Diabetes-Related Quality of Life: Learning From Individuals Making Lifestyle Changes to Improve Type 2 Diabetes Control.

PURPOSE: The purpose of this study was to explore how treatment adherence and lifestyle changes required for glycemic control in type 2 diabetes (T2D) are related to quality of life (QoL) among predominantly ethnic minority and socioeconomically disadvantaged adults engaged in making changes to improve T2D self-management. METHODS: Adults with T2D in New York City were recruited for the parent study based on recent A1C (≥7.5%) and randomly assigned to 1 of 2 arms, receiving educational materials and additional self-management support calls, respectively. Substudy participants were recruited from both arms after study completion. Participants (N = 50; 62% Spanish speaking) were interviewed by phone using a semistructured guide and were asked to define QoL and share ways that T2D, treatment, self-management, and study participation influenced their QoL. Interviews were analyzed using thematic analysis. RESULTS: QoL was described as a multidimensional health-related construct with detracting and enhancing factors related to T2D. Detracting factors included financial strain, symptom progression and burden, perceived necessity to change cultural and lifestyle traditions, and dietary and medical limitations. Enhancing factors included social support, diabetes education, health behavior change, sociocultural connection. CONCLUSION: QoL for diverse and socioeconomically disadvantaged adults with T2D is multifaceted and includes aspects of health, independence, social support, culture, and lifestyle, which may not be captured by existing QoL measures. Findings may inform the development of a novel QoL measure for T2D.

Ecotoxicological assessment of the effects of fluoxetine on Daphnia magna based on acute toxicity, multigenerational reproduction effects, and attraction-repellence responses.

Fluoxetine, a common pharmaceutical used as an antidepressant, is already considered potentially hazardous to biota due to its increasing use and detection in European, North American, and Asian rivers. We studied the effects of fluoxetine on Daphnia magna, as we hypothesized that fluoxetine might have harmful effects, short and long-term, at different levels: survival, behaviour, and reproduction (offspring production). We applied two different approaches: (i) a scenario at environmentally relevant concentrations (0.1-1.0 µg/L) and (ii) a scenario simulating a future worsening of contamination (1-800 µg/L) until the reach of lethal concentrations. In the former, we examined whether there are multigenerational effects on reproduction and on the avoidance/colonisation behaviour in previously exposed populations. In the latter, three responses were assessed: survival, avoidance behaviour and reproduction. We did not detect differences in the reproduction output of D. magna among the treatments over the three generations examined. Irrespective of the multigenerational treatment, D. magna colonised the environments with fluoxetine in a similar way. In the second scenario, we determined the lethal concentration for 50% of the population (96 h-LC50 = 365 µg/L), which, in spite of the toxic effect, was attractive to organisms during the avoidance tests (24 h); in fact, D. magna were attracted (no repellence) even to the highest concentrations of fluoxetine tested (800 µg/L). Lastly, in a 21-day chronic toxicity test the reproduction output of D. magna increased with higher concentrations of fluoxetine. This effect might be related to the fact that the organisms in the contaminated treatment began their first reproduction earlier, when compared to that in the control treatments. In conclusion, this study discusses an identified hazard for aquatic biota due to the fluoxetine attraction effect and a predictive assessment of the consequences expected if its indiscriminate use increases.

Building and Sustaining Community Partnerships: An Organizational Network Analysis in a Low-resource Neighborhood.

BACKGROUND: Launched in 2012, the Claremont Healthy Village Initiative (CHVI) is a partnership focused on fostering community collaboration, addressing the social determinants of health, and reducing health disparities. Partners include local community centers, schools, after-school programs, health care providers, a health insurer, city agencies, tenant associations, resident leaders, elected officials, and other stakeholders. OBJECTIVES: To understand the development and value of collaboration within the CHVI from the perspective of multiple partners. METHODS: Using a community-based participatory research approach, we worked collaboratively with the CHVI leaders, we used paper-and web-based surveys grounded in social network theory were administered in 2017 and 2018. Questions focused on relationships between organizations that are part of the coalition. Our analysis included responses from organizations that participated in the survey at both points in time. Network measures such as density, degree centrality, and node characteristics were used to understand information sharing, referral, and collaboration among the participating organizations. Additional data included stake-holder interviews. RESULTS: Coalition partners increased connectedness with one another over the course of the study, with significantly greater density of relationship and bi-directional partnerships in the follow-up survey. Of the three types of interactions, referrals showed a trend for highest density change. Trust levels were highest among organizations with a local physical presence. CONCLUSIONS: Social network analysis provided visual and quantitative information that helped reinforce relationships and identify opportunities to improve connectedness and collaboration among diverse community partners, helping to support the coalition's goals and objectives.

Distinct cell proliferation patterns underlying the development of defensive crests in Daphnia longicephala.

The freshwater crustacean Daphnia is well known for its expression of morphological defenses in the presence of predators. Research into this phenomenon has mostly centered on the ecology and evolution of Daphnia defenses; information is limited on the cellular mechanisms that underlie site-specific tissue growth. We aimed to determine these cellular mechanisms, specifically those associated with the development of defensive crests in D. longicephala. With the help of a cell-proliferation assay we monitored changes in the epidermal tissue of naïve and predator-exposed D. longicephala. Based on our results, we propose that cell division is delayed in favor of cell growth, which results in crest formation. Further, we identify specific regions of proliferative activity in a time-dependent manner. Defense development starts in the ventral region, before extending in the cranial and then dorsal directions. We demonstrate that these cellular changes begin as early as 2 h after predator exposure. Our results provide new insights into the cellular processes underlying morphological defense expression in Daphnia.

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research.

BACKGROUND: The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components. METHODS: The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination. RESULTS: There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care. CONCLUSIONS: It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.

Facing the Green Threat: A Water Flea's Defenses against a Carnivorous Plant.

Every ecosystem shows multiple levels of species interactions, which are often difficult to isolate and to classify regarding their specific nature. For most of the observed interactions, it comes down to either competition or consumption. The modes of consumption are various and defined by the nature of the consumed organism, e.g., carnivory, herbivory, as well as the extent of the consumption, e.g., grazing, parasitism. While the majority of consumers are animals, carnivorous plants can also pose a threat to arthropods. Water fleas of the family Daphniidae are keystone species in many lentic ecosystems. As most abundant filter feeders, they link the primary production to higher trophic levels. As a response to the high predatory pressures, water fleas have evolved various inducible defenses against animal predators. Here we show the first example, to our knowledge, in Ceriodaphnia dubia of such inducible defenses of an animal against a coexisting plant predator, i.e., the carnivorous bladderwort (Utricularia x neglecta Lehm, Lentibulariaceae). When the bladderwort is present, C. dubia shows changes in morphology, life history and behavior. While the morphological and behavioral adaptations improve C. dubia's survival rate in the presence of this predator, the life-history parameters likely reflect trade-offs for the defense.

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.

BACKGROUND: The 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting. METHODS: TOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination). RESULTS: PCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs). CONCLUSIONS: CDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health. Trial registration https://clinicaltrials.gov/ct2/show/NCT03669939 . Registration date: 9/13/2018.

Toward safer opioid prescribing: effects of the TOWER intervention on HIV care providers.

ABSTRACTRates of opioid use disorder and associated deaths remain alarmingly high. Measures to address the epidemic have included reductions in opioid prescribing, in part guided by the Centers for Disease Control Opioid Prescribing Guideline (CDCG). While reductions in over-prescribing have occurred, these measures have also resulted in decreased access and adverse outcomes for some stable opioid-treated chronic pain patients. The TOWard SafER Opioid Prescribing (TOWER) intervention was designed to support HIV primary care providers in use of the CDCG and in decision-making and patient-provider communication regarding safe opioid prescribing. Eleven HIV primary care providers and 40 of their patients were randomized into intervention and control groups. Transcripts from 21 patient visits were analyzed, focusing on opioid and pain-related communications. Findings from this research indicate greater alignment with the CDCG among visits carried out with providers in the TOWER intervention group. However, control group visits were notably consistent with guideline recommendations in several key areas. Differences observed between the intervention and control group visits demonstrate intervention strengths, as well as areas where additional work needs to be done to ensure prescribing and communication consistent with the CDCG.

Using Public Deliberation to Set Priorities: The Case of COVID-19 Vaccine Access in New York City.

CONTEXT: The COVID-19 pandemic has resulted in a record number of deaths in the United States and tremendous economic and personal strain. During 2020, in anticipation of a vaccine to slow the spread of disease, local and state governments in the United States developed plans for vaccine prioritization, given a limited initial supply. Recognizing the challenges inherent in prioritization, the New York City (NYC) health department sought guidance from members of the public about the fairest approach to early-stage vaccine distribution. OBJECTIVE: To solicit recommendations from NYC residents on priorities regarding vaccine access for essential worker occupations, considering risk factors and preferred approaches to fairness. IMPLEMENTATION: Five public deliberations were conducted with NYC residents (N = 91). Participants heard presentations on the COVID-19 vaccine, the local distribution of illness and death, and approaches to fairness in the context of deliberating on priorities for 6 essential worker occupations and 4 risk factors. Discussions were transcribed, and transcriptions were coded and analyzed using preidentified and emergent themes. Pre- and post-surveys, focused on factors relevant to prioritization, were administered during each public deliberation. RESULTS: Recommendations for prioritization emphasized risk of severe morbidity and mortality, and work and neighborhood conditions with fewer protections (eg, in-person work, exposure to many people). Participants prioritized elementary schoolteachers, grocery store workers, and bus drivers, underlying health conditions, and neighborhood of residence. Participants focused on equity, recognizing that those at highest risk were largely low-income populations of color and individuals living in low-resourced neighborhoods. CONCLUSIONS: Participants' focus on equity, and acknowledgment of racial and ethnic disparities, revealed a nuanced understanding of the broader determinants of health. Recommendations reinforced the NYC health department's approach to vaccine distribution. PUBLIC HEALTH IMPLICATIONS: Results from these public deliberations confirmed community support for approaches prioritizing health equity, recognizing both societal and personal factors affecting vulnerability to poor health.

Determining freshwater pCO2 based on geochemical calculation and modelling using PHREEQC.

Fossil fuel combustion results in rising atmospheric carbon dioxide (CO2), which is known to impact the global climate and the oceans. Latest insights indicate that rising atmospheric CO2 levels also affect CO2 partial pressure (pCO2) in freshwaters, where pCO2 is controlled by a multitude of parameters. However, up to date there is no standardized method, which allows the determination of current and past freshwater pCO2 levels. Ideally methods should incorporate numerous hydrogeochemical and -physical factors to reflect the interplay of all interacting components and their effect on pCO2. We here describe the application of the geochemical program PHREEQC. This freeware serves as an easy method enabling a plausible and comprehensive analysis of pCO2 for field, laboratory, and especially long-term data. We present the use of the different input parameters of a laboratory- and a field long-term monitoring dataset including dissociation constants of carbonic acid measured as total inorganic carbon (TIC) and total CO2 concentration (TCO2) or total alkalinity (TA), together with hydrogeochemical and -physical parameters. Based on current literature and our analyses PHREEQC appears a solid strategy to determine freshwater pCO2 that can moreover be used for long-term datasets.•Comprehensive analysis of pCO2 for field, laboratory, and long-term data.•PHREEQC is not dependent on just one sampling method or parameter scheme.•PHREEQC includes testing the plausibility of a water analysis and enables the assessment of the quality of the laboratory analysis, as well as automatic calculation of all relevant aquatic complexes.

Distinct Gene Expression Patterns of Two Heat Shock Protein 70 Members During Development, Diapause, and Temperature Stress in the Freshwater Crustacean Daphnia magna.

Dormancy is a lifecycle delay that allows organisms to escape suboptimal environmental conditions. As a genetically programmed type of dormancy, diapause is usually accompanied by metabolic depression and enhanced tolerance toward adverse environmental factors. However, the drivers and regulators that steer an organism's development into a state of suspended animation to survive environmental stress have not been fully uncovered. Heat shock proteins 70 (HSP70s), which are often produced in response to various types of stress, have been suggested to play a role in diapause. Considering the diversity of the Hsp70 family, different family members may have different functions during diapause. In the present study, we demonstrate the expression of two hsp70 genes (A and B together with protein localization of B) throughout continuous and diapause interrupted development of Daphnia magna. Before and after diapause, the expression of Dmhsp70-A is low. Only shortly before diapause and during diapause, Dmhsp70-A is significantly upregulated and may therefore be involved in diapause preparation and maintenance. In contrast, Dmhsp70-B is expressed only in developing embryos but not in diapausing embryos. During continuous development, the protein of this Hsp70 family member is localized in the cytosol. When we expose both embryo types to heat stress, expression of both hsp70 genes increases only in developing embryos, and the protein of family member B is translocated to the nucleus. In this stress formation, this protein provides effective protection of nucleoplasmic DNA. As we also see this localization in diapausing embryos, it seems that Daphnia embryo types share a common subcellular strategy when facing dormancy or heat shock, i.e., they protect their DNA by HSP70B nuclear translocation. Our study underlines the distinctive roles that different Hsp70 family members play throughout continuous and diapause interrupted development.

Thwarting predators? A three-dimensional perspective of morphological alterations in the freshwater crustacean Daphnia.

Predation is a major selective agent, so that many taxa evolved phenotypically plastic defensive mechanisms. Among them are many species of the microcrustacean genus Daphnia, which respond to an increased predation risk by developing inducible morphological alterations. Some of these features are obvious and easily recognized, e.g., crests in D. longicephala, while others are rather hidden, such as the bulkier shape of D. magna induced by the presence of the tadpole shrimp Triops. In this study we investigated the extraordinary diversity of morphological adaptations in the presence of predators with different foraging strategies in six predator-prey systems. For the first time we were able to analyze the unexposed and predator-exposed morphs comprehensively using three-dimensional scanning and reconstruction. We show that morphological changes are manifold in appearance between species and predators, and go beyond what has been known from previous 2D analyses. This further demonstrates the enormous trait flexibility of Daphnia. Interestingly, we found that among this variety some species share morphological strategies to counter a predator, while others use a different strategy against the same predator. Based on these intra- and interspecific comparisons, we discuss the mechanisms by which the respective defense might operate. These data therefore contribute to a deeper understanding of the inducible defenses' morphology as well as their diversified modes of operation in Daphnia, being a cornerstone for subsequent investigations, including the determination of costs associated with morphological change.

Long-term effects of elevated pCO2 levels on the expression of Chaoborus-induced defences in Daphnia pulex.

Increased carbon dioxide from fossil fuel combustion results in an enrichment of CO2 in the global carbon cycle. Recent evidence indicates that rising atmospheric CO2 impacts the partial pressure of carbon dioxide (pCO2) in freshwaters. This affects freshwater biota by disrupting chemical communication between predator and prey. One such well-described predator-prey interaction is the phantom midge larva Chaoborus preying on the freshwater crustacean Daphnia pulex. To counter Chaoborus predation, D. pulex develops defensive neckteeth in response to chemical cues. The strength of neckteeth expression is reduced when D. pulex experience elevated pCO2 levels. This is discussed to directly impair predator perception and results in reduced defence expression. However, it is not known whether there are also long-term effects associated with continuous elevated pCO2. Here, we investigated the effect of long-term exposure of D. pulex to elevated pCO2 levels in a life-table experiment over three generations. Using a flow-through system, we continuously exposed D. pulex to cues released by the predatory larva Chaoborus and control or elevated pCO2 levels. We determined morphological defence expression in the 2nd juvenile instar and the number of neonates as a measure for life-history traits over three successive generations. We detected that elevated pCO2 significantly reduces the expression of predator-induced morphological defences (i.e. neckteeth) and life-history parameters (i.e. number of neonates) in successive generations. Our data clearly show that at least three generations become more vulnerable to predation without indications of transgenerational acclimation. As Daphnia is a keystone grazer of freshwater ecosystems, this may destabilise population growth rates. In conclusion, long-term effects of pCO2-induced reduction of predator-induced plasticity may significantly affect trophic interactions.

Evaluation of an Integrated Health Promotion Program for a low-income urban population: Findings and lessons learned.

OBJECTIVES: To evaluate a multicomponent pilot program for low-income individuals with, or at risk for, hypertension, diabetes, and/or overweight. DESIGN: Pre-post evaluation including baseline and follow-up assessments, satisfaction surveys, program utilization data, and focus groups. SAMPLE: The evaluation included 138 participants. The majority were Latinx (88%), female (82%), born outside the United States (80%), and had not graduated from high school (52%). The most common health conditions were hypertension (59%), overweight or obesity (55%), high cholesterol (53%), and diabetes (34%). MEASUREMENTS: Engagement in program activities, health indicators (e.g., blood pressure), and behavior change. Qualitative data focused on perceptions of the program and its impacts. INTERVENTION: The program offered a number of health promotion services, including consultation with a nurse and a community health worker (CHW), health and nutrition talks, subsidized farm shares, cooking classes, exercise classes, and home visits. RESULTS: There were improvements in general health, blood pressure, and knowledge and behavior related to disease management and healthy eating. CONCLUSIONS: Program success was attributed to the wide range of complementary program components. The staffing model was also a strength: the CHW/nurse collaboration combined clinical expertise with cultural, language, and community knowledge to create a program that was accessible and empowering.

"Hey, We Can Do This Together": Findings from an Evaluation of a Multi-sectoral Community Coalition.

Multi-sectoral coalitions focused on systemic health inequities are commonly promoted as important mechanisms to facilitate changes with lasting impacts on population health. However, the development and implementation of such initiatives present significant challenges, and evaluation results are commonly inconclusive. In an effort to add to the evidence base, we conducted a mixed-methods evaluation of the Claremont Healthy Village Initiative, a multi-sectoral partnership based in the Bronx, New York City. At an organizational level, there were positive outcomes with respect to expanded services, increased access to resources for programs, improved linkages, better coordination, and empowerment of local leaders-all consistent with a systemic, community building approach to change. Direct impacts on community members were more difficult to assess: perceived access to health and other services improved, while community violence and poor sanitation, which were also priorities for community members, remained important challenges. Findings suggest significant progress, as well as continued need.

The expression of circadian clock genes in Daphnia magna diapause.

Diapause is a mechanism necessary for survival in arthropods. Often diapause induction and resurrection is light-dependent and therefore dependent on the photoperiod length and on the number of consecutive short-days. In many organisms, including the microcrustacean Daphnia magna, one functional entity with the capacity to measure seasonal changes in day-length is the circadian clock. There is a long-standing discussion that the circadian clock also controls photoperiod-induced diapause. We tested this hypothesis in D. magna, an organism which goes into a state of suspended animation with the shortening of the photoperiod. We measured gene expression of clock genes in diapause-destined embryos of D. magna in the initiation, resting and resurrection phases and checked it against gene expression levels of continuously developing embryos. We demonstrate that some genes of the clock are differentially expressed during diapause induction but not during its maintenance. Furthermore, the photoreceptor gene cry2 and the clock-associated gene brp are highly expressed during induction and early diapause, probably in order to produce excess mRNA to prepare for immediate resurrection. After resurrection, both types of embryos show a similar pattern of gene expression during development. Our study contributes significantly to the understanding of the molecular basis of diapause induction, maintenance and termination.

Elevated pCO2 affects behavioural patterns and mechano-sensation in predatory phantom midge larvae Chaoborus obscuripes.

Aquatic acidification is a major consequence of fossil fuel combustion. In marine ecosystems it was shown, that increasing pCO2 levels significantly affect behavioural and sensory capacities in a diversity of species. This can result in altered predator and prey interactions and thereby change community structures. Just recently also CO2 dependent acidification of freshwater habitats has been shown. Also here, increased levels of pCO2 change organisms' behaviour and sensory capacities. For example, the freshwater crustacean Daphnia's ability to detect predators and accurately develop morphological defences was significantly reduced, rendering Daphnia more susceptible to predation. It was speculated that this may have cascading effects on freshwater food webs. However, for a comprehensive understanding of how increased levels of CO2 affect trophic interactions, it is also important to study how CO2 affects predators. We tested this using the dipeteran phantom midge larva Chaoborus obscuripes, which is a world-wide abundant inhabitant of freshwater impoundments. We monitored activity parameters, predation parameters, and predation rate. Chaoborus larvae are affected by increased levels of pCO2 as we observed an increase in undirected movements and at the same time, reduced sensory abilities to detect prey items. This is likely to affect the larvae's energy budgets. Chaoborus is a central component of many freshwater food-webs. Therefore, CO2 effects on predator and prey levels will likely have consequences for community structures.