Latino-White Disparities in Identification and Control of Elevated Blood Pressure Among Adults With Hypertension.

BACKGROUND: Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers. METHODS AND RESULTS: Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90). CONCLUSIONS: In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

Association of neighbourhood walkability and haemoglobin A1c levels among Latino and non-Hispanic White patients with diabetes.

BACKGROUND: Neighbourhood walkability can benefit cardiovascular health. Latino patients are more likely than non-Hispanic White patients to have diabetes, and evidence has shown better diabetes-related outcomes for patients living in neighbourhoods conducive to physical activity. Our objective was to determine whether neighbourhood walkability was associated with haemoglobin A1c (HbA1c) levels among English- and Spanish-preferring Latino patients compared to non-Hispanic White patients. METHODS: We used electronic health record data from patients in the OCHIN, Inc. network of community health centres (CHC) linked to public walkability data. Patients included those age ≥ 18 with ≥ 1 address recorded, with a study clinic visit from 2012 to 2020, and a type 2 diabetes diagnosis (N = 159,289). Generalized estimating equations logistic regression, adjusted for relevant covariates, was used to model the primary binary outcome of always having HbA1c < 7 by language/ethnicity and walkability score. RESULTS: For all groups, the walkability score was not associated with higher odds and prevalence of always having HbA1c < 7. Non-Hispanic White patients were most likely to have HbA1c always < 7 (prevalence ranged from 32.8% [95%CI = 31.2-34.1] in the least walkable neighbourhoods to 33.4% [95% CI 34.4-34.7] in the most walkable), followed by English-preferring Latinos (28.6% [95%CI = 25.4-31.8]-30.7% [95% CI 29.0-32.3]) and Spanish-preferring Latinos (28.3% [95% CI 26.1-30.4]-29.3% [95% CI 28.2-30.3]). CONCLUSIONS: While walkability score was not significantly associated with glycaemic control, control appeared to increase with walkability, suggesting other built environment factors, and their interaction with walkability and clinical care, may play key roles. Latino patients had a lower likelihood of HbA1c always < 7, demonstrating an opportunity for equity improvements in diabetes care.

Cardiovascular disease risk management during COVID-19: in-person vs virtual visits.

OBJECTIVES: Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits. STUDY DESIGN: Retrospective interrupted time-series analysis. METHODS: Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding. RESULTS: There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality. CONCLUSIONS: Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Pandemic-related practice changes and CVD risk management in community clinics.

OBJECTIVES: Understanding how the COVID-19 pandemic affected cardiovascular disease (CVD) risk monitoring in primary care may inform new approaches for addressing modifiable CVD risks. This study examined how pandemic-driven changes in primary care delivery affected CVD risk management processes. STUDY DESIGN: This retrospective study used electronic health record data from patients at 70 primary care community clinics with scheduled appointments from September 1, 2018, to September 30, 2021. METHODS: Analyses examined associations between appointment type and select care process measures: appointment completion rates, time to appointment, and up-to-date documentation for blood pressure (BP) and hemoglobin A1c (HbA1c). RESULTS: Of 1,179,542 eligible scheduled primary care appointments, completion rates were higher for virtual care (VC) vs in-person appointments (10.7 percentage points [PP]; 95% CI, 10.5-11.0; P < .001). Time to appointment was shorter for VC vs in-person appointments (-3.9 days; 95% CI, -4.1 to -3.7; P < .001). BP documentation was higher for appointments completed pre- vs post pandemic onset (16.2 PP; 95% CI, 16.0-16.5; P < .001) and for appointments completed in person vs VC (54.9 PP; 95% CI, 54.6-55.2; P < .001). HbA1c documentation was higher for completed appointments after pandemic onset vs before (5.9 PP; 95% CI, 5.1-6.7; P < .001) and for completed VC appointments vs in-person appointments (3.9 PP; 95% CI, 3.0-4.7; P < .001). CONCLUSIONS: After pandemic onset, appointment completion rates were higher, time to appointment was shorter, HbA1c documentation increased, and BP documentation decreased. Future research should explore the advantages of using VC for CVD risk management while continuing to monitor for unintended consequences.

Does Clinical Decision Support Increase Appropriate Medication Prescribing for Cardiovascular Risk Reduction?

PURPOSE: To assess the impact of a clinical decision support (CDS) system's recommendations on prescribing patterns targeting cardiovascular disease (CVD) when the recommendations are prioritized in order from greatest to least benefit toward overall CVD risk reduction. METHODS: Secondary analysis of trial data from September 20, 2018, to March 15, 2020, where 70 community health center clinics were cluster-randomized to the CDS intervention (42 clinics; 8 organizations) or control group (28 clinics; 7 organizations). Included patients were medication-naïve and aged 40 to 75 years with ≥1 uncontrolled cardiovascular disease risk factor, with known diabetes or cardiovascular disease, or ≥10% 10-year reversible CVD risk. RESULTS: Among eligible encounters with 29,771 patients, the probability of prescribing a medication targeting hypertension was greater at intervention clinic encounters when CDS was used (34.9% [95% CI, 31.5 to 38.3]) versus dismissed (29.6% [95% CI, 26.7 to 32.6]; P < .001), but not when compared with control clinic encounters (34.9% [95% CI, 31.1 to 38.7]; P = .998). Prescribing for dyslipidemia was significantly higher at intervention encounters where the CDS system was used (11.3% [95% CI, 9.3 to 13.3]) compared with dismissed (7.7% [95% CI, 6.1 to 9.3]; P = .003) and to control encounters (8.7% [95% CI, 7.0 to 10.4]; P = .044); smoking cessation medication showed a similar pattern. Except for dyslipidemia, prescribing rates increased according to their prioritization. CONCLUSIONS: Use of this CDS system was associated with significantly higher prescribing targeting most cardiovascular risk factors. These results highlight how displaying prioritized actions to reduce reversible CVD risk could improve risk management. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.

Adoption of shared decision-making and clinical decision support for reducing cardiovascular disease risk in community health centers.

Objective: Electronic health record (EHR)-based shared decision-making (SDM) and clinical decision support (CDS) systems can improve cardiovascular disease (CVD) care quality and risk factor management. Use of the CV Wizard system showed a beneficial effect on high-risk community health center (CHC) patients' CVD risk within an effectiveness trial, but system adoption was low overall. We assessed which multi-level characteristics were associated with system use. Materials and Methods: Analyses included 80 195 encounters with 17 931 patients with high CVD risk and/or uncontrolled risk factors at 42 clinics in September 2018-March 2020. Data came from the CV Wizard repository and EHR data, and a survey of 44 clinic providers. Adjusted, mixed-effects multivariate Poisson regression analyses assessed factors associated with system use. We included clinic- and provider-level clustering as random effects to account for nested data. Results: Likelihood of system use was significantly higher in encounters with patients with higher CVD risk and at longer encounters, and lower when providers were >10 minutes behind schedule, among other factors. Survey participants reported generally high satisfaction with the system but were less likely to use it when there were time constraints or when rooming staff did not print the system output for the provider. Discussion: CHC providers prioritize using this system for patients with the greatest CVD risk, when time permits, and when rooming staff make the information readily available. CHCs' financial constraints create substantial challenges to addressing barriers to improved system use, with health equity implications. Conclusion: Research is needed on improving SDM and CDS adoption in CHCs. Trial Registration: ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.

Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial.

Importance: Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. Objective: To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). Design, Setting, and Participants: This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. Interventions: A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. Main Outcomes and Measures: One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). Results: Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001). Conclusions and Relevance: The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. Trial Registration: ClinicalTrials.gov Identifier: NCT03001713.

Sourcing Cannabis sativa L. by thermogravimetric analysis.

Marijuana, dried and ground Cannabis, is the most consumed illicit drug in the world. Many undesirable and risky effects to human health are caused by its use. The medicinal use or legal recreational use of Cannabis has also been rising in many countries. These facts make traceability methodologies increasingly important whether for forensic use, such as drug trafficking eradication, or for quality control purposes of legal medicinal Cannabis. Consequently, the objective of this study was to analyze Cannabis by means of thermogravimetric analysis (TGA) in order to assess the capability of this technique to trace the geographical origin of Cannabis cultivated in Colorado, United States of America. TGA appears to be sensitive enough to detect the degradation/decarboxylation of cannabinoids and terpenes, at least to some extent; also, the degradation of cellulose, hemicellulose and lignin was indicated. Overall, the temperature ranges we analyzed using linear discriminant analysis showed high accuracies, with the 200 to 300 °C and 600 to 700 °C ranges achieving 100% accuracy.

Uncovering the Roles of Oxygen in Cr(III) Photoredox Catalysis.

A combined experimental and theoretical investigation aims to elucidate the necessary roles of oxygen in photoredox catalysis of radical cation based Diels-Alder cycloadditions mediated by the first-row transition metal complex [Cr(Ph2phen)3](3+), where Ph2phen = bathophenanthroline. We employ a diverse array of techniques, including catalysis screening, electrochemistry, time-resolved spectroscopy, and computational analyses of reaction thermodynamics. Our key finding is that oxygen acts as a renewable energy and electron shuttle following photoexcitation of the Cr(III) catalyst. First, oxygen quenches the excited Cr(3+)* complex; this energy transfer process protects the catalyst from decomposition while preserving a synthetically useful 13 µs excited state and produces singlet oxygen. Second, singlet oxygen returns the reduced catalyst to the Cr(III) ground state, forming superoxide. Third, the superoxide species reduces the Diels-Alder cycloadduct radical cation to the final product and reforms oxygen. We compare the results of these studies with those from cycloadditions mediated by related Ru(II)-containing complexes and find that the distinct reaction pathways are likely part of a unified mechanistic framework where the photophysical and photochemical properties of the catalyst species lead to oxygen-mediated photocatalysis for the Cr-containing complex but radical chain initiation for the Ru congener. These results provide insight into how oxygen can participate as a sustainable reagent in photocatalysis.

Photodriven Multi-electron Storage in Disubstituted Ru(II) Dppz Analogues.

Four derivatives of the laminate acceptor ligand dipyrido-[3,2-a:2',3'-c]phenazine (dppz) and their corresponding ruthenium complexes, [Ru(phen)2 (dppzX2 )](2+) , were prepared and characterized by NMR spectroscopy, ESI-MS, and elemental analysis. The new ligands, generically denoted dppzX2 , were symmetrically disubstituted on the distal benzene ring to give 10,13-dibromodppz (dppz-p-Br), 11,12-dibromodppz (dppz-o-Br), 10,13-dicyanodppz (dppz-p-CN), 11,12-dicyanodppz (dppz-o-CN). Solvated ground state MO calculations of the ruthenium complexes reveal that these electron-withdrawing substituents not only lower the LUMO of the dppz ligand (dppz(CN)2

Electrocatalytic and photocatalytic conversion of CO(2) to methanol using ruthenium complexes with internal pyridyl cocatalysts.

The ruthenium complexes [Ru(phen)2(ptpbα)](2+) (Ruα) and [Ru(phen)2(ptpbß)](2+) (Ruß), where phen =1,10-phenanthroline ; ptpbα = pyrido[2',3':5,6]pyrazino[2,3-f][1,10]phenanthroline; ptpbß = pyrido[3',4':5,6]pyrazino[2,3-f][1,10]phenanthroline, are shown as electrocatalysts and photocatalysts for CO2 reduction to formate, formaldehyde, and methanol. Photochemical activity of both complexes is lost in water but is retained in 1 M H2O in DMF. Controlled current electrolysis of a solution of Ruß in CO2 saturated DMF:H2O (1 M) yields predominantly methanol over a 6 h period at ∼ -0.60 V versus Ag/AgCl, with traces of formaldehyde. After this time, the potential jumped to -1.15 V producing both methanol and CO as products. Irradiation of Ruß in a solution of DMF:H2O (1 M) containing 0.2 M TEA (as the sacrificial reductant) yields methanol, formaldehyde, and formate. Identifications of all of the relevant redox and protonated states of the respective complexes were obtained by a combination of voltammetry and differential reflectance measurements. Spectroelectrochemistry was particularly useful to probe the photochemical and electrochemical reduction mechanisms of both complexes as well as the complexes speciation in the absence and presence of CO2.

Photochemical reduction of carbon dioxide to methanol and formate in a homogeneous system with pyridinium catalysts.

Photochemical catalytic CO2 reduction to formate and methanol has been demonstrated in an aqueous homogeneous system at pH 5.0 comprising ruthenium(II) trisphenanthroline as the chromophore, pyridine as the CO2 reduction catalyst, KCl, and ascorbic acid as a sacrificial reductant, using visible light irradiation at 470 ± 20 nm. Isotopic labeling with (13)CO2 yields the six-electron-reduced product (13)CH3OH. After 1 h photolysis, the two-electron-reduced product formate and the six-electron-reduced product methanol are produced with quantum yields of 0.025 and 1.1 × 10(­4), respectively. This represents 76 and 0.15 turnovers per Ru for formate and methanol, respectively, and 152 and 0.9 turnovers per Ru on an electron basis for formate and methanol, respectively. The system is inactive after 6 h irradiation, which appears largely to be due to chromophore degradation. A partial optimization of the methanol yield showed that high pyridine to Ru ratios are needed (100:1) and that the optimum pH is near 5.0. The presence of potassium salts enhances the yield in formate and methanol by 8- and 2-fold, respectively, compared to electrolyte-free solutions; however, other alkali and alkali earth cations have little effect. The addition of small amounts of solid metal catalysts immobilized on carbon had either no effect (M = Pt or Pd) or deleterious effects (M = Ni or Au) on methanol production. Addition of colloidal Pt resulted in no methanol production at all. This is in notable contrast with the pyridine-based electrocatalysis of CO2 to methanol in which metallic or conductive surfaces such as Pt, Pd, or p-type GaP are necessary for methanol formation.

Photoinduced ligand transformations in a ruthenium complex of dimethoxytetrapyridotetraazapentacene.

The dinuclear ruthenium(II) complex [(phen)(2)Ru(tatpOMe)Ru(phen)(2)](4+) (2(4+); phen is 1,10-phenanthroline and tatpOMe is 10,21-dimethoxy-9,10,20,33-tetraazatetrapyrido[3,2-a:2'3'-c:3'',2''-l:2''',3'''-n]pentacene) has been synthesized and characterized by (1)H NMR, ESI mass spectroscopy and elemental analysis. Loss of methoxy group from bridging ligand of complex 2(4+) due to irradiation is observed by (1)H NMR and photochemistry. The interrelated electronic properties UV-Vis, electrochemistry, photochemistry and molecular orbital calculation are analyzed and discussed on the bridging ligand of the complex 2(4+).