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Background: Yearly influenza vaccination is strongly recommended at age 65 and reimbursed by Medicare without copays or deductibles at pharmacies and clinical settings. Uptake is low among patients with a high risk for influenza complications and good access to specialist care, such as recent cancer survivors. We hypothesized that more accessible pharmacies could be associated with higher immunization uptake in such patients.Objectives: To determine whether pharmacy access is associated with influenza vaccination in subjects recently diagnosed with breast cancer, and whether this association differs by additional risk factors for influenza complications.Methods: We examined a cohort of patients with stage 0-III breast cancer diagnosed 2011-2015 from the Surveillance, Epidemiology, and End Results-Medicare cancer registry. All retail pharmacies in the United States were identified, and pharmacy access was measured by assessing supply and demand in each census tract using a 2-stage floating catchment area approach that accounted for pharmacy driving distances recommended by the Centers for Medicare and Medicaid Services. We examined the association of pharmacy access with influenza vaccination after breast cancer diagnosis in regression models.Results: More than 11% of 45,722 patients with breast cancer lived in census tracts where no pharmacies were within recommended driving distances from the population-weighted tract center. Vaccination in the year after diagnosis was less likely for patients in these very low-access tracts (adjusted odds ratio 0.92 [95% CI 0.86-0.96]), black (0.55 [0.51-0.60]) and Hispanic (0.76 [0.70-0.83]) women, and Medicaid recipients (0.74 [0.69-0.79]). Vaccination was inversely associated with per capita income in the subject's census tract, but there was no difference in the pharmacy effect by race, ethnicity, or census tract income.Conclusion: Very low pharmacy access is associated with modest reductions in vaccination that could be useful for policy and planning regarding vaccinator resources and outreach. [ABSTRACT FROM AUTHOR]

Residential segregation is an important factor that negatively impacts cancer disparities, yet studies yield mixed results and complicate clear recommendations for policy change and public health intervention. In this study, we examined the relationship between local and Metropolitan Statistical Area (MSA) measures of Black isolation (segregation) and survival among older non-Hispanic (NH) Black women with breast cancer (BC) in the United States. We hypothesized that the influence of local isolation on mortality varies based on MSA isolation—specifically, that high local isolation may be protective in the context of highly segregated MSAs, as ethnic density may offer opportunities for social support and buffer racialized groups from the harmful influences of racism. Local and MSA measures of isolation were linked by Census Tract (CT) with a SEER-Medicare cohort of 5,231 NH Black women aged 66–90 years with an initial diagnosis of stage I-IV BC in 2007–2013 with follow-up through 2018. Proportional and cause-specific hazards models and estimated marginal means were used to examine the relationship between local and MSA isolation and all-cause and BC-specific mortality, accounting for covariates (age, comorbidities, tumor stage, and hormone receptor status). Of 2,599 NH Black women who died, 40.0% died from BC. Women experienced increased risk for all-cause mortality when living in either high local (HR = 1.20; CI = 1.08–1.33; p < 0.001) or high MSA isolation (HR = 1.40; CI = 1.17–1.67; p < 0.001). A similar trend existed for BC-specific mortality. Pairwise comparisons for all-cause mortality models showed that high local isolation was hazardous in less isolated MSAs but was not significant in more isolated MSAs. Both local and MSA isolation are independently associated with poorer overall and BC-specific survival for older NH Black women. However, the impact of local isolation on survival appears to depend on the metropolitan area's level of segregation. Specifically, in highly segregated MSAs, living in an area with high local isolation is not significantly associated with poorer survival. While the reasons for this are not ascertained in this study, it is possible that the protective qualities of ethnic density (e.g., social support and buffering from experiences of racism) may have a greater role in more segregated MSAs, serving as a counterpart to the hazardous qualities of local isolation. More research is needed to fully understand these complex relationships. National Cancer Institute. • Residential racial segregation is an important factor that influences mortality outcomes. • The impact of isolation, a measure of segregation, on survival may vary by race/ethnicity. • Racial/ethnic enclaves may provide protective health benefits for breast cancer survival. • Greater isolation/segregation negatively impacts survival outcomes for NH Black women. [ABSTRACT FROM AUTHOR]

Background Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop “Top Five” lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown. Methods We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) “basic” public reporting and (ii) an “enhanced” intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions. Discussion The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care. Trial Registration: ClinicalTrials.gov number pending. [ABSTRACT FROM AUTHOR]

Background: Adjuvant endocrine therapy (AET) for breast cancer reduces mortality, but one-third to one-half of patients discontinue it early or are nonadherent.Objective: We developed a pilot single-site study of patients with evidence of early nonadherence to AET to assess the feasibility of a novel, clinical pharmacist-led intervention targeting symptom and medication management.Methods: Patients with prescription fill records showing nonadherence were enrolled in a single-arm feasibility study. Automated reminders were sent by e-mail or text with a link to symptom monitoring assessments weekly for 1 month and monthly until 6 months. Clinical oncology pharmacists used guideline-based symptom management and other medication management tools to support adherence and ameliorate symptoms reported on the assessments. Patient-reported outcome assessments included physical, mental, and social health domains and self-efficacy to manage symptoms and medications. Feasibility outcomes included completion of symptom reports and pharmacist recommendations.Results: Of 19 participants who were nonadherent who enrolled and completed initial assessments, 18 completed all final study procedures, with 14 completing all assessments and no patient missing more than 3 assessments. All 18 participants reported at least one of 3 symptom types, and the majority reported attempting pharmacist recommendations. Patient-reported measures of physical, mental, and social health and self-efficacy improved, and 44% of the patients became adherent.Conclusion: An intervention using pharmacists in an oncology practice to systematically monitor and manage symptoms shows promise to reduce symptoms, enhance support and self-efficacy, and improve adherence to AET. [ABSTRACT FROM AUTHOR]

Abstract: Although risk prediction tools providing absolute fracture risk information are currently under development, little is known about US physicians'' current thresholds for osteoporosis treatment or the potential effect of fracture risk information on treatment decisions. To investigate this, a random sample of US primary care physicians was surveyed. Treatment recommendations for 4 patient scenarios depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) were elicited. Physicians were randomly assigned to receive all scenarios with either a basic BMD report or an augmented BMD report containing 5-yr and lifetime absolute hip fracture risk estimates. Over 95% of physicians recommended prescription pharmacologic treatment of a 70-yr-old patient with osteoporosis. For 3 scenarios depicting women with T-scores of −1.01, treatment recommendations ranged from 30% to 44%. There were no statistically significant differences between physicians who received augmented and basic BMD reports, although those with augmented BMD reports were less likely to recommend prescription treatments. Physician specialty had inconsistent and small effects on recommendations. We conclude that nearly all of a random sample of US primary care physicians recommend pharmacologic treatment of osteoporosis, but a substantial minority also recommend treatment for patients who would not fit current guidelines. A BMD report including absolute hip fracture risk estimates did not change treatment recommendations. [Copyright &y& Elsevier]

Racial health disparities continue to be a serious problem in the United States and have been linked to contextual factors, including racial segregation. In some cases, including breast cancer survival, racial disparities appear to be worsening. Using the Home Mortgage Disclosure Act (HMDA) database, we extend current spatial analysis methodology to derive new, spatially continuous indices of (1) racial bias in mortgage lending and (2) redlining. We then examine spatial patterns of these indices and the association between these new measures and breast cancer survival among Black/African American women in the Milwaukee, Wisconsin metropolitan area. These new measures can be used to examine relationships between mortgage discrimination and patterns of disease throughout the United States. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies. Purpose: To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions. Study design: Retrospective cohort study. Patient sample: Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007. Outcome measures: Readmissions within 30 days of discharge, excluding readmissions for rehabilitation. Methods: Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software). Results: Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions. Conclusions: Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit. [Copyright &y& Elsevier]

Abstract: Postmortem preservation conditions may be one of factors contributing to wide material property variations in brain tissues in literature. The objective of present study was to determine the effects of preservation temperatures on high strain-rate material properties of brain tissues using the split Hopkinson pressure bar (SHPB). Porcine brains were harvested immediately after sacrifice, sliced into 2mm thickness, preserved in ice cold (group A, 10 samples) and 37°C (group B, 9 samples) saline solution and warmed to 37°C just prior to the test. A SHPB with tube aluminum transmission bar and semi-conductor strain gauges were used to enhance transmitted wave signals. Data were gathered using a digital acquisition system and processed to obtain stress–strain curves. All tests were conducted within 4h postmortem. The mean strain-rate was 2487±72s−1. A repeated measures model with specimen-level random effects was used to analyze log transformed stress–strain responses through the entire loading range. The mean stress–strain curves with ±95% confidence bands demonstrated typical power relationships with the power value of 2.4519 (standard error, 0.0436) for group A and 2.2657 (standard error, 0.0443) for group B, indicating that responses for the two groups are significantly different. Stresses and tangent moduli rose with increasing strain levels in both groups. These findings indicate that storage temperatures affected brain tissue material properties and preserving tissues at 37°C produced a stiffer response at high strain-rates. Therefore, it is necessary to incorporate material properties obtained from appropriately preserved tissues to accurately predict the responses of brain using stress analyses models, such as finite element simulations. [ABSTRACT FROM AUTHOR]

Abstract: The objective of this study was to test the hypothesis that the human lumbosacral joint behaves differently from L1–L5 joints and provides primary moment–rotation responses under pure moment flexion and extension and left and right lateral bending on a level-by-level basis. In addition, range of motion (ROM) and stiffness data were extracted from the moment–rotation responses. Ten T12–S1 column specimens with ages ranging from 27 to 68 years (mean: 50.6±13.2) were tested at a load level of 4.0Nm. Nonlinear flexion and extension and left and right lateral bending moment–rotation responses at each spinal level are reported in the form of a logarithmic function. The mean ROM was the greatest at the L5–S1 level under flexion (7.37±3.69°) and extension (4.62±2.56°) and at the L3–L4 level under lateral bending (4.04±1.11°). The mean ROM was the least at the L1–L2 level under flexion (2.42±0.90°), L2–L3 level under extension (1.58±0.63°), and L1–L2 level under lateral bending (2.50±0.75°). The present study proved the hypothesis that L5–S1 motions are significantly greater than L1–L5 motions under flexion and extension loadings, but the hypothesis was found to be untrue under the lateral bending mode. These experimental data are useful in the improved validation of FE models, which will increase the confidence of stress analysis and other modeling applications. [Copyright &y& Elsevier]

Abstract: The objective of this study was to determine the bone mineral density (BMD) of cervical vertebrae and correlate with the lumbar spine. Fifty-seven young adult healthy male volunteers, ranging from 18 to 41 years of age, underwent quantitative computed tomography (QCT) scanning of C2-T1 and L2–L4 vertebrae. To account for correlations, repeated measures techniques were used to compare data as a function of spinal level and region. Linear regression methods were used (±95% CI) to compare data as a function of spinal level and region. The mean age and body height were 25.0 ± 5.8 years and 181.0 ± 7.6 cm. BMD decreased from the rostral to caudal direction along the spinal column. Grouped data indicated that the neck is the densest followed by the first thoracic vertebra and low back with mean BMD of 256.0 ± 48.1, 194.3 ± 44.2, and 172.2 ± 28.4 mg/cm3, respectively; differences were statistically significant. While BMD did not vary significantly between the three lumbar bodies, neck vertebrae demonstrated significant trends. The matrix of correlation coefficients between BMD and spinal level indicated that the relationship is strong in the lumbar (r = 0.92–0.96) and cervical (r = 0.73–0.92) spines. Data from the present study show that the trabecular bony architecture of the neck is significantly different from the low back. These quantitative BMD data from a controlled young adult healthy human male volunteer population may be valuable in establishing normative data specifically for the neck. From a trabecular bone density perspective, these results indicate that lumbar vertebrae cannot act as the best surrogates for neck vertebrae. Significant variations in densities among neck vertebrae, unlike the low back counterpart, may underscore the need to treat these bones as different structures. [Copyright &y& Elsevier]