Management of Inpatient Elevated Blood Pressures : A Systematic Review of Clinical Practice Guidelines.

BACKGROUND: Management of elevated blood pressure (BP) during hospitalization varies widely, with many hospitalized adults experiencing BPs higher than those recommended for the outpatient setting. PURPOSE: To systematically identify guidelines on elevated BP management in the hospital. DATA SOURCES: MEDLINE, Guidelines International Network, and specialty society websites from 1 January 2010 to 29 January 2024. STUDY SELECTION: Clinical practice guidelines pertaining to BP management for the adult and older adult populations in ambulatory, emergency department, and inpatient settings. DATA EXTRACTION: Two authors independently screened articles, assessed quality, and extracted data. Disagreements were resolved via consensus. Recommendations on treatment targets, preferred antihypertensive classes, and follow-up were collected for ambulatory and inpatient settings. DATA SYNTHESIS: Fourteen clinical practice guidelines met inclusion criteria (11 were assessed as high-quality per the AGREE II [Appraisal of Guidelines for Research & Evaluation II] instrument), 11 provided broad BP management recommendations, and 1 each was specific to the emergency department setting, older adults, and hypertensive crises. No guidelines provided goals for inpatient BP or recommendations for managing asymptomatic moderately elevated BP in the hospital. Six guidelines defined hypertensive urgency as BP above 180/120 mm Hg, with hypertensive emergencies requiring the addition of target organ damage. Hypertensive emergency recommendations consistently included use of intravenous antihypertensives in intensive care settings. Recommendations for managing hypertensive urgencies were inconsistent, from expert consensus, and focused on the emergency department. Outpatient treatment with oral medications and follow-up in days to weeks were most often advised. In contrast, outpatient BP goals were clearly defined, varying between 130/80 and 140/90 mm Hg. LIMITATION: Exclusion of non-English-language guidelines and guidelines specific to subpopulations. CONCLUSION: Despite general consensus on outpatient BP management, guidance on inpatient management of elevated BP without symptoms is lacking, which may contribute to variable practice patterns. PRIMARY FUNDING SOURCE: National Institute on Aging. (PROSPERO: CRD42023449250).

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study.

BACKGROUND: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. OBJECTIVE: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. DESIGN: Retrospective cohort study. SETTING: Medicare. PARTICIPANTS: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. MEASUREMENTS: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. RESULTS: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. LIMITATION: Generalizability to other payers. CONCLUSION: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. PRIMARY FUNDING SOURCE: National Institute on Aging.

Differences in Primary Care Follow-up After Acute Care Discharge Within and Across Health Systems: a Retrospective Cohort Study.

BACKGROUND: Timely primary care follow-up after acute care discharge may improve outcomes. OBJECTIVE: To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system). DESIGN: Retrospective cohort study. PATIENTS: Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay. MAIN MEASURES: Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics. KEY RESULTS: The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges). CONCLUSIONS: Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.

Racial and Ethnic Disparities in Opioid Prescribing on Hospital Discharge Among Older Adults: A National Retrospective Cohort Study.

BACKGROUND: Disparities in opioid prescribing among racial and ethnic groups have been observed in outpatient and emergency department settings, but it is unknown whether similar disparities exist at discharge among hospitalized older adults. OBJECTIVE: To determine filled opioid prescription rates on hospital discharge by race/ethnicity among Medicare beneficiaries. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicare beneficiaries 65 years or older discharged from hospital in 2016, without opioid fills in the 90 days prior to hospitalization (opioid-naïve). MAIN MEASURES: Race/ethnicity was categorized by the Research Triangle Institute (RTI), grouped as Asian/Pacific Islander, Black, Hispanic, other (American Indian/Alaska Native/unknown/other), and White. The primary outcome was an opioid prescription claim within 2 days of hospital discharge. The secondary outcome was total morphine milligram equivalents (MMEs) among adults with a filled opioid prescription. KEY RESULTS: Among 316,039 previously opioid-naïve beneficiaries (mean age, 76.8 years; 56.2% female), 49,131 (15.5%) filled an opioid prescription within 2 days of hospital discharge. After adjustment, Black beneficiaries were 6% less likely (relative risk [RR] 0.94, 95% CI 0.91-0.97) and Asian/Pacific Islander beneficiaries were 9% more likely (RR 1.09, 95% CI 1.03-1.14) to have filled an opioid prescription when compared to White beneficiaries. Among beneficiaries with a filled opioid prescription, mean total MMEs were lower among Black (356.9; adjusted difference - 4%, 95% CI - 7 to - 1%), Hispanic (327.0; adjusted difference - 7%, 95% CI - 10 to - 4%), and Asian/Pacific Islander (328.2; adjusted difference - 8%, 95% CI - 12 to - 4%) beneficiaries when compared to White beneficiaries (409.7). CONCLUSIONS AND RELEVANCE: Black older adults were less likely to fill a new opioid prescription after hospital discharge when compared to White older adults and received lower total MMEs. The factors contributing to these differential prescribing patterns should be investigated further.

Association of Device Industry Payments, Physician Supply, and Regional Utilization of Orthopedic and Cardiac Procedures.

BACKGROUND: Geographic variation in high-cost medical procedure utilization in the USA is not fully explained by patient factors but may be influenced by the supply of procedural physicians and marketing payments. OBJECTIVE: To examine the association between physician supply, medical device-related marketing payments to physicians, and utilization of knee arthroplasty (KA) and percutaneous coronary interventions (PCI) within hospital referral regions (HRRs). DESIGN: Cross-sectional analysis of data from the 2018 CMS Open Payments database and procedural utilization data from the CMS Provider Utilization and Payment database. PARTICIPANTS: Medicare-participating procedural cardiologists and orthopedic surgeons. MAIN MEASURES: Regional rates of PCIs and KAs per 100,000 Medicare fee-for-service (FFS) beneficiaries were estimated after adjustment for beneficiary demographics. KEY RESULTS: Across 306 HRRs, there were 109,301 payments (value $17,554,728) to cardiologists for cardiac stents and 68,132 payments (value $40,492,126) to orthopedic surgeons for prosthetic knees. Among HRRs, one additional interventional cardiologist was associated with an increase of 12.9 (CI, 9.3-16.5) PCIs per 100,000 beneficiaries, and one additional orthopedic surgeon was associated with an increase of 20.6 (CI, 16.9-24.4) KAs per 100,000 beneficiaries. A $10,000 increase in gift payments from stent manufacturers was associated with an increase of 26.0 (CI, 5.1-46.9) PCIs per 100,000 beneficiaries, while total and service payments were not associated with greater regional PCI utilization. A $10,000 increase in total payments from knee prosthetic manufacturers was associated with an increase of 2.9 (CI, 1.4-4.5) KAs per 100,000 beneficiaries, while a similar increase in gift and service payments was associated with an increase of 14.5 (CI, 5.0-24.1) and 3.4 (CI, 1.6-5.2) KAs, respectively. CONCLUSIONS: Among Medicare FFS beneficiaries, regional supply of physicians and receipt of industry payments were associated with greater use of PCIs and KAs. Relationships between payments and procedural utilization were more consistent for KAs, a largely elective procedure, compared to PCIs, which may be elective or emergent.

Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries.

BACKGROUND: Patients with dementia are frequently hospitalized and may face barriers in post-discharge care. OBJECTIVE: To determine whether patients with dementia have an increased risk of adverse outcomes following discharge. DESIGN: Retrospective cohort study. SUBJECTS: Medicare beneficiaries hospitalized in 2016. MAIN MEASURES: Co-primary outcomes were mortality and readmission within 30 days of discharge. Multivariable logistic regression models were estimated to assess the risk of each outcome for patients with and without dementia accounting for demographics, comorbidities, frailty, hospitalization factors, and disposition. KEY RESULTS: The cohort included 1,089,109 hospitalizations of which 211,698 (19.3%) were of patients with diagnosed dementia (median (IQR) age 83 (76-89); 61.5% female) and 886,411 were of patients without dementia (median (IQR) age 76 (79-83); 55.0% female). At 30 days following discharge, 5.7% of patients with dementia had died compared to 3.1% of patients without dementia (adjusted odds ratio (aOR) 1.21; 95% CI 1.17 to 1.24). At 30 days following discharge, 17.7% of patients with dementia had been readmitted compared to 13.1% of patients without dementia (aOR 1.02; CI 1.002 to 1.04). Dementia was associated with an increased odds of readmission among patients discharged to the community (aOR 1.07, CI 1.05 to 1.09) but a decreased odds of readmission among patients discharge to nursing facilities (aOR 0.93, CI 0.90 to 0.95). Patients with dementia who were discharged to the community were more likely to be readmitted than those discharged to nursing facilities (18.9% vs 16.0%), and, when readmitted, were more likely to die during the readmission (20.7% vs 4.4%). CONCLUSIONS: Diagnosed dementia was associated with a substantially increased risk of mortality and a modestly increased risk of readmission within 30 days of discharge. Patients with dementia discharged to the community had particularly elevated risk of adverse outcomes indicating possible gaps in post-discharge services and caregiver support.

National Trends in Antihypertensive Treatment Among Older Adults by Race and Presence of Comorbidity, 2008 to 2017.

BACKGROUND: In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy. OBJECTIVE: To evaluate older adults' antihypertensive use following guideline changes. DESIGN: Time series analysis. PATIENTS: Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension. INTERVENTION: Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations. KEY RESULTS: The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients. CONCLUSIONS: Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.

Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction.

Importance: Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown. Objective: To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018. Design, Setting, and Participants: Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019). Exposures: Enrollment in Medicare Advantage vs traditional Medicare. Main Outcomes and Measures: The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions). Results: The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]). Conclusions and Relevance: Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study.

BACKGROUND: Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only. METHODS AND FINDINGS: We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; relative risk [RR] 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding. CONCLUSIONS: Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.

Association of Primary Language and Hospitalization for Ambulatory Care Sensitive Conditions.

BACKGROUND: Limited English proficiency is associated with decreased access to ambulatory care, however, it is unclear if this disparity leads to increased use of emergency departments (EDs) for low severity ambulatory care sensitive conditions (ACSCs). OBJECTIVE: We sought to determine the association between the patient's preferred language and hospital utilization for ACSCs. RESEARCH DESIGN: We conducted a retrospective cohort study of all ED visits in New Jersey in 2013 and 2014. The primary outcome was hospital admission for acute ACSCs, chronic ACSCs, and fractures (a nonambulatory care sensitive control condition). Secondary outcomes included intensive care unit (ICU) utilization and length of stay. Mixed-effect regression models estimated the association between preferred language (English vs. non-English) and study outcomes, controlling for demographics, comorbidities, and hospital characteristics. RESULTS: We examined 201,351 ED visits for acute ACSCs, 251,193 visits for chronic ACSCs, and 148,428 visits for fractures, of which 13.5%, 11.1%, and 9.9%, respectively, were by non-English speakers. In adjusted analyses, non-English speakers were less likely to be admitted for acute ACSCs [-3.1%; 95% confidence interval (CI), -3.6% to -2.5%] and chronic ACSCs (-2.3%; 95% CI, -2.8% to -1.7%) but not fractures (0.4%; 95% CI, -0.2% to 1.0%). Among hospitalized patients, non-English speakers were less likely to receive ICU services but had no difference in length of stay. CONCLUSIONS: These findings suggest non-English-speaking patients may seek ED care for lower acuity ACSCs than English-speaking patients. Efforts to decrease preventable ED and increase access to ambulatory care use should consider the needs of non-English-speaking patients.

Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use.

BACKGROUND: Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance. OBJECTIVES: The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use. RESEARCH DESIGN: Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications. RESULTS: The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care. CONCLUSION: Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.

Iron Complexes for Cyclic Carbonate and Polycarbonate Formation: Selectivity Control from Ligand Design and Metal-Center Geometry.

A family of 17 iron(III) aminobis(phenolate) complexes possessing different phenolate substituents, coordination geometries, and donor arrangements were used as catalysts for the reaction of carbon dioxide (CO2) with epoxides. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry of the iron complexes with a bis(triphenylphosphine)iminium chloride cocatalyst in negative mode revealed the formation of six-coordinate iron "ate" species. Under low catalyst loadings (0.025 mol % Fe and 0.1 mol % chloride cocatalyst), all complexes showed good-to-excellent activity for converting propylene oxide to propylene carbonate under 20 bar of CO2. The most active complex possessed electron-withdrawing dichlorophenolate groups and for a 2 h reaction time gave a turnover frequency of 1240 h-1. Epichlorohydrin, styrene oxide, phenyl glycidyl ether, and allyl glycidyl ether could also be transformed to their respective cyclic carbonates with good-to-excellent conversions. Selectivity for polycarbonate formation was observed using cyclohexene oxide, where the best activity was displayed by trigonal-bipyramidal iron(III) complexes having electron-rich phenolate groups and sterically unencumbering tertiary amino donors. Those containing bulky tertiary amino ligands or those with square-pyramidal geometries around iron showed no activity for polycarbonate formation. While the overall conversions declined with decreasing CO2 pressure, CO2 incorporation remained high, giving a completely alternating copolymer. The difference in the optimum catalyst reactivity for cyclic carbonate versus polycarbonate formation is particularly noteworthy; that is, electron-withdrawing-group-containing phenolates give the most active catalysts for propylene carbonate formation, whereas catalysts with electron-donating-group-containing phenolates are the most active for polycyclohexene carbonate formation. This study demonstrates that the highly modifiable aminophenolate ligands can be tailored to yield iron complexes for both CO2/epoxide coupling and ring-opening copolymerization activity.

A systematic review of methods for determining cross-sectional active medications using pharmacy databases.

PURPOSE: Pharmacy dispensing databases are often used to identify patients' medications at a particular time point, for example to measure prescribing quality or the impact of medication use on clinical outcomes. We performed a systematic review of studies that examined methods to assess medications in use at a specific point in time. METHODS: Comprehensive literature search to identify studies that compared active medications identified using pharmacy databases to medications identified using nonautomated data sources. Two investigators independently reviewed abstracts and full-text material. RESULTS: Of 496 studies screened, 29 studies evaluating 50 comparisons met inclusion criteria. Twenty-nine comparisons evaluated fixed look-back period approaches, defining active medications as those filled in a specified period prior to the index date (range 84-730 days). Fourteen comparisons evaluated medication-on-hand approaches, defining active medications as those for which the most recent fill provided sufficient supply to last through the study index date. Sensitivity ranged from 48% to 93% for fixed look-back period approaches and 35% to 97% for medication-on-hand approaches. Interpretation of comparative performance of methods was limited by use of different reference sources, target medication classes, and databases across studies. In four studies with head-to-head comparisons of these methods, sensitivity of the medication-on-hand approach was a median of 7% lower than the corresponding fixed look-back approach. CONCLUSIONS: The reported accuracy of methods for identifying active medications using pharmacy databases differs greatly across studies. More direct comparisons of common approaches are needed to establish the accuracy of methods within and across populations, medication classes, and databases.

A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences.

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.

Trends in Phenylephrine and Pseudoephedrine Sales in the US.

This study examines purchasing patterns regarding oral decongestants, concerns about their efficacy, and the need for timelier postmarket evaluation.