Building community resilience to prevent and mitigate community impact of gun violence: conceptual framework and intervention design.

INTRODUCTION: The USA has the highest rate of community gun violence of any developed democracy. There is an urgent need to develop feasible, scalable and community-led interventions that mitigate incident gun violence and its associated health impacts. Our community-academic research team received National Institutes of Health funding to design a community-led intervention that mitigates the health impacts of living in communities with high rates of gun violence. METHODS AND ANALYSIS: We adapted 'Building Resilience to Disasters', a conceptual framework for natural disaster preparedness, to guide actions of multiple sectors and the broader community to respond to the man-made disaster of gun violence. Using this framework, we will identify existing community assets to be building blocks of future community-led interventions. To identify existing community assets, we will conduct social network and spatial analyses of the gun violence episodes in our community and use these analyses to identify people and neighbourhood blocks that have been successful in avoiding gun violence. We will conduct qualitative interviews among a sample of individuals in the network that have avoided violence (n=45) and those living or working on blocks that have not been a location of victimisation (n=45) to identify existing assets. Lastly, we will use community-based system dynamics modelling processes to create a computer simulation of the community-level contributors and mitigators of the effects of gun violence that incorporates local population-based based data for calibration. We will engage a multistakeholder group and use themes from the qualitative interviews and the computer simulation to identify feasible community-led interventions. ETHICS AND DISSEMINATION: The Human Investigation Committee at Yale University School of Medicine (#2000022360) granted study approval. We will disseminate study findings through peer-reviewed publications and academic and community presentations. The qualitative interview guides, system dynamics model and group model building scripts will be shared broadly.

Preparing for Disaster: a Cross-Sectional Study of Social Connection and Gun Violence.

Living in communities with persistent gun violence is associated with negative social, behavioral, and health outcomes, analogous to those of a natural disaster. Taking a disaster-preparedness approach may identify targets for community-based action to respond to on-going gun violence. We assessed the relevance of adapting a disaster-preparedness approach to gun violence and, specifically, the relationship between perceived collective efficacy, its subscales of social cohesion and informal social control, and exposure to gun violence. In 2014, we conducted a cross-sectional study using a community-based participatory research approach in two neighborhoods in New Haven, CT, with high violent crime rates. Participants were ≥18 years of age and English speaking. We measured exposure to gun violence by adapting the Project on Human Development in Chicago Neighborhoods Exposure to Violence Scale. We examined the association between perceived collective efficacy, measured by the Sampson Collective Efficacy Scale, and exposure to gun violence using multivariate modeling. We obtained 153 surveys (51% response rate, 14% refusal rate, and 35% non-response rate). Ninety-five percent reported hearing gunfire, 58% had friend or family member killed by gun violence, and 33% were physically present during a shooting. In the fully adjusted model, one standard deviation higher perceived collective efficacy was associated with lower reported exposure to gun violence (ß = -0.91, p < 0.001). We demonstrated that it is possible to activate community members and local officials to engage in gun violence research. A novel, community-based approach adapted from disaster-preparedness literature may be an effective framework for mitigating exposure to gun violence in communities with persistent gun violence.

The TRPv1 receptor is a mediator of the exercise pressor reflex in rats.

The skeletal muscle exercise pressor reflex (EPR) induces increases in heart rate (HR) and mean arterial pressure (MAP) during physical activity. This reflex is activated during contraction by stimulation of afferent fibres responsive to mechanical distortion and/or the metabolic by-products of skeletal muscle work. The molecular mechanisms responsible for activating these afferent neurons have yet to be identified. It has been reported that activation of the transient receptor potential vanilloid 1 (TRPv1) receptor within skeletal muscle (localized to unmyelinated afferent fibres) elicits increases in MAP and HR similar to those generated by the EPR. Thus, we hypothesized that stimulation of the TRPv1 receptor during muscle contraction contributes to the activation of the EPR. The EPR was activated by electrically induced static muscle contraction of the hindlimb in decerebrate Sprague-Dawley rats (n = 61) before and after the administration of the TRPv1 receptor antagonists, capsazepine (Capz; 100 microg/100 microl), iodoresinaferatoxin (IRTX; 1 microg/100 microl), or Ruthenium Red (RR; 100 microg/100 microl). Static muscle contraction alone induced increases in both HR (8 +/- 2 bpm) and MAP (21 +/- 3 mmHg). The HR and MAP responses to contraction were significantly lower (P < 0.05) after the administration of Capz (2 +/- 1 bpm; 7 +/- 1 mmHg, respectively), IRTX (3 +/- 2 bpm; 5 +/- 3 mmHg, respectively) and RR (0 +/- 1, bpm; 5 +/- 2 mmHg, respectively). These data suggest that the TRPv1 receptor contributes importantly to activation of the EPR during skeletal muscle contraction in the rat.

Partners reducing effects of diabetes (PREDICT): a diabetes prevention physical activity and dietary intervention through African-American churches.

Type 2 diabetes is epidemic in the United States with greater incidence rates in African-American communities. Lifestyle interventions during the phase of insulin resistance mitigate cardiovascular risk and prevent diabetes. The primary aim of this study is to test the impact of a Community Health Advisor (CHA)-based diabetes prevention controlled intervention in urban African-American communities. In this controlled trial, church congregants in New Haven, CT, receiving a 1-year CHA-led diabetes prevention intervention were compared with church congregants in Bridgeport, CT, who did not receive an intervention. Outcome measures included physical activity, dietary pattern, anthropometric measure, social support, diabetes knowledge, nutrition and exercise self-efficacy. The results indicate that at the end of the 1-year intervention period, there were no significant differences observed between intervention and control groups. Possible explanations for the lack of change include difficulty in engaging the CHAs, variability in the CHA-led interventions, baseline discrepancies between the two sites which could not be fully controlled and loss to follow-up. The results indicate important obstacles which impeded the successful implementation of this intervention and lessons learned for future interventions.

Evidence for functional alterations in the skeletal muscle mechanoreflex and metaboreflex in hypertensive rats.

Exercise in hypertensive individuals elicits exaggerated increases in mean arterial pressure (MAP) and heart rate (HR) that potentially enhance the risk for adverse cardiac events or stroke. Evidence suggests that exercise pressor reflex function (EPR; a reflex originating in skeletal muscle) is exaggerated in this disease and contributes significantly to the potentiated cardiovascular responsiveness. However, the mechanism of EPR overactivity in hypertension remains unclear. EPR function is mediated by the muscle mechanoreflex (activated by stimulation of mechanically sensitive afferent fibers) and metaboreflex (activated by stimulation of chemically sensitive afferent fibers). Therefore, we hypothesized the enhanced cardiovascular response mediated by the EPR in hypertension is due to functional alterations in the muscle mechanoreflex and metaboreflex. To test this hypothesis, mechanically and chemically sensitive afferent fibers were selectively activated in normotensive Wistar-Kyoto (WKY) and spontaneously hypertensive (SHR) decerebrate rats. Activation of mechanically sensitive fibers by passively stretching hindlimb muscle induced significantly greater increases in MAP and HR in SHR than WKY over a wide range of stimulus intensities. Activation of chemically sensitive fibers by administering capsaicin (0.01-1.00 microg/100 microl) into the hindlimb arterial supply induced increases in MAP that were significantly greater in SHR compared with WKY. However, HR responses to capsaicin were not different between the two groups at any dose. This data is consistent with the concept that the abnormal EPR control of MAP described previously in hypertension is mediated by both mechanoreflex and metaboreflex overactivity. In contrast, the previously reported alterations in the EPR control of HR in hypertension may be principally due to overactivity of the mechanically sensitive component of the reflex.

The group IV afferent neuron expresses multiple receptor alterations in cardiomyopathyic rats: evidence at the cannabinoid CB1 receptor.

The exercise pressor reflex (EPR) is an important neural mechanism that controls blood pressure and heart rate during static muscle contraction. It has been previously demonstrated that the EPR is exaggerated in cardiomyopathy. Both mechanically (group III) and metabolically (group IV) sensitive afferent neurons are important to this reflex in normal humans and animals. In cardiomyopathy, however, the metabolically sensitive afferents are less responsive to activation whereas the mechanically sensitive fibres are overactive. We have demonstrated that this overactivity is responsible for the exaggeration in the EPR. Of importance, we have also demonstrated that the reduced responsiveness in the group IV afferent neuron is an initiating factor in the development of the exaggerated EPR. To date, the mechanism mediating this reduced group IV responsiveness remains unclear. Given that group IV afferent neurons are activated via chemically sensitive receptors, it is logical to suggest that changes in receptor function are responsible for the blunted behaviour of group IV neurons in cardiomyopathy. In order to test this postulate, however, potential receptor candidates must first be identified. The transient receptor potential vanilloid 1 (TRPv1) receptor is a non-selective cation channel that serves as a marker of the group IV afferent neurons in the periphery. We have demonstrated that the TRPv1 is abnormal in cardiomyopathy. It has been shown that the TRPv1 receptor is colocalized with the cannabinoid 1 (CB(1)) receptor on group IV afferent neurons. Therefore, we hypothesized that the function of CB(1) receptors is abnormal in cardiomyopathy. We explored this possibility by using anandamide (AEA), an endogenously produced cannabinoid that has been shown to control blood pressure via activation of the CB(1) receptor. In these studies, we evaluated the cardiovascular responses to intra-arterial injection of AEA into the hindlimb of normal, cardiomyopathic and neonatally capsaicin-treated (NNCAP) rats (rats that lack group IV afferent neurons) to determine whether administration of AEA results in abnormal responses of group IV afferent neurons in cardiomyopathic rats. We determined that AEA controls changes in blood pressure, predominately via activation of the CB(1) receptor in this preparation. We further observed that the blood pressure response to AEA is blunted in cardiomyopathic rats when compared to normal rats. We also observed a reduced blood pressure response to AEA in NNCAP animals, indicating that AEA is acting on group IV afferent neurons in this preparation. To determine whether programmed cell death could account for the decreased responsiveness that we observed during activation of the CB(1) and TRPv1 receptors on group IV afferent neurons in heart failure, we performed terminal deoxynucleotidyl transferase-mediated dUTP nick end-labelling (TUNEL) assay. We observed no evidence of cell death within the dorsal root ganglia in rats with cardiomyopathy. The data suggest that the responsiveness of CB(1) receptors on group IV afferent neurons is blunted in cardiomyopathy. Importantly, these data indicate that group IV primary afferent neurons express multiple receptor defects in cardiomyopathy that may contribute to the decreased CB(1) receptor sensitivity in this disease.

Viscerosomatic interaction induced by myocardial ischemia in conscious dogs.

Studies tested the hypothesis that myocardial ischemia induces increased paraspinal muscular tone localized to the T(2)-T(5) region that can be detected by palpatory means. This is consistent with theories of manual medicine suggesting that disturbances in visceral organ physiology can cause increases in skeletal muscle tone in specific muscle groups. Clinical studies in manual and traditional medicine suggest this phenomenon occurs during episodes of myocardial ischemia and may have diagnostic potential. However, there is little direct evidence of a cardiac-somatic mechanism to explain these findings. Chronically instrumented dogs [12 neurally intact and 3 following selective left ventricular (LV) sympathectomy] were examined before, during, and after myocardial ischemia. Circumflex blood flow (CBF), left ventricular contractile function, electromyographic (EMG) analysis, and blinded manual palpatory assessments (MPA) of tissue over the transverse spinal processes at segments T(2)-T(5) and T(11)-T(12) (control) were performed. Myocardial ischemia was associated with a decrease in myocardial contractile function and an increase in heart rate. MPA revealed increases in muscle tension and texture/firmness during ischemia in the T(2)-T(5) segments on the left, but not on the right or in control segments. EMG demonstrated increased amplitude for the T(4)-T(5) segments. After LV sympathectomy, MPA and EMG evidence of increased muscle tone were absent. In conclusion, myocardial ischemia is associated with significant increased paraspinal muscle tone localized to the left side T(4)-T(5) myotomes in neurally intact dogs. LV sympathectomy eliminates the somatic response, suggesting that sympathetic neural traffic between the heart and somatic musculature may function as the mechanism for the interaction.

Reparative myocardial mechanisms in adult C57BL/6 and MRL mice following injury.

Previous studies have suggested that the heart may be capable of limited repair and regeneration in response to a focal injury, while other studies indicate that the mammalian heart has no regenerative capacity. To further explore this issue, we performed a series of superficial and transmural myocardial injuries in C57BL/6 and MRL/MpJ adult mice. At defined time intervals following the respective injury (days 3, 14, 30 and 60), we examined cardiac function using echocardiography, morphology, fluorescence-activated cell sorting for 5-bromo-2-deoxyuridine-positive cells and molecular signature using microarray analysis. We observed restoration of myocardial function in the superficial MRL cryoinjured heart and significantly less collagen deposition compared with the injured hearts of C57BL/6 mice. Following a severe transmural myocardial injury, the MRL mouse has increased survival and decreased ventricular remodeling compared with the C57BL/6 mouse but without evidence of complete regeneration. The cytoprotective program observed in the severely injured MRL heart is in part due to increased cellular proliferation, increased vasculogenesis, and decreased apoptosis that limits the extension of the injury. We conclude that MRL injured hearts have evidence of myocardial regeneration, in response to superficial injury, but the stabilized left ventricular function and improved survival observed in the MRL mouse following severe injury is not associated with complete myocardial regeneration.

Exercise pressor reflex function is altered in spontaneously hypertensive rats.

In hypertension, exercise elicits excessive elevations in mean arterial pressure (MAP) and heart rate (HR) increasing the risk for adverse cardiac events and stroke during physical activity. The exercise pressor reflex (a neural drive originating in skeletal muscle), central command (a neural drive originating in cortical brain centres) and the tonically active arterial baroreflex contribute importantly to cardiovascular control during exercise. Each of these inputs potentially mediates the heightened cardiovascular response to physical activity in hypertension. However, given that exercise pressor reflex overactivity is known to elicit enhanced circulatory responses to exercise in disease states closely related to hypertension (e.g. heart failure), we tested the hypothesis that the exaggerated cardiovascular response to exercise in hypertension is mediated by an overactive exercise pressor reflex. To test this hypothesis, we used a rat model of exercise recently developed in our laboratory that selectively stimulates the exercise pressor reflex independent of central command and/or the arterial baroreflex. Activation of the exercise pressor reflex during electrically induced static muscle contraction in the absence of input from central command resulted in significantly larger increases in MAP and HR in male spontaneously hypertensive rats as compared to normotensive Wistar-Kyoto rats over a wide range of exercise intensities. Similar findings were obtained in animals in which input from both central command and the arterial baroreflex were eliminated. These findings suggest that the enhanced cardiovascular response to exercise in hypertension is mediated by an overactive exercise pressor reflex. Potentially, effective treatment of exercise pressor reflex dysfunction may reduce the cardiovascular risks associated with exercise in hypertension.

The capsaicin-sensitive afferent neuron in skeletal muscle is abnormal in heart failure.

BACKGROUND: In heart failure, the cardiovascular response to activation of the skeletal muscle exercise pressor reflex (EPR) is exaggerated. Group IV afferent neurons, primarily stimulated by the metabolic by-products of skeletal muscle work, contribute significantly to the EPR. Therefore, it was postulated that alterations in the activity of group IV neurons contribute to the EPR dysfunction manifest in heart failure. METHODS AND RESULTS: Group IV afferent fibers were ablated in neonatal Sprague-Dawley rats by subcutaneous administration of capsaicin. In neonatal capsaicin-treated adult animals, selective activation of the EPR, by electrically induced static muscle contraction, recapitulated the exaggerated increases in heart rate and blood pressure observed in rats with dilated cardiomyopathy (DCM). Furthermore, compared with control animals, both neonatal capsaicin-treated and DCM rats displayed a decreased pressor response to the intra-arterial administration of capsaicin within the hindlimb, a maneuver that selectively excites group IV afferent neurons. Moreover, expression of mRNA for the capsaicin receptor TRPv1, a marker of group IV fibers, was downregulated in DCM animals compared with controls. CONCLUSIONS: These findings suggest that EPR dysfunction in heart failure results in part from functional and molecular alterations in group IV fibers. Furthermore, the responsiveness of these metabolically sensitive neurons appears to be blunted in DCM, indicating that their contribution to the EPR may be reduced. This occurs despite an overall exaggeration of the EPR in heart failure. These insights into the basic mechanisms of EPR dysfunction are essential to the development of effective therapeutic strategies aimed at improving exercise capacity in heart failure.