Co-created Mobile Apps for Palliative Care Using Community-Partnered Participatory Research: Development and Usability Study.

BACKGROUND: Open design formats for mobile apps help clinicians and stakeholders bring their needs to direct, co-creative solutions. Palliative care for patients with advanced cancers requires intensive monitoring and support and remains an area in high need for innovation. OBJECTIVE: This study aims to use community-partnered participatory research to co-design and pretest a mobile app that focuses on palliative care priorities of clinicians and patients with advanced cancer. METHODS: In-person and teleconference workshops were held with patient and family stakeholders, researchers, and clinicians in palliative care and oncology. Question prompts, written feedback, semistructured interviews, and facilitated group discussions identified the core palliative care needs. Using Chorus, a no-code app-building platform, a mobile app was co-designed with the stakeholders. A pretest with 11 patients was conducted, with semistructured interviews of clinician and patient users for feedback. RESULTS: Key themes identified from the focus groups included needs for patient advocacy and encouragement, access to vetted information, patient-clinician communication support, and symptom management. The initial prototype, My Wellness App, contained a weekly wellness journal to track patient-reported symptoms, goals, and medication use; information on self-management of symptoms; community resources; and patient and caregiver testimonial videos. Initial pretesting identified value in app-based communication for clinicians, patients, and caregivers, with suggestions for improving user interface, feedback and presentation of symptom reports, and gamification and staff coordinators to support patient app engagement. CONCLUSIONS: The development of a mobile app using community-partnered participatory research is a low-technology and feasible intervention for palliative care. Iterative redesign and user interface expertise may improve implementation.

Perceptual and Structural Facilitators and Barriers to Becoming a Surgeon: A Qualitative Study of African American and Latino Surgeons.

PURPOSE: As racial and ethnic heterogeneity in the United States increases, it is important that the health care workforce, including surgery, mirror that diversity. Structural and perceptual barriers may contribute to an underrepresentation of African American and Latino surgeons. Understanding these barriers may translate into interventions and, in turn, improved diversification of the U.S. surgery workforce. METHOD: In 2016, the authors conducted in-depth semistructured interviews, exploring structural and perceptual barriers that African American and Latino surgeons face. The authors used conventional qualitative techniques to analyze data and identify themes. RESULTS: The authors interviewed 23 participants and observed three major themes characterizing the path to becoming a surgeon: creating a path to medicine, surgical culture, and mentorship. Subthemes provided further nuance. For creating a path to medicine, the subthemes were personal attributes, family support, community assets/barriers, and minority experience. For surgical culture, the subthemes comprised quality of life, surgeon-patient relationship, and restoring health. For mentorship, the subthemes were aspirational figures, formal programs/peer support, and professional opportunities. Experiences described by African Americans and Latinos were similar, but the experiences of participants of different self-identified childhood socioeconomic status were dissimilar. CONCLUSIONS: The path to a surgical career as experienced by African American and Latino surgeons is heavily influenced by mentors mediating their integration into surgical culture and engendering a feeling of belonging. Future surgeons from groups underrepresented in medicine would benefit from identifying aspirational figures early, a structured introduction into the rigors of the profession, and a deconstruction of negative surgical norms.

Design and characterization of optimized adenosine A2A/A1 receptor antagonists for the treatment of Parkinson's disease.

The design and characterization of two, dual adenosine A(2A)/A(1) receptor antagonists in several animal models of Parkinson's disease is described. Compound 1 was previously reported as a potential treatment for Parkinson's disease. Further characterization of 1 revealed that it was metabolized to reactive intermediates that caused the genotoxicity of 1 in the Ames and mouse lymphoma L51784 assays. The identification of the metabolites enabled the preparation of two optimized compounds 13 and 14 that were devoid of the metabolic liabilities associated with 1. Compounds 13 and 14 are potent dual A(2A)/A(1) receptor antagonists that have excellent activity, after oral administration, across a number of animal models of Parkinson's disease including mouse and rat models of haloperidol-induced catalepsy, mouse and rat models of reserpine-induced akinesia, and the rat 6-hydroxydopamine (6-OHDA) lesion model of drug-induced rotation.

In vivo characterization of a dual adenosine A2A/A1 receptor antagonist in animal models of Parkinson's disease.

The in vivo characterization of a dual adenosine A(2A)/A(1) receptor antagonist in several animal models of Parkinson's disease is described. Discovery and scale-up syntheses of compound 1 are described in detail, highlighting optimization steps that increased the overall yield of 1 from 10.0% to 30.5%. Compound 1 is a potent A(2A)/A(1) receptor antagonist in vitro (A(2A) K(i) = 4.1 nM; A(1) K(i) = 17.0 nM) that has excellent activity, after oral administration, across a number of animal models of Parkinson's disease including mouse and rat models of haloperidol-induced catalepsy, mouse model of reserpine-induced akinesia, rat 6-hydroxydopamine (6-OHDA) lesion model of drug-induced rotation, and MPTP-treated non-human primate model.

Methylene amine substituted arylindenopyrimidines as potent adenosine A(2A)/A(1) antagonists.

A novel series of arylindenopyrimidines were identified as A(2A) and A(1) receptor antagonists. The series was optimized for in vitro activity by substituting the 8- and 9-positions with methylene amine substituents. The compounds show excellent activity in mouse models of Parkinson's disease when dosed orally.

Optimization of arylindenopyrimidines as potent adenosine A(2A)/A(1) antagonists.

Two reactive metabolites were identified in vivo for the dual A(2A)/A(1) receptor antagonist 1. Two strategies were implemented to successfully mitigate the metabolic liabilities associated with 1. Optimization of the arylindenopyrimidines led to a number of amide, ether, and amino analogs having comparable in vitro and in vivo activity.

Clinical and subthreshold panic disorder.

BACKGROUND: Panic disorder (PD) is a highly prevalent and disabling condition, and subthreshold cases may be even more prevalent. This study examined psychiatric comorbidities, work functioning, and health-care utilization of individuals with subthreshold panic. The purpose of this study was to add to the accumulating evidence of significant comorbidity and disability associated with subthreshold PD. METHODS: Data are drawn from the Health Care for Communities study, a national household survey of the United States' adult, civilian, noninstitutionalized population (N=9585). Data assessing psychiatric disorders, employment and work productivity, and health-care utilization were collected. Seven categories of panic and subthreshold panic were created. RESULTS: The prevalence of clinical and subthreshold panic in the general population was 40%. Subthreshold panic was associated with increased odds of several comorbid disorders, including depression, dysthymia, psychosis, generalized anxiety disorder, bipolar disorder, and alcohol and drug use disorders. Subthreshold panic was also associated with greater likelihood of health-care service utilization but not with the intensity of mental health services. CONCLUSION: Psychiatric comorbidities and health-care utilization are common among patients with subthreshold panic. The relationship between varying degrees of panic symptomology and other mental health problems and indices of functioning impairment warrants further investigation. These results inform further research focusing on the course of subthreshold PD and its impact on quality of life.

Screening for domestic violence among adult women in the United States.

BACKGROUND: Domestic violence is a problem frequently encountered in health care settings and a risk factor for physical and mental health problems. OBJECTIVE: To provide nationally representative estimates of rates of domestic violence screening among women, to identify predictors of screening, and to describe settings where women are screened. DESIGN AND PARTICIPANTS: We examined 4,821 women over the age of 18 from the second wave of Healthcare for Communities, a nationally representative household telephone survey conducted in 2000-2001. MEASUREMENTS: Self-reports concerning whether the respondent was ever asked about domestic or family violence by any health care provider. RESULTS: Only 7% (95% CI, 6%-8%) of women reported they were ever asked about domestic violence or family violence by a health care professional. Of women who were asked about abuse, nearly half (46%) were asked in a primary care setting, and 24% were asked in a specialty mental health setting. Women with risk factors for domestic violence were more likely to report being asked about it by a health care professional, but rates were still low. CONCLUSIONS: Self-reported rates of screening for domestic violence are low even among women at higher risk for abuse. These findings reinforce the importance of developing training and raising awareness of domestic violence and its health implications. This is especially true in primary care and mental health specialty settings.

beta-Alkylthio indolyl carbinols: potent nonsteroidal antiandrogens with oral efficacy in a prostate cancer model.

Through an in vivo screening model, we developed the in vivo SAR of beta-alkylthio indolyl carbinols. Through these efforts we identified a compound with potent oral in vivo efficacy in both immature and mature rat prostate weight reduction models and in a murine xenograft prostate cancer model.

Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities.

OBJECTIVE: We sought to estimate national rates of screening and treatment of alcohol, drug, and mental (ADM) problems in primary care. DESIGN: This was a cross-sectional survey administered from 1997 to 1998. PARTICIPANTS: Our study included a nationally representative household probability sample of 7301 primary care patients. MEASUREMENT: We used patient self-reports from a telephone survey to estimate rates of screening and treatment of common ADM problems, to examine the types of screening and treatment received, and to investigate adherence with treatment recommendations. Covariates included measures of ADM conditions, physical health, and sociodemographic indicators. RESULTS: Among adult primary care patients, 38.6% (95% confidence intervals [CI] 37.2-40.0) reported clinician screening for an ADM problem. Alcohol or drug screening occurred more frequently (28.3%; 95% CI 27.0-29.6) than screening for depression and anxiety (21.2%; 95% CI 20.1-22.2). Among those screened, 30.1% (95% CI; 27.8-32.4) reported ADM treatment in primary care. Medications (16.4%; 95% CI 14.3-18.5) and counseling (18.2%; 95% CI 16.1-20.3) were the most common treatments. Rates of screening were higher among individuals with ADM disorders, the young and middle aged, and the college educated. Treatment rates were higher among individuals with ADM disorders. CONCLUSIONS: Substantial effort is expended screening and treating common ADM problems in primary care, and these efforts are targeted towards those with ADM disorders. However, only about half of individuals with an ADM disorder report being screened, and among this group, about 60% report receiving any treatment.

Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.

BACKGROUND: Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE: To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN: A group-level randomized controlled trial. SETTING: Forty-six primary care practices in 6 managed care organizations. PATIENTS: Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS: Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES: Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS: Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS: Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.