustain transition programs. Ongoing studies are investigating interventions in comparative effectiveness trials to improve health-related quality of life and reduce acute care utilization among emerging adults with SCD. Although these studies will identify best practices for health care transition, it is also important to define how the transition outcomes will be measured, as no consensus definition exists for successful health care transition in SCD. Future research is needed to define best practices for health care transition, systematically assess transition outcomes, and revise payment models to promote sustainability of health care transition programs.

BACKGROUND: Changing Medicaid fees is a common approach for states to address budget fluctuations, and many currently set Medicaid physician fees at levels lower than Medicare and private insurers. The Affordable Care Act included a temporary Medicaid fee bump for primary care providers (PCPs) in 2013–2014 that recently led to both an increase and then subsequent decrease in PCP fees in many states. OBJECTIVE: To conduct a systematic literature review on the effects of changing Medicaid fees on provider participation and enrollees’ access to care and service use. METHODS: We searched PubMed/Medline and JSTOR and identified 18 studies that assessed the longitudinal impact of provider fee changes in Medicaid on the outcomes of interest. We summarized information on study design, methods, and findings. RESULTS: Seven studies examined the impact of fee changes on provider participation in Medicaid. Of these, three studies found that fee increases were associated with positive effects on providers’ likelihood of accepting Medicaid patients or on their Medicaid caseloads. Five studies that examined the impact of fee changes on Medicaid enrollees’ access to care found a positive association with one or more access measure, such as having a usual source of care or appointment availability. Lastly, eight of 14 studies that examined service use found positive associations between fee changes and at least one measure of use, such as changes in the probability of enrollees having any visit, the number of visits, and shifts in the site of care toward office-based care; others largely did not find significant associations. CONCLUSIONS: There is mixed evidence on the impact of changing Medicaid fees on provider participation and enrollees’ service use; however, increasing fees appears to have more consistent positive effects on access to care. Whether these improvements in access translate into better health outcomes or downstream cost savings are critical questions.

BACKGROUND: Dense breast tissue increases breast cancer risk and lowers mammography sensitivity, but the value of supplemental imaging for dense breasts remains uncertain. Since 2009, 37 states and Washington DC have passed legislation requiring patient notification about breast density. OBJECTIVE: Examine the effects of state breast density notification laws on use of supplemental breast imaging and breast biopsies. DESIGN: Difference-in-differences analysis of supplemental imaging and biopsies before and after notification laws in 12 states enacting breast density notification laws from 2009 to 2014 and 12 matched control states. Supplemental imaging/biopsy within 6 months following an index mammogram were evaluated during four time periods related to legislation: (1) 6 months before, (2) 0–6 months after, (3) 6–12 months after, and (4) 12–18 months after. PARTICIPANTS: Women ages 40–64 years receiving an initial mammogram in a state that passed a breast density notification law or a control state. INTERVENTION: Mandatory breast density notification following an index mammogram. MAIN MEASURES: Use of breast biopsies and supplemental breast imaging (breast ultrasound, tomosynthesis, magnetic resonance imaging, scintimammography, and thermography), overall and by specific test. KEY RESULTS: Supplemental breast imaging and biopsy increased modestly in states with notification laws and changed minimally in control states. Adjusted rates of supplemental imaging and biopsy within 6 months of mammography before legislation were 8.5% and 3.1%, respectively. Compared with pre-legislation in intervention and control states, legislation was associated with adjusted difference-in-differences estimates of + 1.3% (p

Background: Adults with type 2 diabetes and Medicaid insurance are a highly vulnerable population. Despite the vital role of primary care for diabetes management, few studies have examined how the type of primary care setting affects quality of care for this population, and existing studies have not examined data across the US. Since federally qualified health centers (FQHCs) are the primary care safety net for many Medicaid patients, we compared process of care outcomes and acute care utilization for non-elderly adult Medicaid enrollees with type 2 diabetes at FQHC vs. non-FQHC primary care settings. Methods: We analyzed 2012 Medicaid fee-for-service and managed care claims data in all 50 states and DC in order to compare 8 processes of care and acute care utilization for patients receiving care at FQHCs (N=121,977) vs. non-FQHCs (N=700,401). We used propensity score overlap weighting to obtain groups balanced on covariates, then used generalized estimating equation models to compare the two groups. Results: FQHC patients had 2.6-3.6% lower rates of each measure compared to non-FQHC patients, with the exception of a higher rate of diabetes education (relative risk, 1.09 [95% CI, 1.03-1.16]). Compared to non-FQHC patients, FQHC patients had more overall (incident rate ratio, 1.06 [1.05-1.07]) and diabetes-related emergency department (ED) visits (1.10 [1.08-1.13]), but fewer overall (0.87 [0.86-0.88]) and diabetes-related hospitalizations (0.79 [0.77-0.81]). Conclusions: Our findings suggest that Medicaid enrollees with type 2 diabetes receiving primary care at FQHCs may have limited access to both preventative and urgent diabetes care. FQHC patients with diabetes may visit EDs more frequently as a result of limited appointment availability or access to specialists at FQHCs. These results underscore the need for increased support and funding for Medicaid patients with type 2 diabetes, especially in FQHCs. Disclosure A. C. Knitter: None. M. Murugesan: None. L. Saulsberry: None. W. Wan: None. R. Nocon: None. E. Huang: None. J. Bolton: None. M. Chin: Advisory Panel; Self; Bristol-Myers Squibb Company. N. Laiteerapong: Other Relationship; Self; American Diabetes Association. Funding Health Resources and Services Administration (HHSH250201300025I); National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092949)

Introduction/Background We aimed to update the previous evaluation of hypofractionated whole-breast irradiation (HF-WBI) use over time in the United States and factors related to its adoption for patients undergoing a lumpectomy from 2004 to 2016. Materials and Methods Among the patients who underwent a lumpectomy, we identified 688,079 patients with early-stage invasive breast cancer and 248,218 patients with ductal carcinoma in situ in the National Cancer Database from 2004 to 2016. We defined HF-WBI as 2.5 to 3.33 Gy/fraction to the breast and conventional fractionated whole-breast irradiation as 1.8 to 2.0 Gy/fraction. We evaluated the trend of HF-WBI use and examined factors associated with HF-WBI use using logistic regression models. Results Among invasive cancer patients, the use of HF-WBI increased exponentially from 0.7% in 2004 to 15.6% in 2013 and then to 38.1% in 2016. Among patients with ductal carcinoma in situ, the use of HF-WBI has increased significantly from 0.42% in 2004 to 13.4% in 2013 and then to 34.3% in 2016. Factors found to be associated with HF-WBI use included age, patient geographical location, race/ethnicity, tumor stage, grade, treating facility type, and volume. Conclusion HF-WBI use in the United States has more than doubled from 2013 to 2016. Although its use is close to that of conventional fractionated whole-breast irradiation, HF-WBI is still far from the preferred standard of care in the United States. We identified several patient and facility factors that can impact the uptake of HF-WBI treatment. Microabstract Using the National Cancer Database from 2004 to 2016, we evaluated the trend of hypofractionated whole-breast radiation therapy use and factors associated with use. Use in the United States has more than doubled from 2013 to 2016, but it has not become the standard of care. We identified several patient and facility factors that impact the uptake of hypofractionated whole-breast radiation therapy treatment.

Neurocognitive deficits in sickle cell disease (SCD) may impair adult care engagement. We investigated the relationship between neurocognitive functioning and socio-environmental factors with healthcare transition outcomes. Adolescents aged 15-18 years who had neurocognitive testing and completed a visit with an adult provider were included. Transition outcomes included transfer interval from paediatric to adult care and retention in adult care at 12 and 24 months. Eighty adolescents (59% male, 64% HbSS/HbSβ0 -thalassaemia) were included. Mean age at adult care transfer was 18·0 (±0·3) years and transfer interval was 2·0 (±2·3) months. Higher IQ (P = 0·02; PFDR = 0·05) and higher verbal comprehension (P = 0·008; PFDR = 0·024) were associated with

AIM: To evaluate the anti-cancer and anti-tumor activities of ceramide analog 315 in nude mice. METHODS: Nude mice (n=10) were injected bilaterally with 5×10(6) MDA-MB-231 cells on each side. Tumors were allowed to form for two weeks. The mice were then divided into two groups (n=5 in each group). The control group mice were injected with 25 μL of DMSO (dimethyl sulfoxde) and the treatment group mice were injected with 10 mg/kg of analog 315 (in DMSO, 25 μL volume) every day for a period of 3 weeks. Animal weights and tumors were measured every week for 3 weeks. RESULTS: At the end of the experimental period, control animals had retained excess fluid, and showed larger tumor sizes compared to the treated group (2.95 g vs. 1.67 g). A 45% reduction in tumor size and 80% decrease in tumor volume were observed in the treatment group. There was a significant increase in the weights of liver (10%) and spleen (19%) between the control and treated animals. Hematoxylin and Eosin (H&E) staining of MDA-MB-231 tumor sections revealed more acellular necrotic regions in tumors from the treatment groups compared to the ones from the control group. Ki67, a proliferation marker was higher in number in control tumor section (71.8 ±12.8) compared to the treatment tumor section (37.4±10.4), (P

Background This study explored the implementation of Chicago Urban Resiliency Building (CURB), a randomized clinical trial designed as an Internet-based primary care depression prevention intervention for urban African American and Latino adolescents. Methods We utilized a mixed methods analysis to explore four aims. First, we estimated the percent of at-risk adolescents that were successfully screened. Second, we examined clinic site factors and performance. Third, primary care providers (n = 10) and clinic staff (n = 18) were surveyed to assess their knowledge and attitudes about the intervention. Fourth, clinic staff (nursing and medical assistant) interviews were analyzed using thematic analysis to gather perspectives of the implementation process. Results We found that the estimated percent of at-risk adolescents who were successfully screened in each clinic varied widely between clinics with a mean of 14.48%. Daily clinic communication was suggestive of greater successful screening. Feasibility of screening was high for both primary care providers and clinic staff. Clinic staff exit interviews indicated the presence of community barriers that inhibited successful implementation of the intervention. Conclusion This study shares the challenges and successes for depression screening and implementing Internet-based mental health interventions for urban racial/ethnic minority adolescents in primary care settings.

Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19–86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.

This study assessed the extent to which high fat diet (HFD)-induced β-amyloid accumulation and cognitive decline in APP/PSEN1 mice are reversible through control of fat intake. Ten months of HFD (60% calories from fat) led to significant deficits in a 2-trial Y maze task, and nest building assay, and decreased voluntary locomotor activity. The HFD induced an inflammatory response, indicated by increased expression of several inflammatory markers. Substituting a low fat diet led to pronounced weight loss and correction of glucose intolerance, decreases in the inflammatory response, and improved performance on behavioral tasks in both wild-type and APP/PSEN1 transgenic mice. Insoluble β-amyloid levels, and extent of tau phosphorylation were also lower following dietary reversal in APP/PSEN1 mice compared to high fat-fed animals, indicating that the inflammatory response may have contributed to key pathogenic pathways in the Alzheimer's disease model. The data suggest that weight loss can be a vital strategy for cognitive protection, but also highlight potential mechanisms for intervention when sustained weight loss is not possible.

PURPOSE OF REVIEW: Review innovations in health care financing promoting health system investments in addressing medical and social determinants of health (SDH) for patients with diabetes. RECENT FINDINGS: Particular payment models implemented in the public and private sectors increasingly offer flexibility in health care organizations (HCOs) to allocate resources towards helping patients with diabetes overcome the medical and socioeconomic problems driving poor population and individual health. SUMMARY: The barriers imposed by the traditional fee-for-service (FFS) payment model to incorporating SDH into health care delivery across the health system are being overcome with new payment approaches rewarding the quality of care provided rather than strictly the volume of health services rendered. Evidence suggests health care financing changes will facilitate the realization of health reform goals to provide the right care to the right people at the right time through the expansion of the role of integrated care teams that can address patients’ medical and health-related social needs.

BACKGROUND Advancements in treatment have contributed to increased survivorship among children with sickle cell disease (SCD). Increased transition readiness, encompassing disease knowledge and self-management skills before transfer to adult care, is necessary to ensure optimal health outcomes. The Sickle Cell Transition E-Learning Program (STEP) is a public, Web-based, 6-module tool designed to increase transition readiness for youth with SCD. OBJECTIVE The objective of our study was to investigate the participation rate of youth with SCD in STEP and its association with transition readiness. METHODS This was a single-center, Institution Review Board–approved, retrospective cohort review. A total of 183 youths with SCD, aged between 12 and 15 years, were offered STEP as an adjunct to in-clinic disease education sessions. Participation rate (number of patients who used at least one STEP module divided by those approached) was calculated. The association among the number of STEP modules completed, disease knowledge, and self-management was explored. RESULTS Overall, 53 of the 183 approached adolescents completed at least one STEP module, yielding a participation rate in STEP of 29.0%. Of the 53 participants, 37 and 39 adolescents had disease knowledge and self-management confidence rating available, respectively. A positive correlation (r=0.47) was found between the number of STEP modules completed and disease knowledge scores (P=.003). No association was found between the number of modules completed and self-management confidence ratings. Disease knowledge scores were significantly higher among participants who completed ≥3 STEP modules compared with those who completed U=149.00; P=.007). CONCLUSIONS Improvement in disease knowledge in adolescence is critical to ensure the youth’s ability to self-care during the period of transition to adult care. Despite low participation, the cumulative exposure to the STEP program suggested greater promotion of disease knowledge among adolescents with SCD before transfer to adult care.

Since its FDA approval in 2006, the Human papillomavirus (HPV) vaccine has been politically-charged, given its association with sexual health among young women and its history of controversial, and largely unsuccessful, legislative mandates. The extent to which perceived politicization is related to public support for the vaccine's use, however, is not clear. We sought to examine the relationship between public perceptions of politicization of the HPV vaccine and public support for HPV vaccine policies.We fielded a survey from May-June 2016 using a nationally representative sample of U.S. adults (18-59 years). Among respondents aware of the HPV vaccine (n = 290), we predict support for HPV vaccine policies based on respondents' perceptions of three characteristics of the vaccine's portrayal in public discourse: degree of controversy, certainty of the scientific evidence supporting the vaccine's use, and frequency with which the vaccine appears in political discussion.Respondents who perceived greater certainty about the scientific evidence for the HPV vaccine were more supportive of HPV vaccine policies (p 0.0001) than respondents who perceived the scientific evidence to be uncertain, after adjusting for respondents' characteristics, including demographics and partisanship.Public perceptions of the HPV vaccine's politicization, particularly the portrayal of scientific evidence, are associated with receptivity to legislative mandates.How the certainty of a body of evidence gets communicated to the public may influence the policy process for a critical cancer prevention intervention.

Summary tables of data and analyses.

Objective To examine the life experiences of African American and Hispanic adults whose personal chronic illness and/or that of a family member is the biggest health problem for their families. Data source Telephone (landline and cell phone) interviews of random, nationally representative samples of 1081 African-American and 1478 Hispanic adults, age 18 and older. We evaluated the responses of 757 African-American and 697 Hispanic participants who reported a chronic illness as the biggest health problem in their families. Methods Weighted analysis of cross-sectional survey responses from African-American and Hispanic adults. Results African Americans and Hispanics with chronic illness in their families reported experiencing challenges with the health care delivery system, with financial/economic insecurity, and with their communities that may influence how they live with chronic disease. Discussion Policymakers and clinicians should be aware that some African-American and Hispanic patients face obstacles within and beyond the health care system that are relevant to how they live with chronic conditions affecting their families. Additional tools and supports may need to be identified and supplied to effectively manage chronic illness in these communities. The payment system for physicians should account for the supplementary supports and services these patients might require.

Understanding the molecular regulation of hematopoietic stem and progenitor cell (HSPC) engraftment is paramount to improving transplant outcomes. To discover novel regulators of HSPC repopulation, we transplanted >1,300 mice with shRNA-transduced HSPCs within 24 h of isolation and transduction to focus on detecting genes regulating repopulation. We identified 17 regulators of HSPC repopulation: Arhgef5, Armcx1, Cadps2, Crispld1, Emcn, Foxa3, Fstl1, Glis2, Gprasp2, Gpr56, Myct1, Nbea, P2ry14, Smarca2, Sox4, Stat4, and Zfp521. Knockdown of each of these genes yielded a loss of function, except in the cases of Armcx1 and Gprasp2, whose loss enhanced hematopoietic stem cell (HSC) repopulation. The discovery of multiple genes regulating vesicular trafficking, cell surface receptor turnover, and secretion of extracellular matrix components suggests active cross talk between HSCs and the niche and that HSCs may actively condition the niche to promote engraftment. We validated that Foxa3 is required for HSC repopulating activity, as Foxa3−/− HSC fails to repopulate ablated hosts efficiently, implicating for the first time Foxa genes as regulators of HSPCs. We further show that Foxa3 likely regulates the HSC response to hematologic stress. Each gene discovered here offers a window into the novel processes that regulate stable HSPC engraftment into an ablated host.

This viewgraph presentation includes the following main concepts. Goal: To evaluate Raman spectroscopy as a potential NDE tool for the detection of stress rupture in Kevlar. Objective: Test a series of strand samples that have been aged under various conditions and evaluate differences and trends in the Raman response. Hypothesis: Reduction in strength associated with stress rupture may manifest from changes in the polymer at a molecular level. If so, than these changes may effect the vibrational characteristics of the material, and consequently the Raman spectra produced from the material. Problem Statement: Kevlar composite over-wrapped pressure vessels (COPVs) on the space shuttles are greater than 25 years old. Stress rupture phenomena is not well understood for COPVs. Other COPVs are planned for hydrogen-fueled vehicles using Carbon composite material. Raman spectroscopy is being explored as an non-destructive evaluation (NDE) technique to predict the onset of stress rupture in Kevlar composite materials. Test aged Kevlar strands to discover trends in the Raman response. Strength reduction in Kevlar polymer will manifest itself on the Raman spectra. Conclusions: Raman spectroscopy has shown relative changes in the intensity and FWHM of the ~1613 cm(exp -1) peak. Reduction in relative intensity for creep, fleet leader, and SIM specimens compared to the virgin strands. Increase in FWHM has been observed for the creep and fleet leader specimens compared to the virgin strands. Changes in the Raman spectra may result from redistributing loads within the material due to the disruption of hydrogen bonding between crystallites or defects in the crystallites from aging the Kevlar strands. Peak shifting has not been observed to date. Analysis is ongoing. Stress measurements may provide a tool in the short term.

Summary Background Observational studies suggest index clinical manifestation of venous thromboembolism (VTE) predicts recurrence type. Data regarding the association between index manifestation and recurrence rates are conflicting. Objectives To perform a meta-analysis of randomized controlled trials (RCTs) to determine the type and frequency of recurrent VTE (rVTE) in persons after an index deep vein thrombosis (DVT) or pulmonary embolism (PE). Patients/Methods We searched bibliographic databases for RCTs of acute (early) treatment of rVTE in persons with an index DVT or PE (±DVT), enrolling ≥ 50 subjects anticoagulated ≥ 3-months and reporting types of rVTE. We pooled (random-effects) the proportion of rVTEs that were DVTs, PEs, and fatal PEs, the proportion of recurrent PEs that were fatal, and absolute rVTE rates. Results In nine RCTs (N = 13 640; 413 rVTEs) evaluating persons with an index PE; 66% (95% CI, 60–72%) of rVTEs were PE and 27% (95% CI, 22–33%) were fatal PE. Among 25 RCTs (N = 17 340; 692 rVTEs) evaluating persons with an index DVT, 36% (95% CI, 29–44%) experienced a recurrent PE and 10% (95% CI, 7–13%) a fatal PE. Recurrent PEs following an index PE had a higher fatality rate than after an index DVT (41%; 95% CI, 33–48% vs. 25%; 95% CI, 18–33%; P = 0.007). The rVTE rate was higher following an index DVT compared with a PE (2.6%; 95% CI, 1.6–3.8% vs. 4.9%; 95% CI, 4.0–6.0%; P = 0.002). Conclusions Our meta-analysis suggests most rVTEs will be the same type as the index event. While index DVTs are associated with a higher rVTE rate than index PEs; recurrent PEs are associated with high fatality.

Objective: The purpose of this study is to use a strengths-based approach to determine African American parents’ skills and strategies for management of children with ADHD. Method: Four focus groups were conducted to identify African American parent beliefs about appropriate ADHD management. Sixteen parents participated and reported having a total of 21 children diagnosed with ADHD. Results: Participants discussed several parenting challenges but advocated for the child by working closely with the child’s school and physician. They also managed relationships with family members to protect the child from possible physical or emotional harm. However, parents desired more social support for management of ADHD. Conclusion: African American parents possess key skills and strategies in their management of children with ADHD. Further research is needed to determine the roles and responsibilities of extended family members for children with this disorder, and to identify the social supports parents access to aid with ADHD management.

OBJECTIVE Examine use of the Internet (eHealth) and mobile health (mHealth) technologies by privately insured, publicly insured (Medicare/Medicaid), or uninsured U.S. adults in 2012. DATA SOURCE Pew Charitable Trust telephone interviews of a nationally representative, random sample of 3,014 adult U.S. residents, age 18+. METHODS Estimate health information seeking behavior overall and by segment (i.e., insurance type), then, adjust estimates for individual traits, clinical need, and technology access using logistic regression. RESULTS Most respondents prefer offline to online (Internet) health information sources; over half across all segments use the Internet. More respondents communicate with providers offline compared with online. Most self-reported Internet users use online tools for health information, with privately insured respondents more likely to use new technologies. Unadjusted use rates differ across segments. Medicaid beneficiaries are more likely than the privately insured to share health information online, and Medicare beneficiaries are more likely than the privately insured to text with health professionals. After adjustment, these differences were minimal (e.g., Medicare beneficiaries had odds similar to the privately insured of online physician consultations), or the direction of the association reversed (e.g., Medicaid beneficiaries had greater odds than the privately insured of online physician consultations versus lower odds before adjustment). DISCUSSION Few adults report eHealth or mHealth use in 2012. Use levels appear unevenly distributed across insurance types, which could be mostly attributed to differences in individual traits and/or need. As out-of-pocket costs of medical care increases, consumers may increasingly turn to these generally free electronic health tools.

Introduction: In the United States, most children with sickle cell disease (SCD) survive into adulthood and transfer from pediatric to adult-centered care. Cognitive deficits begin during childhood and are highly prevalent among individuals with SCD, potentially affecting their functional ability to establish adult care and navigate the new adult care environment. Lack of engagement in adult care can place youth with SCD at higher risk for care discontinuity and higher disease morbidity and mortality. The relationship between cognition and transition to adult care has not been examined. We hypothesized that better performance on measures of neurocognition were associated with decreased latency in initiating adult care, greater retention in adult care, and increased utilization of adult ambulatory services. As a secondary objective, we examined the relationship of environmental outcomes to transition outcomes. Methods: We included participants enrolled in the Sickle Cell Research and Intervention Program (SCCRIP; Hankins J. et al, Pediatric Blood and Cancer 2018), a longitudinal lifetime cohort study of individuals with SCD that monitors neurocognition. Participants were included if they underwent neurocognitive screening assessment in adolescence, prior to their transfer to adult care and if they satisfied their first appointment in adult care. The neurocognitive screening battery included measures of estimated global intelligence (Wechsler Abbreviated Scales of Intelligence, 2nd Ed; WASI-2) and sustained attention (Continuous Performance Test, 2nd Ed; CPT-2). Environmental factors included the Economic Hardship Index (EHI), guardian employment status while in pediatric care, and the number of persons living in the household. Use of adult ambulatory services was measured by the number of outpatient visits per patient-year. The association between cognitive performance and the latency from pediatric to adult care, adult care retention and environmental variables was examined using the 2-sample t test if the data were normally distributed or the Wilcoxon rank-sum test otherwise. Categorical variables were analyzed with the Chi-square test or Fisher's exact test. Transition outcomes were also analyzed as continuous variables using univariate linear regression. All reported p-values are two-sided. Results: Eighty adolescents with SCD ages 15-18 years at the time of their cognitive assessment (58% male, 63% HbSS/HbSβ0-thalassemia) were included; most transferred 12 months, and 31 of the 43 (72%) remained in adult care >24 months after their first adult visit. Higher Full-Scale IQ was associated with establishing adult care ≤2 months from last pediatric visit (Table 1; Figure 1A, 1B). Belonging to families with fewer children, smaller households and a higher WASI-2 Verbal Comprehension Index were associated with establishing adult care ≤6 months from last pediatric visit. Better CPT-2 Commissions performance (less attention deficit) was associated with increased adult care retention at 12 and 24 months (Table 2; Figure 1C,1D). Having a working guardian was associated with less retention at 12 months (p=0.01), whereas having an unemployed primary guardian was associated with greater retention at 24 months (p=0.02). Further, an employed guardian was associated with greater utilization of adult ambulatory services (p=0.01). EHI was not significantly related to transition outcomes. No relationship was found between adult ambulatory services and neurocognitive assessment. Conclusion: Neurocognitive deficit (lower IQ and attention deficits) may decrease short and long-term engagement in adult care among youth with SCD as demonstrated by longer latency periods between pediatric and adult care and shorter adult care retention. Socio-economic factors may also play a role in transition outcomes but require further investigation. Investigation of disease modifying therapies that preserve cognitive function should be prioritized. Interventions that account for patients' cognitive level and their environment should be considered in the individualization of transition plans. Disclosures King: Magenta Therapeutics: Membership on an entity's Board of Directors or advisory committees; Novimmune: Research Funding; Amphivena Therapeutics: Research Funding; Incyte: Consultancy; Tioma Therapeutics (formerly Vasculox, Inc.):: Consultancy; Cell Works: Consultancy; Bioline: Consultancy; Celgene: Consultancy; RiverVest: Consultancy; WUGEN: Equity Ownership. Wang:Agios Pharmaceuticals: Consultancy; Novartis: Consultancy. Zhao:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Kang:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Hankins:National Committee for Quality Assurance: Consultancy; NHLBI: Research Funding; Global Blood Therapeutics: Research Funding; Novartis: Research Funding; LYNKS Foundation: Research Funding; NHLBI: Honoraria; ASPHO: Honoraria; Bluebird Bio: Consultancy.

Introduction: During transition from pediatric to adult care, young adults with sickle cell disease (SCD) experience increased acute healthcare utilization and mortality. Functional transitional programs maintain care quality; however, there is a dearth of program outcomes concerning adult care retention. The St. Jude Transition to Adult Care Program is embedded within a co-located medical home for SCD spanning the ages of 12-25 years. The co-location model bridges pediatric and adult care at three levels: (1) hematology provider (2) neuropsychologist and (3) transition nurse coordinator. Previous work demonstrated that young adults who receive care within a co-located transition model of care do not have the typical increase in acute care utilization during transition (Nolan, AJH 2017). Here, we tested the hypothesis that individuals who participated in the co-location model until age 25 years have greater retention in adult care 12- or 24- months after engaging in adult care, compared to those who only received pediatric co-location transition services (until age 18). Further, we explored adult environmental factors as predictors of retention in adult care at 12- and 24- months. Methods: With IRB approval, we analyzed the outcomes of participants of the longitudinal cohort study Sickle Cell Clinical Research and Intervention Program (SCCRIP, PBC 2018), who completed transfer from pediatric to adult care from January 2007 to December 2017. Participants were excluded if they did not have enough time in adult care for the 12- and 24-month retention analysis. Adult care retention was defined as continuation with the same provider for ≥12 or ≥24 months post-pediatric care and was compared among adults who transferred to adult care within the co-location model vs. those who did not. Chi-square tests were used to test associations between demographics and co-location model exposure. Logistic regression estimated the association between care abandonment (defined as voluntarily discontinuing pediatric care or dying before 12- or 24- months from initiating adult care) and co-location status at 12- and 24- months. Each model was tested for effect modification and confounding by the following variables: sex, genotype, year of last pediatric visit, and age at transfer. Fisher's Exact Test investigated predictors of adult care retention within the adult co-location model including employment status, education level, crowding, marital status, household income, and health insurance status during the first year of adult care. P-values Results: Of the 364 patients who transferred to adult care, 211 (58.0%) participated in the transition co-location model. Fifty-three (14.5%) individuals were excluded from the 12-month analysis due to having Conclusion: Continuity of providers from pediatric to adult care may increase long-term retention in adult care. Longitudinal monitoring of adult outcomes is critical to identifying the efficacy of transition services. Disclosures Ataga: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Emmaus Life Sciences: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bioverativ: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding; Modus Therapeutics: Honoraria. Hankins:ASPHO: Honoraria; NHLBI: Honoraria; National Committee for Quality Assurance: Consultancy; Global Blood Therapeutics: Research Funding; NHLBI: Research Funding; LYNKS Foundation: Research Funding; Novartis: Research Funding; Bluebird Bio: Consultancy.

When confronted with a parasite or pathogen, hosts can defend themselves by resisting or tolerating the attack. While resistance can be diminished when resources are limited, it is unclear how robust tolerance is to changes in environmental conditions. Here, we investigate the sensitivity of tolerance in a single host population living in a highly variable environment. We manipulated the abundance of an invasive parasitic fly,Philornis downsi, in nests of Galápagos mockingbirds (Mimus parvulus) over four field seasons and measured host fitness in response to parasitism. Mockingbird tolerance toP. downsivaried significantly among years and decreased when rainfall was limited. Video observations indicate that parental provisioning of nestlings appears key to tolerance: in drought years, mockingbirds likely do not have sufficient resources to compensate for the effects ofP. downsi. These results indicate that host tolerance is a labile trait and suggest that environmental variation plays a major role in mediating the consequences of host–parasite interactions.

Objective Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection [hyaluronic acid (HA)] versus steroid [intra-articular corticosteroid (IAS)] and placebo [intra-articular placebo (IAP)] is based on the evaluation of treatment effect by examining the number of subjects within a treatment arm that met the Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups was clinically different. Data sources We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE, and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. Main results Eleven articles met the inclusion criteria from the search strategy. On NMA, those subjects receiving HA were 15% and 11% more likely to respond to treatment by the OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (P Conclusions In light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

It is my goal, through this autoethnography, to take you through a reflective journey and present to you my personal theory of how facilitated dialogue in the context of transformative learning, critical reflection, systems thinking, shared vision, and holarchy can create a paradigm shift in our personal consciousness, decisions, behaviors, practice, and social policies—social change. My objective is to show how each theory is like a stepping-stone in the path towards social change. The purpose of this living work is to offer an alternative way of creating a healthy and whole society by exploring how facilitated dialogue can lead to the desired goal of social change. The ideas discussed throughout this document—namely the web of life, re-envisioning through shared vision—life through interruption, and new model, provide us with an opportunity to better understand how individuals can engage in a more empathetic and conscious way of being and connecting with one another, taking into consideration that we share a common world view that lies at the core desire of each human being—a whole, safe, healthy, secure, and light filled life experience. This document is offered as a living blueprint for a practical application for the creation of a healthy and whole society.

Early preventive interventions for depressive disorders in racial/ethnic minorities may help to reduce lifetime depression outcome disparities by improving developmental trajectories and social outcomes. We describe the development process, intervention and evaluation plan for a culturally adapted, low-cost, primary care/Internet-based depression-prevention intervention (CURB, Chicago Urban Resiliency Building). CURB is culturally adapted for socio-economically disadvantaged African-American and Latino adolescents according to the PEN-3 model of health promotion programs (Airhihenbuwa in Health and culture: beyond the Western paradigm, Sage Publishers, Thousand Oaks, 1995). Based on the idea that health behavior is rooted in culture, the PEN-3 model contains three interdependent dimensions that influence health beliefs and behaviors. Within each dimension are factors (using the acronym PEN) that must be considered about the target culture. Application of the PEN-3 model occurred in 3 phases. In each phase, a dimension of the model was explored and subsequent changes were made to the intervention so as to be more culturally suitable. In the CURB clinical trial, adolescents ages 13–17 will be recruited from wait-lists for mental health services at community health care provider organizations and screened for risk of future depressive disorder in the primary care sites. Adolescents screening positive for persistent depressed mood will be randomly assigned to either the CURB intervention group or the wait-list control group. The study aims are to determine if participants in the CURB intervention group will have lower levels of depressive symptoms and/or a lower cumulative incidence of depressive episodes.