Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life.

INTRODUCTION: Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation. RESULTS: Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89). CONCLUSIONS: Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.

Air pollution and serious bleeding events in high-risk older adults.

IMPORTANCE: Despite biological plausibility, very few epidemiologic studies have investigated the risks of clinically significant bleeding events due to particulate air pollution. OBJECTIVE: To measure the independent and synergistic effects of PM2.5 exposure and anticoagulant use on serious bleeding events. DESIGN: Retrospective cohort study (2008-2016). SETTING: Nationwide Medicare population. PARTICIPANTS: A 50% random sample of Medicare Part D-eligible Fee-for-Service beneficiaries at high risk for cardiovascular and thromboembolic events. EXPOSURES: Fine particulate matter (PM2.5) and anticoagulant drugs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin). MAIN OUTCOMES AND MEASURES: The outcomes were acute hospitalizations for gastrointestinal bleeding, intracranial bleeding, or epistaxis. Hazard ratios and 95% CIs for PM2.5 exposure were estimated by fitting inverse probability weighted marginal structural Cox proportional hazards models. The relative excess risk due to interaction was used to assess additive-scale interaction between PM2.5 exposure and anticoagulant use. RESULTS: The study cohort included 1.86 million high-risk older adults (mean age 77, 60% male, 87% White, 8% Black, 30% anticoagulant users, mean PM2.5 exposure 8.81 µg/m3). A 10 µg/m3 increase in PM2.5 was associated with a 48% (95% CI: 45%-52%), 58% (95% CI: 49%-68%) and 55% (95% CI: 37%-76%) increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis, respectively. Significant additive interaction between PM2.5 exposure and anticoagulant use was observed for gastrointestinal and intracranial bleeding. CONCLUSIONS: Among older adults at high risk for cardiovascular and thromboembolic events, increasing PM2.5 exposure was significantly associated with increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis. In addition, PM2.5 exposure and anticoagulant use may act together to increase risks of severe gastrointestinal and intracranial bleeding. Thus, clinicians may recommend that high-risk individuals limit their outdoor air pollution exposure during periods of increased PM2.5 concentrations. Our findings may inform environmental policies to protect the health of vulnerable populations.

Ambient heat exposure patterns and emergency department visits and hospitalizations among medicare beneficiaries 2008-2019.

OBJECTIVE: To assess the association between ambient heat and all-cause and cause-specific emergency department (ED) visits and acute hospitalizations among Medicare beneficiaries in the conterminous United States. DESIGN: Retrospective cohort study. SETTING: Conterminous US from 2008 and 2019. PARTICIPANTS: 2% random sample of all Medicare fee-for-service beneficiaries eligible for Parts A, B, and D. MAIN OUTCOME MEASURES: All-cause and cause-specific (cardiovascular, renal, and heat-related) ED visits and unplanned hospitalizations were identified using primary ICD-9 or ICD-10 diagnosis codes. We measured the association between ambient temperature - defined as daily mean temperature percentile of summer (June through September) - and the outcomes. Hazard ratios and their associated 95% confidence intervals were estimated using multivariable Cox proportional hazards regression, adjusting for individual level demographics, comorbidities, healthcare utilization factors and zip-code level social factors. RESULTS: Among 809,636 Medicare beneficiaries (58% female, 81% non-Hispanic White, 24% <65), older beneficiaries (aged ≥65) exposed to >95th percentile temperature had a 64% elevated adjusted risk of heat-related ED visits (HR [95% CI], 1.64 [1.46,1.85]) and a 4% higher risk of all-cause acute hospitalization (1.04 [1.01,1.06]) relative to <25th temperature percentile. Younger beneficiaries (aged <65) showed increased risk of heat-related ED visits (2.69 [2.23,3.23]) and all-cause ED visits (1.03 [1.01,1.05]). The associations with heat related events were stronger in males and individuals dually eligible for Medicare and Medicaid. No significant differences were observed by climatic region. We observed no significant relationship between temperature percentile and risk of CV-related ED visits or renal-related ED visits. CONCLUSIONS: Among Medicare beneficiaries from 2008 to 2019, exposure to daily mean temperature ≥ 95th percentile was associated with increased risk of heat-related ED visits, with stronger associations seen among beneficiaries <65, males, and patients with low socioeconomic position. Further longitudinal studies are needed to understand the impact of heat duration, intensity, and frequency on cause-specific hospitalization outcomes.

National Trends in Anticoagulation Therapy for COVID-19 Hospitalized Adults in the United States: Analyses of the National COVID Cohort Collaborative.

BACKGROUND: Anticoagulation (AC) utilization patterns and their predictors among hospitalized coronavirus disease 2019 (COVID-19) patients have not been well described. METHODS: Using the National COVID Cohort Collaborative, we conducted a retrospective cohort study (2020-2022) to assess AC use patterns and identify factors associated with therapeutic AC employing modified Poisson regression. RESULTS: Among 162 842 hospitalized COVID-19 patients, 64% received AC and 24% received therapeutic AC. Therapeutic AC use declined from 32% in 2020 to 12% in 2022, especially after December 2021. Therapeutic AC predictors included age (relative risk [RR], 1.02; 95% confidence interval [CI], 1.02-1.02 per year), male (RR, 1.29; 95% CI, 1.27-1.32), non-Hispanic black (RR, 1.16; 95% CI, 1.13-1.18), obesity (RR, 1.48; 95% CI, 1.43-1.52), increased length of stay (RR, 1.01; 95% CI, 1.01-1.01 per day), and invasive ventilation (RR, 1.64; 95% CI, 1.59-1.69). Vaccination (RR, 0.88; 95% CI, 84-.92) and higher Charlson Comorbidity Index (CCI) (RR, 0.98; 95% CI, .97-.98) were associated with lower therapeutic AC. CONCLUSIONS: Overall, two-thirds of hospitalized COVID-19 patients received any AC and a quarter received therapeutic dosing. Therapeutic AC declined after introduction of the Omicron variant. Predictors of therapeutic AC included demographics, obesity, length of stay, invasive ventilation, CCI, and vaccination, suggesting AC decisions driven by clinical factors including COVID-19 severity, bleeding risks, and comorbidities.

Air Pollution and Cardiovascular and Thromboembolic Events in Older Adults With High-Risk Conditions.

Little epidemiologic research has focused on pollution-related risks in medically vulnerable or marginalized groups. Using a nationwide 50% random sample of 2008-2016 Medicare Part D-eligible fee-for-service participants in the United States, we identified a cohort with high-risk conditions for cardiovascular and thromboembolic events (CTEs) and linked individuals with seasonal average zip-code-level concentrations of fine particulate matter (particulate matter with an aerodynamic diameter ≤ 2.5 µm (PM2.5)). We assessed the relationship between seasonal PM2.5 exposure and hospitalization for each of 7 CTE-related causes using history-adjusted marginal structural models with adjustment for individual demographic and neighborhood socioeconomic variables, as well as baseline comorbidity, health behaviors, and health-service measures. We examined effect modification across geographically and demographically defined subgroups. The cohort included 1,934,453 individuals with high-risk conditions (mean age = 77 years; 60% female, 87% White). A 1-µg/m3 increase in PM2.5 exposure was significantly associated with increased risk of 6 out of 7 types of CTE hospitalization. Strong increases were observed for transient ischemic attack (hazard ratio (HR) = 1.039, 95% confidence interval (CI): 1.034, 1.044), venous thromboembolism (HR = 1.031, 95% CI: 1.027, 1.035), and heart failure (HR = 1.019, 95% CI: 1.017, 1.020). Asian Americans were found to be particularly susceptible to thromboembolic effects of PM2.5 (venous thromboembolism: HR = 1.063, 95% CI: 1.021, 1.106), while Native Americans were most vulnerable to cerebrovascular effects (transient ischemic attack: HR = 1.093, 95% CI: 1.030, 1.161).

Cardiovascular outcomes with SGLT2 inhibitors versus DPP4 inhibitors and GLP-1 receptor agonists in patients with heart failure with reduced and preserved ejection fraction.

BACKGROUND: No study has compared the cardiovascular outcomes for sodium-glucose cotransporter-2 inhibitors (SGLT2i) head-to-head against other glucose-lowering therapies, including dipeptidyl peptidase 4 inhibitor (DDP4i) or glucagon-like peptide-1 receptor agonist (GLP-1RA)-which also have cardiovascular benefits-in patients with heart failure with reduced (HFrEF) or preserved (HFpEF) ejection fraction. METHODS: Medicare fee-for-service data (2013-2019) were used to create four pair-wise comparison cohorts of type 2 diabetes patients with: (1a) HFrEF initiating SGLT2i versus DPP4i; (1b) HFrEF initiating SGLT2i versus GLP-1RA; (2a) HFpEF initiating SGLT2i versus DPP4i; and (2b) HFpEF initiating SGLT2i versus GLP-1RA. The primary outcomes were (1) hospitalization for heart failure (HHF) and (2) myocardial infarction (MI) or stroke hospitalizations. Adjusted hazards ratios (HR) and 95% CIs were estimated using inverse probability of treatment weighting. RESULTS: Among HFrEF patients, initiation of SGLT2i versus DPP4i (cohort 1a; n = 13,882) was associated with a lower risk of HHF (adjusted Hazard Ratio [HR (95% confidence interval)], 0.67 (0.63, 0.72) and MI or stroke (HR: 0.86 [0.75, 0.99]), and initiation of SGLT2i versus GLP-1RA (cohort 1b; n = 6951) was associated with lower risk of HHF (HR: 0.86 [0.79, 0.93]), but not MI or stroke (HR: 1.02 [0.85, 1.22]). Among HFpEF patients, initiation of SGLT2i versus DPP4i (cohort 2a; n = 17,493) was associated with lower risk of HHF (HR: 0.65 [0.61, 0.69]) but not MI or stroke (HR: 0.90 [0.79, 1.02]), and initiation of SGLT2i versus GLP-1RA (cohort 2b; n = 9053) was associated with lower risk of HHF (0.89 [0.83, 0.96]), but not MI or stroke (HR: 0.97 [0.83, 1.14]). Results were robust across range of secondary outcomes (e.g., all-cause mortality) and sensitivity analyses. CONCLUSIONS: Bias from residual confounding cannot be ruled out. Use of SGLT2i was associated with reduced risk of HHF against DPP4i and GLP-1RA, reduced risk of MI or stroke against DPP4i within the HFrEF subgroup, and comparable risk of MI or stroke against GLP-1RA. Notably, the magnitude of cardiovascular benefit conferred by SGLT2i was similar among patients with HFrEF and HFpEF.

A qualitative exploration of knowledge of Chagas disease among adolescents in rural Ecuador.

INTRODUCTION: Chagas disease (CD) is a neglected tropical disease that affects 6 to 7 million people worldwide. In South America, CD is a major health problem in several regions, causing more than 12 000 deaths per year. CD is caused by a parasite called Trypanosoma cruzi, mostly transmitted through the contaminated feces of certain species of triatomine bug, commonly known as the 'kissing bug'. CD is endemic in Loja province in the southern region of Ecuador, where triatomines have been found in 68% of communities. Previous promotion of healthy practices in Loja province have included educational programs directed toward youth to affirm cultural and social norms that support health and prevent CD transmission. The present study was designed to evaluate current knowledge related to CD among youth in the three communities of Loja province following previous intervention programs. METHODS: A descriptive, qualitative approach was applied using individual semi-structured interviews with 14 young people (eight females, six males) from three rural communities in Loja province. Interviews assessed knowledge about CD transmission, knowledge about the parasite-vector-disease pathway, and the role of youth in preventing Chagas disease in their communities. RESULTS: Following a thematic analysis of the data, the study results showed there is cursory knowledge of the triatomine insect that can carry the causative parasite for CD. Participants were able to generally talk about the vector, habitat and prevention practices for triatomine infestation. Nevertheless, limited understanding of transmission dynamics in the parasite-vector-disease pathway itself was found. One major finding was that prevention practices were not correctly applied or followed, increasing the risk of exposure in the community. Youth also articulated that CD is stigmatized in their communities, which may be a barrier for prevention efforts. CONCLUSION: Gaps in knowledge about the parasite-vector-disease pathway were identified among youth. Overall, youth responses indicated positive regard for prevention practices and a desire to be involved in prevention programs. Developing educational programs focusing on CD transmission may be needed to improve control and prevention of this parasitic disease. The implications of these findings are discussed for developing effective control programs in the region.

Identifying health care access barriers in southern rural Ecuador.

BACKGROUND: Access to professional health care providers in Loja Province, Ecuador can be difficult for many citizens. The Health Care Access Barrier Model (HCAB) was established to provide a framework for classification, analysis, and reporting of modifiable health care access barriers. This study uses the HCAB Model to identify barriers and themes impacting access to health care access in southern rural Ecuador. METHODS: The research team interviewed 22 participants and completed 15 participant observation studies in the study area. Interviews and a single focus group session of artisans were recorded and transcribed from Spanish to English, and thematic analysis was performed. RESULTS: The thematic analysis found financial, structural, and cognitive health care access barriers. Cost of medications, transportation, missed responsibilities at work and home, difficulty scheduling appointments, and misconceptions in health literacy were the predominant themes contributing to health care access. These pressure points provide insight on where actions may be taken to alleviate access barriers. CONCLUSION: Modifiable health care access barriers outlined in the HCAB are evident in the study area. Further research and implementation of programs to resolve these barriers, such as the creation of health care subcenters and/or mobile clinic, insurance coverage of specialized care, increasing availability and accessibility to affordable transportation, improving roadways, introduction of a 24/7 call center to schedule medical visits, monetary incentive for primary care physicians to practice in rural and underserved areas, provision of affordable work equipment, and emphasizing the improvement of health care literacy through education, may diminish current barriers, identify additional barriers, and improve overall health in the rural area of Loja, Ecuador and similar rural regions around the world.

How the COVID-19 Pandemic Reshaped the Management of Leukemia and Affected Patient Outcomes.

OPINION STATEMENT: The coronavirus disease-19 (COVID-19) pandemic has posed numerous challenges to the global healthcare system. Of particular gravity is adult and pediatric patients with hematologic malignancies who are among the most vulnerable groups of patients at risk of severe COVID-19 outcomes. In the early phases of the pandemic, several treatment modifications were proposed for patients with leukemia. Largely speaking, these were adopting less-intense therapies and more utilization of the outpatient setting. Over time, our understanding and management have become more nuanced. Furthermore, equipped with vaccinations to prevent COVID-19 infection and availability of treatments in the presence of COVID-19 infection, the recommendations on management of patients with leukemia have evolved. Patient's leukemia characteristics, possibility of targeted therapy, vaccination status, symptomatology, comorbidities, goal of anti-leukemic therapy, the intensity of therapy, the setting of treatment, as well as loco regional factors like dynamic incidence of COVID-19 in the community and hospital/ICU bed status are among many factors that influence the decisions. Furthermore, the oncology community has adopted delaying the anti-leukemia therapy for a limited time frame, if clinically possible, so as to still deliver most appropriate therapy while minimizing risks. Early adoption of growth factor support and conservative blood transfusion practices have helped as well. In this review, we discuss the impact of COVID-19 on outcomes and share considerations for treatments of leukemias. We describe the impact on both clinical care (from diagnosis to treatment) and research, and cover the literature on vaccines and treatments for COVID-19 in relation to leukemia.

Correlates of Covid-19 Vaccine Acceptance among Residents of Ohio: A Cross-sectional Study.

BACKGROUND: Recent studies in the United States have shown that between 56 to 74% are willing to receive the COVID-19 vaccine. A significant portion of the population should be vaccinated to avoid severe illness and prevent unnecessary deaths. We examined correlates of COVID-19 vaccine acceptance among a representative sample of adults residing in Ohio. METHODS: We conducted a cross-sectional study using an online platform (n = 2358). Descriptive statistics, chi-square test and multivariable regression analysis were performed. RESULTS: Overall, 59.1% of the participants indicated COVID-19 vaccine acceptance to be vaccinated. In the multivariable model, the likelihood of COVID-19 vaccine acceptance was lower for younger individuals compared to those 55 years and older. The odds of COVID-19 vaccine acceptance were lower for: females compared to males (OR 0.58, 95% CI: 0.47-0.71; P = 0.001), non-Hispanic blacks compared to non-Hispanic whites (OR: 0.49 95% CI: 0.35-0.70; P = 0.001), previously married (OR 0.64 95% CI: 0.49-0.84; P = 0.002) and never been married (OR 0.75 95% CI: 0.59-0.96; P = 0.023) compared to married people, individuals with less than high school (OR 0.21 95% CI: 0.08-0.60; P = 0.003) and high school education (OR: 0.45 95% CI: 0.36-0.55; P < 0.001) compared to those with education beyond high school, and for individuals who had no confidence in the abilities of the state government (OR 0.69 95% CI: 0.53-0.89; P = 0.005) and other world governments to combat COVID-19 (OR 0.67 95% CI: 0.50-0.91; P = 0.009). A one unit increase in knowledge about COVID-19 (OR 1.19, 95% CI: 1.13-1.26; P < 0.001), behavioral adherence (OR 1.25, 95% CI: 1.15-1.37; P < 0.001), perceived susceptibility (OR 1.10, 95% CI: 1.03-1.17; P = 0.004), perceived severity (OR 1.09, 95% CI: 1.03-1.16; P = 0.003), and trust in COVID-19 messages from the government scores (OR 1.08, 95% CI: 1.06-1.10; P < 0.001) were associated with an increase in the likelihood of COVID-19 vaccine acceptance. CONCLUSIONS: COVID-19 vaccine acceptance differed by sociodemographic and other modifiable factors. Findings can inform local public health authorities in the development of effective, context-specific communication strategies to improve vaccination uptake.

Use of Hydroxychloroquine, Remdesivir, and Dexamethasone Among Adults Hospitalized With COVID-19 in the United States : A Retrospective Cohort Study.

BACKGROUND: Relatively little is known about the use patterns of potential pharmacologic treatments of COVID-19 in the United States. OBJECTIVE: To use the National COVID Cohort Collaborative (N3C), a large, multicenter, longitudinal cohort, to characterize the use of hydroxychloroquine, remdesivir, and dexamethasone, overall as well as across individuals, health systems, and time. DESIGN: Retrospective cohort study. SETTING: 43 health systems in the United States. PARTICIPANTS: 137 870 adults hospitalized with COVID-19 between 1 February 2020 and 28 February 2021. MEASUREMENTS: Inpatient use of hydroxychloroquine, remdesivir, or dexamethasone. RESULTS: Among 137 870 persons hospitalized with confirmed or suspected COVID-19, 8754 (6.3%) received hydroxychloroquine, 29 272 (21.2%) remdesivir, and 53 909 (39.1%) dexamethasone during the study period. Since the release of results from the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial in mid-June, approximately 78% to 84% of people who have had invasive mechanical ventilation have received dexamethasone or other glucocorticoids. The use of hydroxychloroquine increased during March 2020, peaking at 42%, and started declining by April 2020. By contrast, remdesivir and dexamethasone use gradually increased over the study period. Dexamethasone and remdesivir use varied substantially across health centers (intraclass correlation coefficient, 14.2% for dexamethasone and 84.6% for remdesivir). LIMITATION: Because most N3C data contributors are academic medical centers, findings may not reflect the experience of community hospitals. CONCLUSION: Dexamethasone, an evidence-based treatment of COVID-19, may be underused among persons who are mechanically ventilated. The use of remdesivir and dexamethasone varied across health systems, suggesting variation in patient case mix, drug access, treatment protocols, and quality of care. PRIMARY FUNDING SOURCE: National Center for Advancing Translational Sciences; National Heart, Lung, and Blood Institute; and National Institute on Aging.

COVID-19 Vaccine Hesitancy in Three Latin American Countries: Reasons Given for Not Becoming Vaccinated in Colombia, Ecuador, and Venezuela.

Although vaccines have been developed to prevent COVID-19, vaccine hesitancy is a significant barrier for vaccination programs. Most research on COVID-19 vaccine hesitancy has blamed misinformation and misstated concerns about effectiveness, safety, and side effects of these vaccines. The preponderance of these studies has been performed in the Global North. Although Latin American has been substantially and negatively impacted by COVID-19, few studies have examined COVID-19 vaccine hesitancy there. We explored reasons volunteered for COVID-19 vaccine hesitancy from a sample of 1,173 Colombians, Ecuadorians, and Venezuelans. Overall, COVID-19 vaccine hesitancy in these three countries is higher than desirable, but most people who are COVID-19 vaccine hesitant offered one reason or fewer. The reasons offered are diverse, including myths and exaggerations, but also individual-level contraindications for vaccination and structural barriers. Because of the diversity of reasons, single-issue mass campaigns are unlikely to bring about large shifts in COVID-19 vaccine hesitancy in Colombia, Ecuador, and Venezuela. Our data suggest that interpersonal communication, particularly in Ecuador, and addressing structural concerns, particularly in Venezuela, are likely to have the greatest impact on vaccine uptake.

Social support in rural communities in Manabi province, Ecuador.

INTRODUCTION: Social support has been found in many contexts, and in urban Ecuador, to be protective of health, particularly in the context of disaster. Fewer studies have explored the presence and impact of social support in rural Ecuador. This study engages a rural community in Ecuador to examine the general levels of social support, differences in social support based on different demographic groupings and relationships among social support and health outcomes and protective health behaviors. METHODS: A cross-sectional design was used to survey 416 people in a rural Ecuadorian community that had recently experienced an earthquake. Spanish-language versions of the Multidimensional Scale of Perceived Social Support and the Interpersonal Support Evaluation List-12 were applied, as well as questions about demographics and risk reduction behaviors. Body mass index, blood pressure, and cholesterol and blood sugar levels were assessed. Analysis of variance assessed differences in social support among demographic groupings, risk reduction behaviors, and health outcomes. RESULTS: Levels of social support were moderate. Few statistically significant (ie p<0.05) differences in amount of social support received or in sources of social support were found. Men, people 80 years or older, divorced or widowed people, and people living in peripheral areas received less social support than women, people of all other ages, married/cohabitating people, and people living within the village, respectively. Effect sizes of these differences were small. No relationship between social support and health outcomes were found, and few were found for risk reduction factors. CONCLUSION: These findings indicate that social support may function differently in rural Ecuador than in urban contexts. Those promoting social support in rural communities may wish to focus on community-level, not individual-level, interventions. Limitations of applying an assessment of social support from urban Ecuadorian contexts to rural Ecuadorian contexts are discussed.

Knowledge, Attitudes, and Practices Towards COVID-19 Among Ecuadorians During the Outbreak: An Online Cross-Sectional Survey.

Preventing the transmission of SARS-CoV-2 (causative agent for COVID-19) requires implementing contact and respiratory precautions. Modifying human behavior is challenging and requires understanding knowledge, attitudes, and practices (KAPs) regarding health threats. This study explored KAPs among people in Ecuador. A cross-sectional, internet-based questionnaire was used to assess knowledge about COVID-19, attitudes toward ability to control COVID-19, self-reported practices related to COVID-19, and demographics. A total of 2399 individuals participated. Participants had moderate to high levels of knowledge. Participants expressed mixed attitudes about the eventual control of COVID-19 in Ecuador. Participants reported high levels of adoption of preventive practices. Binomial regression analysis suggests unemployed individuals, househusbands/housewives, or manual laborers, as well as those with an elementary school education, have lower levels of knowledge. Women, people over 50 years of age, and those with higher levels of schooling were the most optimistic. Men, individuals 18-29, single, and unemployed people took the riskiest behaviors. Generally, knowledge was not associated with optimism or with practices. Our findings indicate knowledge about COVID-19 is insufficient to prompt behavioral change among Ecuadorians. Since current COVID-19 control campaigns seek to educate the public, these efforts' impacts are likely to be limited. Given attitudes determine people's actions, further investigation into the factors underlying the lack of confidence in the ability of the world, and of Ecuador, to overcome COVID-19, is warranted. Edu-communicational campaigns should be accompanied by efforts to provide economically disadvantaged populations resources to facilitate adherence to recommendations to prevent the spread of the virus.

In Pursuit of "queer-friendly" Healthcare: An Interview Study of How Queer Individuals Select Care Providers.

LGBQ+ individuals experience worse health outcomes than do other individuals. Some communication research finds that LGBQ+ individuals report receiving poor care during the mid- to post-health care, but this research assumes that LGBQ+ individuals have already received care. Little research has examined the pre- to early encounter experience of LGBQ+ individuals. This study presents exploratory research into how LGBQ+ individuals seek "queer-friendly" health care during pre- and early encounter experiences. Using an interview methodology, we report the facilitators and barriers to seeking queer-friendly care reported by LGBQ+ individuals. We offer implications for how health care providers and systems can better promote queer-friendly healthcare.

"Better Than Bank Robbery": Yuezi Centers and Neoliberal Appeals to Market Birth Tourism to Pregnant Chinese Women.

"Birth tourism" has rarely been addressed by scholars. The ways that pregnant women are encouraged to leave their homelands and give birth abroad have not been investigated. Birth tourism agencies may seek to persuade women that particular destinations-such as the US-are ideal places for giving birth. An examination of how birth tourism agencies frame birth tourism may offer initial insights into this phenomenon. This study examines 34 agencies' home pages and their arguments advocating birth tourism for Chinese expectant mothers. Using a thematic approach, we find four reasons offered to pregnant Chinese women that make birth tourism appealing. This perspective helps us to understand birth tourism both as a health-related behavior and a cosmopolitan issue. We use neoliberalism as an analytic framework to examine how birth tourism may enhance inequality in health resource distribution both domestically and internationally.

Evaluation of athletes with complex congenital heart disease.

As a result of improvements in congenital heart surgery, there are more adults alive today with congenital heart disease (CHD) than children. Individuals with cardiac birth defects may be able to participate in physical activities but require proper cardiovascular evaluation. The American Heart Association and American College of Cardiology released guidelines in 2015 for athletes with cardiovascular abnormalities. The guidelines express that although restriction from competitive athletics may be indicated for some, the majority of individuals with CHD can and should engage in some form of physical activity. This case study demonstrates the importance of combining all aspects of history, physical examination, ECG, and imaging modalities to evaluate cardiac anatomy and function in young athletes with complex CHD.

The application of subjective job task analysis techniques in physically demanding occupations: evidence for the presence of self-serving bias.

The aim of this study was to determine if perceptions of physically demanding job tasks are biased by employee demographics and employment profile characteristics including: age, sex, experience, length of tenure, rank and if they completed or supervised a task. Surveys were administered to 427 Royal Australian Navy personnel who characterised 33 tasks in terms of physical effort, importance, frequency, duration and vertical/horizontal distance travelled. Results showed no evidence of bias resulting from participant characteristics, however participants who were actively involved in both task participation and supervision rated these tasks as more important than those involved only in the supervision of that task. This may indicate self-serving bias in which participants that are more actively involved in a task had an inflated perception of that task's importance. These results have important implications for the conduct of job task analyses, especially the use of subjective methodologies in the development of scientifically defensible physical employment standards. Practitioner Summary: To examine the presence of systematic bias in subjective job task analysis methodologies, a survey was conducted on a sample of Royal Australian Navy personnel. The relationship between job task descriptions and participant's demographic and job profile characteristics revealed the presence of self-serving bias affecting perceptions of task importance.

When a Spoonful of Fallacies Helps the Sweetener Go Down: The Corn Refiner Association's Use of Straw-Person Arguments in Health Debates Surrounding High-Fructose Corn Syrup.

The American public is increasingly concerned about risks associated with food additives like high-fructose corn syrup (HFCS). To promote its product as safe, the Corn Refiners Association (CRA) employed two forms of straw-person arguments. First, the CRA opportunistically misrepresented HFCS opposition as inept. Second, the CRA strategically chose to refute claims that were easier to defeat while remaining ambiguous about more complex points of contention. We argue that CRA's discursive contributions represented unreasonable yet sustainable use of straw-person arguments in debates surrounding health and risk.

Examining antecedents of caregivers' access to early childhood developmental screening: implications for campaigns promoting use of services in Appalachian Ohio.

Although developmental delays are common in the United States, only about one third of developmental delays are identified before a child enters school. As challenging as use of developmental screening is on a national basis, the Appalachian region faces extreme lack of screening, diagnosis, and treatment for developmental delay. Local health care providers attribute this lack to poor parent understanding and have called for communication interventions to educate caregivers. This investigation sought to understand the antecedents of Appalachian caregivers' intentions to access developmental screening and services for their children as formative research for a communication-based intervention. The investigation was grounded by the health belief model. Surveys completed by 366 caregivers were used to model antecedents to behavioral intention. Perceived severity, perceived benefits, and self-efficacy were found to be the strongest predictors of intention to access developmental screening. Implications for a communication-based intervention are provided.