A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk.

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

"Lock to Live" for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system.

Objective: Few patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications. Methods: Patients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability. Results: The population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support. Conclusion: Despite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

Increasing taxonomic diversity and spatial resolution clarifies opportunities for protecting US imperiled species.

Continental- and regional-scale assessments of gaps in protected area networks typically use relatively coarse range maps for well documented species groups, creating uncertainty about the fate of unexamined biodiversity and providing insufficient guidance for land managers. By building habitat suitability models for a taxonomically diverse group of 2216 imperiled plants and animals, we revealed comprehensive and detailed protection opportunities in the conterminous United States. Summing protection-weighted range-size rarity (PWRSR, the product of the percent of modeled habitat outside of protected areas and the inverse of modeled habitat extent) uncovered novel patterns of biodiversity importance. Concentrations of unprotected imperiled species in places such as the northern Sierra Nevada, central and northern Arizona, the Rocky Mountains of Utah and Colorado, southeastern Texas, southwestern Arkansas, and Florida's Lake Wales Ridge have rarely if ever been featured in continental- and regional-scale analyses. Inclusion of diverse taxa (vertebrates, freshwater mussels, crayfishes, bumble bees, butterflies, skippers, and vascular plants) partially drove these new patterns. When analyses were restricted to groups typically included in previous studies (birds, mammals, and amphibians), up to 53% of imperiled species in other groups were left out. The finer resolution of modeled inputs (990 m) also resulted in a more geographically dispersed pattern. For example, 90% of the human population of the conterminous United States lives within 50 km of modeled habitat for one or more species with high PWRSR scores. Over one-half of the habitat for 818 species occurs within federally lands managed for biodiversity protection; an additional 360 species have over one-half of their modeled habitat on federal multiple use land. Freshwater animals occur in places with poorer landscape condition but with less exposure to climate change than other groups, suggesting that habitat restoration is an important conservation strategy for these species. The results provide fine-scale, taxonomically diverse inputs for local and regional priority-setting and show that although protection efforts are still widely needed on private lands, notable gains can be achieved by increasing protection status on selected federal lands.

Modeling the distribution of the West Nile and Rift Valley Fever vector Culex pipiens in arid and semi-arid regions of the Middle East and North Africa.

BACKGROUND: The Middle East North Africa (MENA) region is under continuous threat of the re-emergence of West Nile virus (WNV) and Rift Valley Fever virus (RVF), two pathogens transmitted by the vector species Culex pipiens. Predicting areas at high risk for disease transmission requires an accurate model of vector distribution, however, most Cx. pipiens distribution modeling has been confined to temperate, forested habitats. Modeling species distributions across a heterogeneous landscape structure requires a flexible modeling method to capture variation in mosquito response to predictors as well as occurrence data points taken from a sufficient range of habitat types. METHODS: We used presence-only data from Egypt and Lebanon to model the population distribution of Cx. pipiens across a portion of the MENA that also encompasses Jordan, Syria, and Israel. Models were created with a set of environmental predictors including bioclimatic data, human population density, hydrological data, and vegetation indices, and built using maximum entropy (Maxent) and boosted regression tree (BRT) methods. Models were created with and without the inclusion of human population density. RESULTS: Predictions of Maxent and BRT models were strongly correlated in habitats with high probability of occurrence (Pearson's r=0.774, r=0.734), and more moderately correlated when predicting into regions that exceeded the range of the training data (r=0.666,r=0.558). All models agreed in predicting high probability of occupancy around major urban areas, along the banks of the Nile, the valleys of Israel, Lebanon, and Jordan, and southwestern Saudi Arabia. The most powerful predictors of Cx. pipiens habitat were human population density (60.6% Maxent models, 34.9% BRT models) and the seasonality of the enhanced vegetation index (EVI) (44.7% Maxent, 16.3% BRT). Maxent models tended to be dominated by a single predictor. Areas of high probability corresponded with sites of independent surveys or previous disease outbreaks. CONCLUSIONS: Cx. pipiens occurrence was positively associated with areas of high human population density and consistent vegetation cover, but was not significantly driven by temperature and rainfall, suggesting human-induced habitat change such as irrigation and urban infrastructure has a greater influence on vector distribution in this region than in temperate zones.

Invasive plant alters ability to predict disease vector distribution.

Risk models for vector-borne diseases rely on accurate quantification of the relationship between vector abundance and habitat, but this relationship can be obscured if habitats are modified by invasive species in ways that alter vector behavior but are undetectable in remotely sensed data. At a forest in eastern Missouri we assessed whether the presence of an invasive shrub, Amur honeysuckle, Lonicera maackii, affects oviposition by treehole mosquitoes, Aedes triseriatus, a primary vector of La Crosse virus in the United States. Oviposition significantly decreased with increasing density of L. maackii. Moreover, our results indicate that L. maackii may hinder the efficacy of models that use remotely sensed data to predict vector abundance: there was a strong relationship between landscape composition around plots and oviposition, but only in plots not invaded by L. maackii. Overlooking potentially important but cryptic effects of invasive plants on habitat selection by vectors may undermine accurate forecasting of disease risk.

Community-based child abuse prevention: outcomes associated with a differential response program in California.

Traditionally, the American child welfare system intervenes in cases of evident and severe maltreatment. Families in need of help, but who have not reached a crisis, are excluded from typical services. Some suggest that if these families were served, few would be rereferred to the child welfare system. California's Differential Response (DR) has three tracks, of which ''Track 1'' targets families screened out of child protective services (CPS) and refers them to agencies that provide voluntary, home-based services and referrals. This study examined child-welfare trajectories for families receiving Track 1 DR services in one California county. Using survival analysis, treatment group children (N = 134) were compared to children eligible for services but denied due to program capacity (comparison group N = 511). Findings suggest no statistically significant differences between groups on the likelihood of a re-report following program participation, timing of maltreatment reports, or report investigations. The ability to draw strong conclusions from this study, however, is limited by selection bias because prior child maltreatment reports were more common in the treatment group. The intervention may provide families with important supports, but evidence for maltreatment prevention may not be supported. Future studies should examine potential effects on a range of family domains.