Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes.

Background: Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity. Methods: Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity. Findings: Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients. Interpretation: Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity. Funding: Patient-Centered Outcomes Research Institute and National Institutes of Health.

Harmonization of three different accelerometers to classify the 24 h activity cycle.

Increasing interest in measuring key components of the 24 h activity cycle (24-HAC) [sleep, sedentary behavior (SED), light physical activity (LPA), and moderate to vigorous physical activity (MVPA)] has led to a need for better methods. Single wrist-worn accelerometers and different self-report instruments can assess the 24-HAC but may not accurately classify time spent in the different components or be subject to recall errors.Objective. To overcome these limitations, the current study harmonized output from multiple complimentary research grade accelerometers and assessed the feasibility and logistical challenges of this approach.Approach. Participants (n= 108) wore an: (a) ActiGraph GT9X on the wrist, (b) activPAL3 on the thigh, and (c) ActiGraph GT3X+ on the hip for 7-10 d to capture the 24-HAC. Participant compliance with the measurement protocol was compared across devices and an algorithm was developed to harmonize data from the accelerometers. The resulting 24-HAC estimates were described within and across days.Main results. Usable data for each device was obtained from 94.3% to 96.7% of participants and 89.4% provided usable data from all three devices. Compliance with wear instructions ranged from 70.7% of days for the GT3X+ to 93.2% of days for the activPAL3. Harmonized estimates indicated that, on average, university students spent 34% of the 24 h day sleeping, 41% sedentary, 21% in LPA, and 4% in MVPA. These behaviors varied substantially by time of day and day of the week.Significance. It is feasible to use three accelerometers in combination to derive a harmonized estimate the 24-HAC. The use of multiple accelerometers can minimize gaps in 24-HAC data however, factors such as additional research costs, and higher participant and investigator burden, should also be considered.

A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics.

Rationale & Objective: The study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving CKD care in adults. Study Design: This was a cluster randomized trial. Setting & Participants: A total of 32 Midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined glomerular filtration rate categories of CKD Stage G3 and G4, and 1 or more of 6 CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure or glycated hemoglobin levels, indication for angiotensin-converting enzyme inhibitor or angiotensin receptor blocker but not prescribed, a nonsteroidal anti-inflammatory agent on the active medication list, or indication for a nephrology referral. Intervention: The CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters. Outcomes: We assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after 18 months. Results: The adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs 21.8%; risk ratio [RR], 1.17; 95% CI, 0.91-1.51); angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescribed (15.9% vs 16.1%; RR, 0.95; 95% CI, 0.76-1.18); blood pressure control (20.4% vs 20.2%; RR, 0.98; 95% CI, 0.84-1.15); glycated hemoglobin level control (21.4% vs 22.1%; RR, 1.00; 95% CI, 0.80-1.24); nonsteroidal anti-inflammatory agent not on the active medication list (51.5% vs 50.4%; RR, 1.03; 95% CI, 0.90-1.17); and referral or visit to a nephrologist (38.7% vs 36.1%; RR, 1.02; 95% CI, 0.79-1.32). Limitations: We encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization because of the coronavirus disease 2019 pandemic. Conclusions: The CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the coronavirus disease 2019 pandemic likely influenced these results. Funding: National Institute of Diabetes and Digestive and Kidney Diseases (R18DK118463). Trial Registration: clinicaltrials.gov Identifier: NCT03890588.

This study aimed to improve the management of chronic kidney disease (CKD) through a clinical decision support (CDS) system. It involved 32 primary care clinics and 6,420 patients with CKD who had 1 or more of 6 CKD care improvement opportunities. The CDS provided personalized suggestions to both patients and clinicians about CKD care opportunities during primary care visits. After 18 months, the study found no significant differences between patients in clinics with CKD-CDS compared with usual care in diagnosing CKD, prescribing recommended medications, controlling blood pressure or glycated hemoglobin, nonsteroidal anti-inflammatory agent usage, or nephrology referrals. The coronavirus disease 2019 pandemic may have influenced results by introducing unforeseen implementation challenges, reduced visits, and less than expected CDS exposure.

Carbonservation with Demonstrated Biodiversity and Carbon Gains: Carbon Can Pay But Biodiversity Must Lead.

Land use has a critical role to play in both climate change mitigation and biodiversity conservation, and increasingly there have been calls to integrate policies for concurrently meeting Paris Agreement commitments and the UN decade on ecosystem restoration 2021-2030. Currently however, investment activities have been dominated by climate change mitigation activities, including through the development of carbon markets (both voluntary and compliance markets). Whilst climate change mitigation is to be welcomed, the prioritization of carbon in avoided deforestation and reforestation can lead to suboptimal or negative outcomes for biodiversity. Restoration of degraded native vegetation may provide an opportunity for concurrent production of both carbon and biodiversity benefits, by harnessing existing carbon markets without the need to trade-off biodiversity outcomes. Here we demonstrate that carbon sequestered by restoring degraded temperate woodland can pay the price of the restored biodiversity. This is shown using conservative carbon prices in an established market (during both a voluntary and compliance market phase), and the restoration price revealed by a 10-year conservation incentive payment scheme. When recovery rates are high, market prices for carbon could pay the full price of restoration, with additional independent investment needed in cases where recovery trajectories are slower. Using carbon markets to fund restoration of degraded native vegetation thereby provides a solution for constrained resources and problematic trade-offs between carbon and biodiversity outcomes. Multi-attribute markets offer the potential to greatly increase the extent of restoration for biodiversity conservation, while providing an affordable source of carbon sequestration and enhancing economic benefits to landowners.

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.

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.

The Impact of Stimulant Medications on Blood Pressure and Body Mass Index in Children with Attention Deficit Hyperactivity Disorder.

OBJECTIVE: To describe changes in blood pressure (BP) and body mass index (BMI) associated with stimulant medication fills in children. METHODS: Observational, retrospective matched cohort study of children 6-17.9 years initiating stimulant medication between 7/1/2010-6/30/2017 matched 1:3 by age, race, ethnicity, and sex to children with no stimulant use during this period. All BPs and BMIs recorded during ambulatory visits were identified. Generalized linear models were used to estimate differences in change in systolic BP (SBP), diastolic BP (DBP), and BMI over time. RESULTS: The 686 children with stimulant prescription fills and 2048 matched controls did not differ by baseline SBP or BMI. The matched control group (30.5% female, mean age 11.2 ± 3.4 years 79.7% white) was more likely to be publicly insured (35% vs. 21%, P < .01). After adjusting for baseline values, over a mean follow-up of 144 days change in SBP or DBP did not differ significantly between patients with stimulant medication fills and matched controls. Stimulant use was associated with a 4.7 percentile decrease in BMI percentile compared to matched controls (95% CI: 3.69, 5.71; P < .01). CONCLUSIONS: In a pediatric primary care cohort, stimulant prescription fills were associated with marked decreases in BMI but no significant changes in BP over time.

Protocol of a patient randomized clinical trial to improve medication adherence in primary care.

BACKGROUND: Enhanced awareness of poor medication adherence could improve patient care. This article describes the original and adapted protocols of a randomized trial to improve medication adherence for cardiometabolic conditions. METHODS: The original protocol entailed a cluster randomized trial of 28 primary care clinics allocated to either (i) medication adherence enhanced chronic disease care clinical decision support (eCDC-CDS) integrated within the electronic health record (EHR) or (ii) usual care (non-enhanced CDC-CDS). Enhancements comprised (a) electronic interfaces printed for patients and clinicians at primary care encounters that encouraged discussion about specific medication adherence issues that were identified, and (b) pharmacist phone outreach. Study subjects were individuals who at an index visit were aged 18-74 years and not at evidence-based care goals for hypertension (HTN), diabetes mellitus (DM), or lipid management, along with low medication adherence (proportion of days covered [PDC] <80%) for a corresponding medication. The primary study outcomes were improved medication adherence and clinical outcomes (BP and A1C) at 12 months. Protocol adaptation became imperative in response to major implementation challenges: (a) the availability of EHR system-wide PDC calculations that superseded our ability to limit PDC adherence information solely to intervention clinics; (b) the unforeseen closure of pharmacies committed to conducting the pharmacist outreach; and (c) disruptions and clinic closures due to the Covid-19 pandemic. CONCLUSION: This manuscript details the protocol of a study to assess whether enhanced awareness of medication adherence issues in primary care settings could improve patient outcomes. The need for protocol adaptation arose in response to multiple implementation challenges.

The Impact of Whole Egg Consumption on Bone Accrual in Healthy Children: A Randomized Controlled Trial.

Dietary interventions designed to examine the role of nutrition on childhood bone accrual have often focused on the role of individual micronutrients (eg, calcium, vitamin D, and zinc) and macronutrients (eg, protein). The osteogenic benefits of whole foods, such as eggs, are not well understood despite eggs being a source of high-quality nutrients and bioactive compounds known to positively influence bone. A significant positive cross-sectional association between whole egg consumption and tibia cortical bone mass has recently been shown in young children; however, randomized controlled trials (RCTs) have not been conducted. This study is a double-blind RCT in male and female children ages 9-13 years of different ancestries, designed to determine if consuming food products with whole eggs (equivalent to 8-10 eggs/wk) versus foods with milk or gelatin (placebo) over a 9-month period will improve measures of bone strength. Total body less head (TBLH) and lumbar spine bone mineral content (BMC) and areal bone mineral density (aBMD) were assessed using dual-energy X-ray absorptiometry (DXA). DXA Z-scores were computed using published pediatric growth charts and were adjusted for height-for-age Z-score (HAZ). Mid-tibia cortical volumetric BMD, BMC, cortical area, total bone area, cortical thickness, and strength strain index were measured using peripheral quantitative computed tomography. Overall, there were no significant intervention effects for any bone outcomes. The increase in spine BMCHAZ Z-score in the egg group versus the gelatin group approached significance (p = 0.07). Significant time effects in TBLH aBMDHAZ Z-score occurred as all groups decreased over 9 months (p < 0.03). Most tibia cortical bone outcomes increased over time (all p < 0.02), but changes did not differ across intervention groups. Whole eggs provide important nutritional benefits for children, but the bone responses to consumption of 8-10 eggs/wk over a period of 9 months in children entering the early stages of puberty were small. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness.

Introduction: Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods: We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results: In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion: The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

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/.

Adapting a clinical decision support system to improve identification of pediatric hypertension in a rural health system: Design of a pragmatic trial.

BACKGROUND: Identifying hypertension (HTN) early is crucial in preventing and lowering the long-term risk of heart disease, yet HTN in children often goes undiagnosed. An electronic health record linked, web-based clinical decision support (CDS) called PedsBP can help address this care gap and has been previously shown to increase recognition of HTN by primary care clinicians. OBJECTIVES: To adapt the PedsBP tool for use in a mostly rural health system and then to evaluate the effectiveness of PedsBP for repeat of hypertensive level blood pressure (BP) measurements and HTN recognition among youth 6-17 years of age in primary care settings, comparing low-intensity and high-intensity implementation approaches. METHODS AND DESIGN: PedsBP was evaluated through a pragmatic, clinic-randomized trial. The tool was piloted in 2 primary care clinics and modified prior to the full trial. Forty community-based, primary care clinics (or clusters of clinics) were randomly allocated in a 1:1:1 ratio to usual care, low-intensity implementation (CDS only), or high-intensity implementation (CDS plus in-person training, monthly use reports, and ongoing communication between study staff and clinics). Accrual of eligible patients started on August 1, 2022 and will continue for 18 months. Primary outcomes include repeating hypertensive level BP measurements at office visits and clinical recognition of HTN. Secondary outcomes include lifestyle counseling, dietician referral, and BP at follow-up. CONCLUSION: This report focuses on the design and feasibility of adapting and implementing PedsBP in a rural primary care setting. The trial and analysis are ongoing with main results expected in mid-2024.

Differential Effects of an Intervention to Reduce Cardiovascular Risk for Patients With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia: A Randomized Clinical Trial.

Objective: To measure the impact of a clinical decision support (CDS) tool on total modifiable cardiovascular risk at 12 months separately for outpatients with 3 subtypes of serious mental illness (SMI) identified via ICD-9 and ICD-10 codes: bipolar disorder, schizoaffective disorder, and schizophrenia.Methods: This cluster-randomized pragmatic clinical trial was active from March 2016 to September 2018; data were analyzed from April 2021 to September 2022. Clinicians and patients from 78 primary care clinics participated. All 8,922 adult patients aged 18-75 years with diagnosed SMI, at least 1 cardiovascular risk factor not at goal, and an index and follow-up visit during the study period were included. The CDS tool provided a summary of modifiable cardiovascular risk and personalized treatment recommendations.Results: Intervention patients had 4% relative reduction in total modifiable cardiovascular risk at 12 months compared to controls (relative risk ratio = 0.96; 95% CI, 0.94 to 0.98), with similar intervention benefits for all 3 SMI subtypes. At index, 10-year cardiovascular risk was higher for patients with schizophrenia (mean [SD] = 11.3% [9.2%]) than for patients with bipolar disorder (8.5% [8.9%]) or schizoaffective disorder (9.4% [8.1%]), while 30-year cardiovascular risk was highest for patients with schizoaffective disorder (44% with 2 or more major cardiovascular risk factors, compared to 40% for patients with schizophrenia and 37% for patients with bipolar disorder). Smoking was highly prevalent (47%), and mean (SD) BMI was 32.7 (7.9).Conclusions: This CDS intervention produced a clinically and statistically significant 4% relative reduction in total modifiable cardiovascular risk for intervention patients versus controls at 12 months, an effect observed across all 3 SMI subtypes and attributable to the aggregate impact of small changes in multiple cardiovascular risk factors.Trial Registration: ClinicalTrials.gov Identifier: NCT02451670.

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/.

Evaluation of inter-rater and test-retest reliability for near-infrared spectroscopy reactive hyperemia measures.

BACKGROUND: Near-infrared spectroscopy (NIRS) is a non-invasive tool used to measure blood flow in peripheral tissues. More information on inter-rater agreement and test-retest reliability of NIRS-based reperfusion assessments is needed. PURPOSE: To assess inter-rater agreement for NIRS based data analysis, and evaluate the measurement's reliability across days. METHODS: On three separate days (average days between visits 1 and 3: 19.4 ± 6.9 days), participants' (N = 15 males, 22 ± 2 yr.) post-occlusion reactive hyperemia (PORH) was measured in the left gastrocnemius muscle using Continuous-Wave NIRS (CW-NIRS). A blood pressure cuff was placed proximal to the knee and inflated to occlude lower leg blood flow for 5 min. The following CW-NIRS parameters were selected: (1) percent saturation in HbO2 (StO2%) at baseline; (2) the O2Hb range used to normalize the NIRS signal; (3) the time for the O2Hb signal to reach 50 % peak post-occlusion hyperemia (T1/2), and (4) the post peak hyperemic O2Hb recovery slope (O2REC-SLP). Absolute agreement between the two analysts was calculated using two-way random effects Intraclass Correlation Coefficients (ICC2,1). Consistency between analysts and across days was calculated using two-way mixed models (ICC3,1). Mean and 95 % confidence intervals (CI) of ICCs are reported. Coefficient of variation (CV) and standard error of the measurement (SEM) are reported. RESULTS: The ICC2,1 data indicated "adequate" to "excellent" absolute agreement between the two NIRS analysts. ICC2,3 data indicated "adequate" to "good" reliability across visits. The CV and SEM for rater 1 and rater 2 across visit were StO2 (CV: 3.79 % ± 2.71 % and 4.50 % ± 2.37 %; SEM: 3.42 and 3.82), O2Hb range (CV: 10.50 ± 5.93 and 12.79 ± 12.41; SEM: 3.26 and 4.71), T1/2 (CV: 11.15 % ± 5.52 % and 10.96 % ± 4.50; SEM: 1.22 and 1.11), and O2REC-SLP (CV: 19.49 % ± 9.99 % and 18.45 % ± 9.48 %; SEM: 0.04 and 0.04). CONCLUSION: It is concluded that NIRS parameters assessed show adequate reliability between analysts and across three visits. It is recommended, when feasible and because of the absence of 100 % reliability, that investigators employ more than one rater for scoring at least a portion of the data across each trial in a study's control condition in order to have the ability to estimate the magnitude of error attributable to imperfect reliability.

The win-win effects of nitrification inhibitors on soil-crop systems: Decreasing carbendazim residues but promoting soil bacterial community diversities and stabilities and crop yields.

Applying nitrogen (N)-cycling inhibitors is an effective measure to improve N fertilizer utilization efficiency, but the effects of N-cycling inhibitors on fungicide residues in soil-crop systems are unclear. In this study, nitrification inhibitors dicyandiamide (DCD) and 3, 4-dimethylpyrazole phosphate (DMPP) and urease inhibitor N-(n-butyl) thiophosphoric triamide (NBPT) were applied into agricultural soils with fungicide carbendazim applications. The soil abiotic properties, carrot yields, carbendazim residues, bacterial communities and their comprehensive relationships were also quantified. Compared to the control treatment, the DCD and DMPP significantly decreased soil carbendazim residues by 96.2% and 96.0%, and the DMPP and NBPT significantly reduced carrot carbendazim residues by 74.3% and 60.3%, respectively. The nitrification inhibitor applications also generated significant and positive effects on carrot yields and soil bacterial community diversities. The DCD application significantly stimulated soil Bacteroidota and endophytic Myxococcota and modified soil and endophytic bacterial communities. Meanwhile, the DCD and DMPP applications also positively stimulated the co-occurrence network edges of soil bacterial communities by 32.6% and 35.2%, respectively. The linear correlation coefficients between soil carbendazim residues and pH, ETSA and NH4+-N contents were - 0.84, - 0.57 and - 0.80, respectively. The nitrification inhibitor applications generated win-win effects on the soil-crop systems by decreasing carbendazim residues but promoting soil bacterial community diversities and stabilities and crop yields.

All-cause mortality after hypoglycemic and hyperglycemic emergencies among U.S. adults with diabetes, 2011-2020.

Estimated all-cause mortality within 30-days of hypoglycemic emergencies is 0.8 % in adults with type 1 diabetes and 1.7 % with type 2 diabetes; and within 30-days of hyperglycemic emergencies, it is 1.2 % with type 1 diabetes and 2.8 % with type 2 diabetes. These rates changed little between 2011 and 2020.

Session of yoga, with and without slow (Ujjayi) breathing, reduces anxiety; no change on acute pain sensitivity and endogenous pain modulation.

OBJECTIVES: Yoga is an increasingly popular mode of exercise that boasts health promoting effects including pain relief. A single bout of exercise induces a reduced sensitivity to noxious heat, but the mechanism for this effect and whether it occurs after a single session of yoga is unexplored. The primary aim of this study was to test, using a post-test only between-subjects design, main and interactive effects of yoga and slow breathing on both sensitivity to heat pain and endogenous pain modulation processing in healthy young women DESIGN: Fifty-four women were block randomized into one of four conditions: yoga with slow breathing instructions (Vinyasa), yoga with no breathing instructions, seated rest with slow breathing instructions and seated rest with no breathing instructions. The conditions were completed alone is a small room in which participant followed video-based instructions and models. The yoga was perceived as low-to-moderate intensity. RESULTS: Two factor ANOVA demonstrated no significant association between yoga postures and slow breathing, and there was no significant interaction observed for sensitivity to heat pain or endogenous pain modulation. These findings were unchanged in ANCOVAs that controlled for four potential confounding variables: post-condition reduction in systolic blood pressure or state anxiety, pain induced by the conditions and expectations. Compared to the non-yoga conditions, participant in yoga conditions resulted in a significant reduction in state anxiety scores. CONCLUSIONS: It is concluded that a single session of low-to-moderate intensity yoga with, or without slow breathing, reduces state anxiety but has no effect on heat pain sensitivity or endogenous pain modulation.