Assessing health behavior change and comparing remote, hybrid and in-person implementation of a school-based health promotion and coaching program for adolescents from low-income communities.

To assess the impact of a school-based health intervention on adolescents' health knowledge, psychosocial assets and health behaviors, including comparisons of implementation mode: remote, hybrid or in-person. The Stanford Youth Diabetes Coaches Program, an 8-week, school-based health promotion and coaching skills program, was offered to adolescents (ages 14-18 years) from four low-income US communities. Mode of program implementation was remote, hybrid or in-person. Participants completed online pre- and postsurveys. Analysis included paired t-tests, linear regression and qualitative coding. From Fall 2020 to Fall 2021, 262 adolescents enrolled and 179 finished the program and completed pre- and postsurveys. Of the 179, 80% were female, with a mean age of 15.9 years; 22% were Asian; 8% were Black or African American; 25% were White; and 40% were Hispanic. About 115 participants were remote, 25 were hybrid and 39 were in-person. Across all participants, significant improvements (P < 0.01) were reported in health knowledge, psychosocial assets (self-esteem, self-efficacy and problem-solving) and health behaviors (physical activity, nutrition and stress reduction). After adjusting for sex and age, these improvements were roughly equivalent across the three modes of delivery. Participation was associated with significant improvements in adolescent health behaviors. Furthermore, remote mode of instruction was just as effective as in-person and hybrid modes.

Influence of Fluorescence Lifetime Selections and Conformational Flexibility on Brightness of FusionRed Variants.

Fluorescent proteins (FPs) for bioimaging are typically developed by screening mutant libraries for clones with improved photophysical properties. This approach has resulted in FPs with high brightness, but the mechanistic origins of the improvements are often unclear. We focused on improving the molecular brightness in the FusionRed family of FPs with fluorescence lifetime selections on targeted libraries, with the aim of reducing nonradiative decay rates. Our new variants show fluorescence quantum yields of up to 75% and lifetimes >3.5 ns. We present a comprehensive analysis of these new FPs, including trends in spectral shifts, photophysical data, photostability, and cellular brightness resulting from codon optimization. We also performed all-atom molecular dynamics simulations to investigate the impact of side chain mutations. The trajectories reveal that individual mutations reduce the flexibility of the chromophore and side chains, leading to an overall reduction in nonradiative rates.

Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic.

BACKGROUND: Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond. METHODS: The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding. RESULTS: Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation. CONCLUSIONS: Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.

Conformational Dynamics of mCherry Variants: A Link between Side-Chain Motions and Fluorescence Brightness.

The 3-fold higher brightness of the recently developed mCherry-XL red fluorescent protein (FP) compared to its progenitor, mCherry, is due to a significant decrease in the nonradiative decay rate underlying its increased fluorescence quantum yield. To examine the structural and dynamic role of the four mutations that distinguish the two FPs and closely related variants, we employed microsecond time scale, all-atom molecular dynamics simulations. The simulations revealed that the I197R mutation leads to the formation of multiple hydrogen-bonded contacts and increased rigidity of the ß-barrel. In particular, mCherryXL showed reduced nanosecond time scale breathing of the gap between the ß7 and ß10-strands, which was previously shown to be the most flexible region of mCherry. Together with experimental results, the simulations also reveal steric interactions of residue 161 and a network of hydrogen-bonding interactions of the chromophore with residues at positions 59, 143, and 163 that are critical in perturbing the chromophore electronic structure. Finally, we shed light on the conformational dynamics of the conserved residues R95 and S146, which are hydrogen-bonded to the chromophore, and provide physical insights into the observed photophysics. To the best of our knowledge, this is the first study that evaluates the conformational space for a set of closely related FPs generated by directed evolution.

Increasing patient activation scores of vulnerable youth by partnering medical residency programs with public high schools.

OBJECTIVE: To assess whether participation in Stanford Youth Coaches Programs (SYCP) increases patient activation scores and patient activation levels for vulnerable youth from low income communities. METHODS: From 2016 to 18, seven high schools and four residency programs in California, Alabama, Kansas and Missouri participated in SYCPs. Enrolled youth participants completed online pre and post-participation surveys including the Patient Activation Measure (PAM®10). We used paired T-tests, chi square tests, and linear multivariate models to compare pre-and post-scores and levels. RESULTS: 143 participants completed pre- and post-participation surveys. The PAM®10 mean pre-test score was 64.5 and post-test was 69.37, with mean difference 4.89 (p=.002). Participants showed significant improvement in patient activation levels after participation. 60 % participants in lowest activation Level 1; 63 % in Level 2; and 32 % in Level 3 moved to a higher level of activation after participation; 46 % who started in Level 4 moved down to Level 3 after participation. CONCLUSION AND PRACTICE IMPLICATIONS: Participation in SYCPs has potential to significantly increase patient activation for vulnerable youth which could lead to lifelong improvements in health outcomes and decrease in healthcare costs.

Engineering of a Brighter Variant of the FusionRed Fluorescent Protein Using Lifetime Flow Cytometry and Structure-Guided Mutations.

The development of fluorescent proteins (FPs) has revolutionized biological imaging. FusionRed, a monomeric red FP (RFP), is known for its low cytotoxicity and correct localization of target fusion proteins in mammalian cells but is limited in application by low fluorescence brightness. We report a brighter variant of FusionRed, "FR-MQV," which exhibits an extended fluorescence lifetime (2.8 ns), enhanced quantum yield (0.53), higher extinction coefficient (∼140 000 M-1 cm-1), increased radiative rate constant, and reduced nonradiative rate constant with respect to its precursor. The properties of FR-MQV derive from three mutations-M42Q, C159V, and the previously identified L175M. A structure-guided approach was used to identify and mutate candidate residues around the para-hydroxyphenyl and the acylimine sites of the chromophore. The C159V mutation was identified via lifetime-based flow cytometry screening of a library in which multiple residues adjacent to the para-hydroxyphenyl site of the chromophore were mutated. The M42Q mutation is located near the acylimine moiety of the chromophore and was discovered using site-directed mutagenesis guided by X-ray crystal structures. FR-MQV exhibits a 3.4-fold higher molecular brightness and a 5-fold increase in the cellular brightness in HeLa cells [based on fluorescence-activated cell sorting (FACS)] compared to FusionRed. It also retains the low cytotoxicity and high-fidelity localization of FusionRed, as demonstrated through assays in mammalian cells. These properties make FR-MQV a promising template for further engineering into a new family of RFPs.

Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout.

Importance: Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs). Objectives: To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem. Design, Setting, and Participants: This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019. Main Outcomes and Measures: Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions. Results: Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (ß̂ = 1.26; P < .001), control of workload (for optimal control: ß̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (ß̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout. Conclusions and Relevance: Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.

The electronic elephant in the room: Physicians and the electronic health record.

OBJECTIVES: Determine the specific aspects of health information and communications technologies (HICT), including electronic health records (EHRs), most associated with physician burnout, and identify effective coping strategies. MATERIALS AND METHODS: We performed a qualitative analysis of transcripts from 2 focus groups and a burnout assessment of ambulatory physicians-each at 3 different health care institutions with 3 different EHRs. RESULTS: Of the 41 clinicians, 71% were women, 98% were physicians, and 73% worked in primary care for an average of 11 years. Only 22% indicated sufficient time for documentation. Fifty-six percent noted "a great deal of stress" because of their job. Forty-two percent reported "poor" or "marginal" control over workload. Even though 90% reported EHR proficiency, 56% indicated EHR time at home was "excessive" or "moderately high." Focus group themes included HICT "successes" where all patients' information is accessible from multiple locations. HICT "stressors" included inefficient user interfaces, unpredictable system response times, poor interoperability between systems and excessive data entry. "Adverse outcomes" included ergonomic problems (eg, eye strain and hand, wrist, and back pain) and decreased attractiveness of primary care. Suggested "organizational changes" included EHR training, improved HICT usability, and scribes. "Personal/resilience" strategies focused on self-care (eg, exercise, maintaining work-life boundaries, and positive thinking). DISCUSSION AND CONCLUSION: HICT use, while beneficial in many ways for patients and providers, has also increased the burden of ambulatory practice with personal and professional consequences. HICT and clinic architectural and process redesign are likely necessary to make significant overall improvements.

Supporting At-Risk Youth and Their Families to Manage and Prevent Diabetes: Developing a National Partnership of Medical Residency Programs and High Schools.

BACKGROUND: The Stanford Youth Diabetes Coaches Program (SYDCP) is a school based health program in which Family Medicine residents train healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. This study evaluates the impact of the SYDCP when disseminated to remote sites. Additionally, this study aims to assess perceived benefit of enhanced curriculum. METHODS: From 2012-2015, 10 high schools and one summer camp in the US and Canada and five residency programs were selected to participate. Physicians and other health providers implemented the SYDCP with racial/ethnic-minority students from low-income communities. Student coaches completed pre- and posttest surveys which included knowledge, health behavior, and psychosocial asset questions (i.e., worth and resilience), as well as open-ended feedback questions. T-test pre-post comparisons were used to determine differences in knowledge and psychosocial assets, and open and axial coding methods were used to analyze qualitative data. RESULTS: A total of 216 participating high school students completed both pre-and posttests, and 96 nonparticipating students also completed pre- and posttests. Student coaches improved from pre- to posttest significantly on knowledge (p<0.005 in 2012-13, 2014 camp, and 2014-15); worth (p<0.1 in 2014-15); problem solving (p<0.005 in 2014 camp and p<0.1 in 2014-15); and self-efficacy (p<0.05 in 2014 camp). Eighty-two percent of student coaches reported that they considered making a behavior change to improve their own health as a result of program participation. Qualitative feedback themes included acknowledgment of usefulness and relevance of the program, appreciation for physician instructors, knowledge gain, pride in helping family members, improved relationships and connectedness with family members, and lifestyle improvements. CONCLUSION: Overall, when disseminated, this program can increase health knowledge and some psychosocial assets of at-risk youth and holds promise to empower these youth with health literacy and encourage them to adopt healthy behaviors.

Service-Based Learning for Residents: A Success for Communities and Medical Education.

BACKGROUND AND OBJECTIVES: Community-based service-learning opportunities could support residents' acquisition of Accreditation Council for Graduate Medical Education (ACGME) competencies, but this concept has not been tested, and such programs are difficult to find. The objective of this work was to assess the value and the ACGME competency relevance of a service-learning program for residents that could be easily replicated nationally. METHODS: Forty-one family medicine residents from three training programs participated in the Stanford Youth Diabetes Coaches Program at six high schools in California and Georgia serving minority students of low socioeconomic status. Residents completed online surveys to provide qualitative feedback and assess the program's impact on their acquisition of residency program competencies and self-management support proficiencies, including prior use and planned use of action plans-a key self-management support strategy. RESULTS: Ninety-five percent of residents indicated that the program was a valuable experience that contributed to acquisition of residency program competencies, including interpersonal and communication skills and communication with teens. Compared with baseline, significantly more residents reported intention to use action plans with patients following participation. Themes from qualitative feedback included: valuing the overall experience, increasing opportunities to practice teaching, enhancing their ability to communicate with adolescents, contributing to the health of the community, recognizing the potential of action plans, and increasing intent to use action plans. CONCLUSIONS: This pilot demonstrated that a brief service-learning program can enhance standard residency curriculum by encouraging acquisition of ACGME competencies and promoting utilization of self-management support in clinical practice.

Persistent shifts in Caribbean coral microbiota are linked to the 2010 warm thermal anomaly.

The response of corals to warm temperature anomalies includes changes in coral bacterial assemblages. There are clear differences between the microbiota of bleached and healthy corals. However, few studies have tracked the microbiota of individual colonies throughout a warming event. We used 454 pyrosequencing and repeated measures to characterize bacterial assemblages in 15 Gorgonia ventalina colonies before, during, 4 months after, and 1 year after the 2010 Caribbean warm thermal anomaly. In the latter three sampling times, the G. ventalina microbiota differed significantly from the microbiota of Orbicella faveolata colonies, which were sampled only at these three times. O. faveolata microbiota did not exhibit coordinated shifts through time. Notably, the microbiota of the repeatedly sampled G. ventalina colonies shifted persistently from before to during, after, and long after the warming event. The same pattern emerges from the norm of reaction for the individual G. ventalina colonies. This is the first study to show persistent shifts in coral microbiota in association with a warm thermal anomaly. Whether shifting microbiota is adaptive or maladaptive, the lasting change in bacterial assemblages following this warming event identifies a new way that coral microbiota shape the response of coral colonies under thermal stress.

Training at-risk youth to become diabetes self-management coaches for family members: partnering family medicine residents with underserved schools.

PURPOSE: The purpose of this study is to evaluate the impact of a school-based health program in which family medicine residents trained healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. METHODS: A mixed methods study included 97 adolescents from 3 San Francisco Bay Area high schools serving primarily ethnic minority youth of low socioeconomic status. Physicians came to schools once a week for 8 weeks and trained 49 adolescents to become coaches. Student coaches and 48 nonparticipant students completed pre- and posttest intervention questionnaires, and 15 student coaches and 9 family members with diabetes gave in-depth interviews after participation. Linear regression was used to determine differences in knowledge and psychosocial assets on pre- and posttests between student coaches and nonparticipant students, and NVIVO was used to analyze interview transcripts. RESULTS: After controlling for initial score, sex, grade, and ethnicity, student coaches improved from pre- to posttest significantly compared to nonparticipants on knowledge, belonging, and worth scales. Student coaches reported high satisfaction with the program. Articulated program benefits included improvement in diet, increased physical activity, and improved relationship between student coach and family member. CONCLUSIONS: Overall, this program can increase diabetes knowledge and psychosocial assets of at-risk youth, and it holds promise to promote positive health behaviors among at-risk youth and their families.

Friend or foe: the association of Labyrinthulomycetes with the Caribbean sea fan Gorgonia ventalina.

A new syndrome in sea fans Gorgonia ventalina consisting of multifocal purple spots (MFPS) has been observed in the Caribbean Sea. Surveys of MFPS on sea fans were conducted from 2006 to 2010 at a shallow and deep site in La Parguera, Puerto Rico (PR). At the shallow site, MFPS increased between 2006 and 2010 (site average ranged from 8 to 23%), with differences found at depths over time using an analysis of covariance (ANCOVA, p < 0.0001). As a potential causative agent we examined a Labyrinthulomycota-like ovoid parasite that was observed to be abundant in MFPS lesions in light micrographs. Labyrinhylomycetes were successfully isolated, cultured and characterized in sea fans from Florida and PR. Sequence information obtained from the small subunit (SSU) rRNA gene indicated that Labyrinthulomycetes in most sea fans (healthy and MFPS sea fans from Florida; MFPS from PR) and the cultured microorganism are in the genus Aplanochytrium, although some healthy sea fans from PR contained members of the genus Thraustochytrium. Both genera fall within the family Thraustochytriidae. Histology confirmed observations of thraustochytrids within apparently healthy and MFPS sea fans from PR, and specific staining indicated a host melanization response only in colonies containing Labyrinthulomycetes or fungal infections. Growth trials indicate that the temperature-growth optima for the cultured microorganism is ~30°C. In inoculation experiments, the cultured Aplanochytrium did not induce purple spots, and histology revealed that many of the apparently healthy recipients contained Labyrinthulomycetes prior to inoculation. Taken together, these results indicate that the Labyrinthulomycetes associated with sea fans is likely an opportunistic pathogen. Further studies are needed to understand the pathogenesis of this microorganism in sea fans and its relationship with MFPS.

Dual roles for Mcm10 in DNA replication initiation and silencing at the mating-type loci.

Recent studies linking DNA replication proteins to transcriptional silencing suggest that some of the same mechanisms that facilitate the initiation of replication at origins might be involved in establishing repressed chromatin at silencer elements. Our ongoing studies of several mutants of the replication initiation factor Mcm10 of budding yeast revealed an associated defect in the production of mating type pheromones. This observation prompted us to look more directly at the effect of MCM10 mutations on the expression of a reporter gene in the mating type locus and to assay for physical interactions between Mcm10 and known silencing factors. Our findings, that Mcm10 mutants disrupt mating loci silencing and that Mcm10 interacts with Sir2 and Sir3, suggest that Mcm10 also plays an essential, and separable role in transcriptional silencing.

Issues in caring for Afghan American elders: insights from literature and a focus group.

OBJECTIVES: To increase the information available for clinicians and educators to care for, and educate others to care for, elders from Afghan backgrounds more effectively. DESIGN: Focus group methodology. SETTING: Community senior center in Fremont, CA, United States. PARTICIPANTS: Nine leaders of an Afghan elders group. MEASUREMENTS: Content analysis of translated proceedings of focus group. RESULTS: The two most important themes were: 1) Participants identified their health status and effective treatments with their faith in, and practice of, Islam. 2) They also emphasized the importance of care given by same-sex providers. CONCLUSION: Clinicians providing care for older Afghan refugees need to be aware of the importance of respecting the practices of Islam, especially using same sex providers. Allowing for Muslim practices in the hospital is also important, such as washing before daily prayers, not serving pork products (e.g. gelatin), and having the bed face Mecca (Southeast) for prayers, especially for a dying patient.