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Aryltellurium trichlorides have proven themselves as good cyclizing reagents in electrophilic intramolecular cyclization reactions, mainly of propenyl derivatives of heterocycles. On the other hand, information on the use of butenyl derivatives in reactions with p-alkoxyphenyltellurtrichlorides is limited. In this work, the regioselectivity of the process of electrophilic intramolecular cyclization of but-2-enyl thioethers of quinoline-3carbaldehyde and quinazolin-4-one with p-methoxyphenyltellurium trichloride was investigated. It was established that, as a result of the tellurium-induced cyclization with p-methoxyphenyltellurium trichloride of but-2-enyl thioethers of quinoline and quinazoline, angular tricyclic chlorides – 2-(dichloro(4-methoxyphenyl)-tellanyl)-1-methyl-5-formyl-2,3- dihydro-1H-[1,3]thiazino[3,2-a]quinolin-11-ium and 2-(dichloro(4-methoxyphenyl)-tellanyl)-1-methyl-6-oxo-5-phenyl-2, 3,5,6-tetrahydro-1H-[1,3]thiazino[3,2-a]quinazolin-11-ium, respectively, with an annealed six-membered ring in the form of complexes with p-methoxyphenyltellurium trichloride. Optimal conditions for the electrophilic intramolecular cyclization reaction were selected. Keywords: electrophilic heterocyclization; p-methoxyphenyltellurium trichloride; organotellurium compounds; chloride 2-(dichloro(4-methoxyphenyl)-tellanyl)-1-methyl-5-formyl-2,3-dihydro-1H-[1,3]thiazino[3,2 -a]quinolin-11-ium, chloride 2-(dichloro(4-methoxyphenyl)-tellanyl)-1-methyl-6-oxo-5-phenyl-2,3,5,6-tetrahydro-1H-[1,3]thiazino[3,2-a]quinazolin-11-ium

Abstract. This retrospective cohort analysis of claims data used logistic regression to evaluate change in antipsychotic and antiepileptic mood stabilizer prescription frequencies in Virginia nursing homes among residents with and without seizure-epilepsy between the years 2011 and 2016. Over that period, prescription of antipsychotics decreased 13.1% to 5.6% in the long-stay population, while the use of antiepileptic mood stabilizers increased significantly 27.0%, to an 8.6% prevalence rate. These gains were entirely among residents without epilepsy. African-Americans and males were at significantly increased risk for the prescription of mood stabilizers. Growth in long-stay antiepileptic mood stabilizer use is unrelated to seizure-epilepsy, as these changes in prescription occurred only among residents without seizure-epilepsy. More antiepileptic mood stabilizers are now being prescribed to nursing-home residents without epilepsy than antipsychotics in the nursing-home population overall.

OBJECTIVES: Compare Virginia nursing homes in the top- and bottom-quintiles of antipsychotic use for variation in community, social, and facility factors. METHODS: 2018 CMS data ascertained Virginia nursing homes in the top and bottom quintiles for antipsychotic use. The Virginia Health Department provided social determinant of health (SDOH) statistics for each facility’s county/city while claims identified facility demographics. Chi square and independent two-sample t-tests compared quintiles for regional, social, and demographic differences. RESULTS: Quintiles averaged 3000 residents and 56 facilities. Facilities with the lowest rates of antipsychotic use were more likely to be privately owned and had fewer African-American and minority residents and more white residents. All 18 SDOH statistics were superior for the communities of facilities with the lowest antipsychotic rates. Nine of these differences were statistically significant, including the aggregated “Health Opportunity Index.” CONCLUSIONS: The antipsychotic prevalence rate for facilities in the top-quintile of antipsychotic use is fivefold the bottom-quintile’s rate. Antipsychotic prescribing in nursing homes is associated with regional, demographic, and social factors not addressed by existing antipsychotic reduction measures, with vulnerable populations at greatest risk. CLINICAL IMPLICATIONS: The efficacy of measures aimed at curbing long-stay antipsychotic prescribing could be improved by addressing SDOH including economic opportunities.

It is known that thiazolopyrimidines with an exocyclic aryl tellurium moiety exhibit antimalarial activity against the deadliest strain of Plasmodium falciparum. For expanding the number of potentially biologically active compounds with an exocyclic aryl tellurium moiety, a study of tellurium-induced heterocyclization of 2-allylthioquinoline-3-carbaldehyde with p-methoxyphenylteltur trichloride was performed. The selection of this synton is motivated by the fact that quinoline derivatives are used as drugs in the treatment of malaria. The starting compound 2-allylthioquinoline-3-carbaldehyde contains several nucleophilic centers for passing tellurium-induced cyclization, namely the multiple bond of the allyl moiety and the endocyclic nitrogen atom of quinoline. Thus cyclization reaction can lead to the formation of both addition and cyclization products. The reaction of the allyl thioether with p-methoxyphenyltelluriumtrichloride was performed in glacial acetic acid and under stirring the reagents at room temperature for 8 hours. It was found that the tellurium-induced cyclization of 2-allylthioquinoline-3-carbaldehyde with p-methoxyphenyltellurium trichloride leads to the formation of angular thiazoloquinoline with an exocyclic aryltellurium fragment ― 1-(dichloro(4-methoxyphenyl)-tellanyl)methyl)-4-formyl-1,2-dihydrothiazolo[3,2-a]quinolin-10-ium chloride. Based on the spectral data, it is proved that the reaction produces a complex of 1-(dichloro(4-methoxyphenyl)-tellanyl)methyl)-4-formyl-1,2-dihydrothiazolo[3,2-a]quinolin-10-ium chloride with p-methoxyphenyltellturium trichloride with composition 1: 1. It should be noted that the formation and composition of this complex does not depend on the ratio of starting reagents. In order to evaluate the biological activity of 1-(dichloro(4-methoxyphenyl)-tellanyl)methyl)-4-formyl-1,2-dihydrothiazolo[3,2-a]quinolin-10-ium chloride, the theoretical bioscreening was performed using online resource Way2Drug. Analysis of the obtained bioactivity data showed the potential antioxidant, antibacterial and antiviral activity of exotellurofunctionalized thiazolo[3,2-a]quinoline-10-ium. Keywords: 2-allylthioquinoline-3-carbaldehyde; p-methoxyphenyltellurium trichloride; electrophilic heterocyclization; annulation, thiazolo[3,2-a]quinolinium chloride.

Introduction Cytomegalovirus (CMV) is one of the most common and clinically significant viral infections following allogeneic hematopoietic cell transplantation (HCT). Currently available options for CMV prophylaxis and treatment present challenges related to side effects and cost. Methods In this retrospective medical record review, the incidence of clinically significant CMV infection (CMV disease or reactivation requiring preemptive treatment) following allogeneic HCT was compared in patients receiving valacyclovir 1 g three times daily versus acyclovir 400 mg every 12 h for viral prophylaxis. Results Forty-five patients who received valacyclovir were matched based on propensity scoring to 35 patients who received acyclovir. All patients received reduced-intensity conditioning regimens containing anti-thymocyte globulin. Clinically significant CMV infection by day + 180 was lower in the valacyclovir group compared to the acyclovir group (18% vs. 57%, p = 0.0004). Patients receiving valacyclovir prophylaxis also had less severe infection evidenced by a reduction in CMV disease, lower peak CMV titers, delayed CMV reactivation, and less secondary neutropenia. Conclusion Prospective evaluation of valacyclovir 1 g three times daily for viral prophylaxis following allogeneic HCT is warranted. Due to valacyclovir's favorable toxicity profile and affordable cost, it has the potential to benefit patients on a broad scale as an option for CMV prophylaxis.

Introduction Clinical preventive services can reduce mortality and morbidity, but Americans receive only half of the recommended care. Although wellness visits protect time for clinicians to review needs and discuss care with patients, studies have not shown that having a wellness visit improves health outcomes. This study seeks to understand the types of discussions and volume of care delivered during wellness visits. Methods Using a sample of 1,008 patients scheduled for a wellness visit from 22 primary care clinicians across 3 states from 2018 to 2019, electronic health records were reviewed, and a subset of visits was audio recorded. The discussion and delivery of clinical preventive services, as recommended by the U.S. Preventive Services Task Force, were measured, and new diagnoses were identified from the clinical preventive services. Analyses were completed in 2020. Results Even though patients were up to date with 80% of the recommended clinical preventive services 3 months after the visit, only 0.5% of patients were up to date with all the recommended clinical preventive services. On average, 6.9 clinical preventive service discussions occurred during each wellness visit on the basis of electronic health records review, and 7.7 clinical preventive services discussions occurred on the basis of audio recordings. An average of 0.4 new diagnoses was identified, including cancer diagnoses, cardiovascular risks, and infections. Conclusions Wellness visits are an important time for patients and clinicians to discuss prevention strategies and to deliver recommended clinical preventive services, leading to the identification of previously unrecognized diagnoses. This will improve patients’ health. Policies and incentives that promote wellness visits are important, and efforts are needed to deliver them to those most in need.

Our primary objectives are to empirically identify distinct childhood groups based on trajectories of waist circumference (WC) and waist circumference index measurements, and then to estimate associations between these groups and adult diabetes incidence, as well as other outcomes, including blood pressure, body size, body composition, and hemoglobin levels. Childhood WC and height measurements as well as various adult measurements are taken from participants in the Fels Longitudinal Study. Childhood groups are identified using group-based trajectory modeling. Associations between the resulting group probabilities and adult outcomes are examined using mixed models. Our results show that distinct childhood groups are identifiable for both waist size measurements, with growth curves exhibited by these groups becoming distinguishably separate at around 4 years of age. Higher probabilities for groups exhibiting the larger waist size for either measurement were estimated to have higher risks of developing diabetes in adulthood. Associations were also observed between group probabilities and systolic blood pressure, diastolic blood pressure, and various anthropomorphic measurements, with most associations consistently occurring in early adulthood. These findings expand upon the existing literature, showing that childhood trends in waist size, distinguishable at ages as early as 4 years, are associated with adult Type-2 diabetes.

While web-based surveys are a convenient research tool, the ease of dropping out in the online setting has become a growing issue in ensuring data quality. One theory is that dropout, or attrition, occurs in phases that can be generalized to phases of high dropout and phases of stable use. In order to detect these phases, survey dropout is considered as a time-to-event outcome and tests within change-point hazard models are introduced. Here, we apply the multiple change-point exponential model and extend the single change-point Weibull model to account for multiple change-points. We also introduce a likelihood ratio test to aid in determining the number of distinct phases, using Monte Carlo simulations of the null hypothesis of no attrition phases or change-points against the alternative hypothesis that distinct attrition phases exist (at least one change-point). The performances of these change-point hazard models are compared using both a simulation study and also with application to survey data on patient cancer screening preferences, as well as compared to previous work with discrete models.

Background Although rotator cuff syndrome is common and extensively studied from the perspective of producing healed tendons, influence of gender on patient-reported outcomes is less well examined. As activity and role demands may vary widely between men and women, clarity on whether gender is an important factor in outcome would enhance patient education and expectation management. Our purpose was to determine if differences exist in patient-reported outcomes between men and women undergoing rotator cuff surgery. Methods One hundred forty-eight participants (76 W:72 M) aged 35–75 undergoing surgery for unilateral symptomatic rotator cuff syndrome were followed for 12 months after surgery. Demographics, surgical data, and the Western Ontario Rotator Cuff (WORC) scores were collected. Surgery was performed by two fellowship-trained shoulder surgeons at a single site. Results There were no gender-based differences in overall WORC score or subcategory scores by 12 months post-op. Pain scores were similar at all time points in men and women. Women were more likely to have dominant-arm surgery and had smaller rotator cuff tears than men. Complication rates were low, and satisfaction was high in both groups. Conclusion Patient gender doesn’t appear to exert an important effect on patient-reported rotator cuff outcomes in this prospective cohort. Further work examining other covariates as well as the qualitative experience of going through rotator cuff repair should provide greater insight into factors that influence patient-reported outcomes.

Objective Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different. Methods We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of Prenatal Care Utilization Index and the American Academy of Pediatrics recommendations to assess the adequacy of PNC and WCV attendance, respectively. Mothers with less than 50% visit adherence or initiation after 5 months gestation were eligible as cases and those with 80% or more adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with 80% or more adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio from the eligible subjects and frequency matched on birth month. Results In adjusted analyses, mothers and children who were publicly insured or who were uninsured had higher odds of poor preventive visit attendance. Mothers who experienced intimate partner violence and had more living children were more likely to have poor attendance. Children whose mothers had younger age, greater number of pregnancies and transportation difficulties had poorer attendance. Conclusions While lack of insurance and public insurance remained significantly associated with both poor PNC and WCV attendance, other factors varied between groups. Expanding eligibility requirements and streamlining enrollment and renewal processes may improve two generations of preventive visit attendance.

During July 2021, 469 cases of COVID-19 associated with multiple summer events and large public gatherings in a town in Barnstable County, Massachusetts, were identified among Massachusetts residents; vaccination coverage among eligible Massachusetts residents was 69%. Approximately three quarters (346; 74%) of cases occurred in fully vaccinated persons (those who had completed a 2-dose course of mRNA vaccine [Pfizer-BioNTech or Moderna] or had received a single dose of Janssen [Johnson & Johnson] vaccine ≥14 days before exposure). Genomic sequencing of specimens from 133 patients identified the B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, in 119 (89%) and the Delta AY.3 sublineage in one (1%). Overall, 274 (79%) vaccinated patients with breakthrough infection were symptomatic. Among five COVID-19 patients who were hospitalized, four were fully vaccinated; no deaths were reported. Real-time reverse transcription-polymerase chain reaction (RT-PCR) cycle threshold (Ct) values in specimens from 127 vaccinated persons with breakthrough cases were similar to those from 84 persons who were unvaccinated, not fully vaccinated, or whose vaccination status was unknown (median = 22.77 and 21.54, respectively). The Delta variant of SARS-CoV-2 is highly transmissible (1); vaccination is the most important strategy to prevent severe illness and death. On July 27, CDC recommended that all persons, including those who are fully vaccinated, should wear masks in indoor public settings in areas where COVID-19 transmission is high or substantial.* Findings from this investigation suggest that even jurisdictions without substantial or high COVID-19 transmission might consider expanding prevention strategies, including masking in indoor public settings regardless of vaccination status, given the potential risk of infection during attendance at large public gatherings that include travelers from many areas with differing levels of transmission.

The 2020 Sturgis motorcycle rally resulted in widespread transmission of severe acute respiratory syndrome coronavirus 2 across the United States. At least 649 coronavirus disease 2019 cases were identified, including secondary and tertiary spread to close contacts. To limit transmission, persons attending events should be vaccinated or wear masks and practice physical distancing if unvaccinated. Persons with a known exposure should be managed according to their coronavirus disease 2019 vaccination or prior infection status and may include quarantine and coronavirus disease 2019 testing.

Objective Excluded from reporting to CMS's Percentage of long-stay residents who got an antipsychotic medication quality-measure are antipsychotics prescribed to nursing home patients with schizophrenia, Tourette's, or Huntington's. Over the 4 years following its 2012 debut, the quality-measure calculated a 27% reduction in inappropriate antipsychotic use but also an 18.3% increase in exclusion claims. This study evaluated the impact of these exclusions on the measure's findings. Methods Claims data for the years 2011–2016 retrospectively identified the prevalence of schizophrenia, Tourette's, and Huntington's in quarterly cohorts of Virginia long-stay residents prescribed antipsychotics. Annualized diagnoses in 2011 were compared with subsequent years using simple logistic regression. Results In 2016, 29% of the antipsychotics prescribed in Virginia nursing homes were to residents with diagnoses of schizophrenia, Tourette's, and Huntington's, a significant 32% increase from 2011. Conclusion Almost 30% of the antipsychotics employed in Virginia nursing homes are excluded from CMS's long-stay antipsychotic quality-measure.

Sequential multiple assignment randomized trial (SMART) designs tailor individual treatment by re-randomizing participants to subsequent therapies based on their response to initial treatment. Misc...

INTRODUCTION As educators seek to improve medical student well-being, it is essential to understand the interplay between distress and important outcomes. Performance on Step 1 of the United States Medical Licensing Examination has played a significant role in selection for postgraduate residency positions in the United States and consequently has been a source of great stress for medical students. The purpose of this study was to examine whether student well-being correlates with performance on a high stakes licensing examination. METHODS Between 2014 and 2016, three sequential cohorts of medical students at the University of Michigan Medical School completed the Medical Student Well-Being Index (MSWBI) at the end of their 2nd-year curriculum, shortly before taking Step 1. Associations between well-being and Step 1 scores were investigated while adjusting for MCAT scores and cumulative second-year course scores. RESULTS In total, 354 students were included in the analysis (68.1% of potential responders). On bivariate analysis, poor student well-being (0 = low distress [high well-being], 7 = high distress [poor well-being]) was associated with lower Step 1 examination scores (slope = -2.10, P

INTRODUCTION: In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low-, medium-, or high-intensity statins based on cardiovascular risk. We sought to evaluate the guideline’s adoption in a diverse group of practices. METHODS: Using a mixed-methods approach, we analyzed electronic health record data the year before and 2 years following guideline publication in 45 practices across 8 states. We examined associations based on patient, clinician, and practice characteristics and interviewed 24 clinicians and practice leaders to inform findings. RESULTS: The proportion of patients adherent with all recommendations 2 years after the guideline only increased from 18.5% to 20.3% (P

Quinoline and its derivatives represent the important class of nitrogen-containing heterocycles, which are useful intermediates in organic synthesis and exhibit a wide range of biological activity. In addition, the quinoline nucleus is a part of natural alkaloids and drugs that is why the synthesis of new quinoline derivatives is an actual task. The 2-chloroquinoline-3-carbaldehyde pays particular attention among a number of quinolines, which contains a chlorine atom and an aldehyde group, which make it an universal intermediate syntone in the synthesis of various bioactive quinoline derivatives. The purpose of this work is to synthesize Schiff bases based on 2-chloroquinoline-3-carbaldehyde. It was found that the interaction of 3-formyl-2-chloroquinoline with 1-aminopropanol-2 in an alcohol medium occures with the formation of 1-((2-chloroquinolin-3-yl) methylene) amino)propan-2-ol. To determine the impact of the nature of the alkyl substituent near the amino group, the condensation reactions of 2-chloroquinoline-3-carbaldehyde with amines containing cycloheptyl and cyclohexenyl fragment were performed. As results, Schiff bases with good yields (63%, 67%) have been received. The changing the alkyl substituent on the aromatic fragment in the amine molecule can increase the yields of the target azomethines to 75-97%. The use of amines with a heterocyclic moiety in the condensation reaction does not significantly impact on the yield of imines (71-77%). For further functionalization, the interaction of 1-(2-chloroquinolin-3-yl)-N-(4-fluorobenzyl)methanimine with 1,2,3,4-tetrahydroquinoline in ethyl alcohol has been performed. It results in 1-(3,4- dihydro-2H-[1,2'-biquinolin]-3'-yl)-N-(4-fluorobenzyl)methanimine, which contains two quinoline rings in its composition. The 3-(((2-chloroquinolin-3-yl)methylene)amino)tetrahydrothiophene 1,1-dioxide was converted to 3-((tetrazolo[1,5-a]quinolin-4-ylmethylene)amino)tetrahydrothiophene 1,1 -dioxide via reacting of the corresponding imine with sodium azide in dimethyl sulfoxide. Thus, bioperspective functionalized quinolines with imine, amine and azide moieties have been synthesized.

Background Surgery for rotator cuff syndrome does not always produce symptom improvement. Biological factors may explain some symptoms, but mood disorder symptoms may also contribute. The purpose of this study is to examine the interaction between disease severity, prevalence of mood disorder diagnoses, and current mood disorder symptoms in preoperative rotator cuff patients. Methods A prospective cohort of patients aged 35–75 years with unilateral rotator cuff disease awaiting surgery participated. Demographics, psychiatric history, the Hospital Anxiety & Depression Scale, and the Western Ontario Rotator Cuff index were collected. Descriptive and univariate statistical testing was performed. Results Of 140 participants (75M:65W) aged 55 ± 8 years, 34 reported a prior diagnosis of a mood disorder. There was a moderate positive relationship between disease severity and current depression and anxiety scores. Women were more likely to carry a diagnosis of a mood disorder, but there were no differences in current symptom levels between genders. No differences were found in patient-reported outcome measure scores between patients with and without a mood disorder diagnosis. Discussion Current mood disorder symptoms were associated with greater disease severity, whereas the presence of a past mood disorder diagnosis was not. Awareness of this relationship may reduce bias about past mood disorder diagnoses during decision-making.

PURPOSE: Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association’s Masterfile, but these data have limitations that overestimate the workforce. METHODS: We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non–family medicine physicians who were providing primary care. RESULTS: In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable. CONCLUSIONS: Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity.

Cancer treatment nonadherence is associated with higher rates of cancer recurrence and decreased survival. Rural patients with cancer experience a 10% higher mortality rate compared with their nonrural counterparts; geographic differences in nonadherence may contribute to this increased mortality. The goal of this study was to assess for geographic disparities and determine sociodemographic and clinical factors associated with radiation therapy (RT) nonadherence and survival among rural and nonrural patients with cancer.We examined cancer registry, medical records, and billing claims data at a safety net academic medical center. Geographic residence was defined as rural versus nonrural by US Department of Agriculture 2013 Rural-Urban Continuum Codes. Other factors assessed were age, sex, race, marital status, insurance type, employment, area median household income, residential distance to cancer treatment center, clinical stage, cancer type, treatment modality, total radiation dose received, and radiation dose per fraction. We used Cox proportional hazards modeling to examine 7 ways of operationalizing nonadherence and selected the definition that resulted in the best model fit statistics and prediction of mortality. Overall survival rates were estimated with the Kaplan-Meier method. We then examined nonadherence as the main exposure along with additional covariates in least absolute shrinkage and selection operator penalized survival analyses and as the outcome in our multivariable generalized linear regression analyses predicting nonadherence. We considered 2-way interaction terms with the main exposure, geographic residence.We identified 3077 patients with cancer who averaged 62 years old, were 59% female, 34% black, and 14% rural. Twenty-two percent of patients missed at least 2 fractions and missed an average of 10% of their treatment plan. Rural patients experienced a higher mortality rate than nonrural patients (53% vs 42%, P.0001). Survival was assessed through December 31, 2021, with a mean follow-up of 4.5 years. Proportion of missed fractions as the indicator of nonadherence provided the best model fit statistics and prediction of survival. Marital status, employment status, tumor, nodes, metastases stage, cancer type, and age at diagnosis significantly affected survival, in addition to a treatment delay by geographic residence interaction effect. Specifically, patients residing in rural areas who experienced a treatment delay were more than twice as likely to die as nonrural residents who also experienced a treatment delay, and nearly twice as likely to die as rural residents who did not experience a treatment delay. The 2-year survival rate was 76% for nonrural residents who did not experience a treatment delay versus 27% for rural residents who experienced a treatment delay. Patients who were widowed, had stage 4 cancer, or lung cancer were more likely to be nonadherent. Finally, patients residing in rural areas who experienced a treatment delay were more likely to subsequently be nonadherent.In a geographically and racially diverse population, RT nonadherence is a significant concern that affects survival, yet it is a modifiable risk factor. We demonstrated that rural residence was associated with both RT nonadherence and poorer overall survival. Rural patients with a treatment delay had the lowest overall survival, compared with both nonrural survivors and rural survivors without delay. Rural residents who are delayed in starting treatment are at heightened risk for poor outcomes and should receive targeted support to mitigate the observed disparities. Additional patient populations that may benefit from targeted treatment adherence support include widowed patients and those with stage 4 cancer or lung cancer.

BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15–1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15–1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11–1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

Surgical outcomes are dependent on multiple clinical and patient factors. One patient factor is pain catastrophizing, which is associated with poorer outcomes in other surgical populations. Our purpose was to examine relationships between gender, patient-reported disease severity, and catastrophizing in patients in whom rotator cuff surgery is planned. We hypothesized that patients with more catastrophizing would report greater disease severity.Patients undergoing surgery for unilateral symptomatic rotator cuff disease aged 35 to 75 years were prospectively evaluated. Data collected included demographic characteristics; imaging characteristics; range of motion; and Western Ontario Rotator Cuff Index (WORC), Pain Catastrophizing Scale (PCS), and Short Form 36 scores.A total of 156 patients (87 men and 69 women) aged 54 ± 8 years participated. The mean WORC score was similar between men and women (1286 ± 343 vs. 1327 ± 370, P = .38). The mean PCS score was 14.7 ± 10.6 for men and 17.9 ± 12.4 for women (P = .08). A moderate positive correlation was found between the WORC and PCS scores (r = 0.59, P.001). Women had poorer WORC-Lifestyle subscale scores (P = .012). Range of motion, Short Form 36 scores, and tear severity were not related to measures of either the WORC or PCS.The direct relationship between the WORC and PCS scores is consistent with research in other patient populations. Contrary to other work, no gender-based PCS score differences were observed. Differences on the WORC-Lifestyle subscale suggest that women may experience greater functional impacts to specific lifestyle elements than men. Catastrophizing is related to patient-reported disease severity in preoperative rotator cuff patients. Further research will clarify whether this relationship leads to poorer outcomes following surgery.

Introduction: We describe the California Healthy Places Index (HPI) and its performance relative to other indexes for measuring community well-being at the census-tract level. The HPI arose from a need identified by health departments and community organizations for an index rooted in the social determinants of health for place-based policy making and program targeting. The index was geographically granular, validated against life expectancy at birth, and linked to policy actions. Materials and Methods: Guided by literature, public health experts, and a positive asset frame, we developed a composite index of community well-being for California from publicly available census-tract data on place-based factors linked to health. The 25 HPI indicators spanned 8 domains; weights were derived from their empirical association with tract-level life expectancy using weighted quantile sums methods. Results: The HPI’s domains were aligned with the social determinants of health and policy action areas of economic resources, education, housing, transportation, clean environment, neighborhood conditions, social resources, and health care access. The overall HPI score was the sum of weighted domain scores, of which economy and education were highly influential (50% of total weights). The HPI was strongly associated with life expectancy at birth ( r = 0.58). Compared with the HPI, a pollution-oriented index did not capture one-third of the most disadvantaged quartile of census tracts (representing 3 million Californians). Overlap of the HPI’s most disadvantaged quartile of census tracts was greater for indexes of economic deprivation. We visualized the HPI percentile ranking as a web-based mapping tool that presented the HPI at multiple geographies and that linked indicators to an action-oriented policy guide. Practice Implications: The framing of indexes and specifications such as domain weighting have substantial consequences for prioritizing disadvantaged populations. The HPI provides a model for tools and new methods that help prioritize investments and identify multisectoral opportunities for policy action.