Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial.

BACKGROUND: Disparities in hypertension control are well documented but underaddressed. METHODS: RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline. RESULTS: A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]). CONCLUSIONS: Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial.

BACKGROUND: Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE: We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN: Randomized comparative effectiveness trial. PARTICIPANTS: One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS: Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES: We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS: BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION: A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY: ClinicalTrials.gov Identifier: NCT01902719.

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities.

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

The cost of self-imposed regulatory burden in animal research.

U.S. federal regulations and standards governing the care and use of research animals enacted in the mid- to late 1980s, while having positive effects on the welfare and quality of the animals, have resulted in dramatic increases in overall research costs. In addition to the expenses of housing and caring for animals according to the standards, establishing the requisite internal compliance bureaucracies has markedly driven up costs, in both institutional monetary expenditures and lost research effort. However, many institutions are increasing these costs even further through additional self-imposed regulatory burden, typically characterized by overly complex compliance organizations and unnecessary policies and procedures. We discuss the sources of this self-imposed burden and recommend strategies for avoiding it while preserving an appropriate focus on animal well-being and research success.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans.

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

Acute Effects of Hypothermia and Inhalant Anesthesia on Ultrasonic Vocalizations and Neuroendocrine Markers in Neonatal Rats.

Neonatal rodents undergo anesthesia for numerous procedures and for euthanasia by anesthetic overdose. However, data regarding whether neonatal anesthesia is humane are limited. Hypothermia (cryoanesthesia) is the most commonly used anesthetic protocol for neonatal rats 10 d of age or younger. However, hypothermia has recently been restricted in several countries due to perceived painful effects, including pain on rewarming. Minimizing the potential pain and distress of neonates in research is imperative, although very challenging. Traditional validated and nonvalidated behavioral and physiologic outcome measures used for adult rats undergoing anesthesia are unsuitable for evaluating neonates. Therefore, we investigated the effects of several anesthetic methods on neonatal rats by using the innovative objective approaches of noninvasive ultrasonic vocalizations and more invasive neuroendocrine responses (i. e., serum corticosterone, norepinephrine, glucose). Our results show that hypothermia leads to heightened acute distress in neonatal rats as indicated by prolonged recovery times, increased duration of vocalizations, and elevated corticosterone levels, as compared with neonates undergoing inhalational anesthesia. We demonstrate that inhalational anesthesia is preferable to cryoanesthesia for neonatal rats, and researchers using hypothermia anesthesia should consider using inhalational anesthesia as an alternative method.

Euthanasia of Neonatal Rats and Mice using Carbon Monoxide.

Minimization of potential pain and distress of rodents undergoing euthanasia is a touchstone of veterinary clinical medicine. Evaluation of this issue in postweanling rodents has supported revisions to the AVMA (American Veterinary Medical Association) Guidelines on Euthanasia in 2020. However, relatively little information is available on humane aspects of anesthesia and euthanasia in neonatal mice and rats. These neonates are not reliably euthanized by exposure to commonly used inhalant anesthetic agents due to their physiologic adaptations to hypercapnic environments. Therefore, options such as prolonged inhalant anesthetic gas exposure, decapitation, or use of injectable anesthetics are recommended for neonates. All of these recommended methods have operational implications, ranging from reported job dissatisfaction by animal care staff to rigorous reporting requirements associated with the use of controlled substances. This lack of a euthanasia method that does not entail operational issues hampers the ability of veterinary professionals to provide appropriate guidance to scientists working with neonates. This study was designed to assess the effectiveness of carbon monoxide (CO) as an alternative euthanasia agent for mouse and rat pups on postnatal days (PND) 0 to 12. The study demonstrates that CO may be a potential alternative for preweanling mice and rats at PND6 or older but is not appropriate for neonates at PND5 or younger.

Voices, Images, And Experiences Of Community Health Workers: Advancing Antiracist Policy And Practice.

Community health workers (CHWs) are front-line public health personnel who share common attributes with or have a nuanced understanding of the communities they serve. Their membership in marginalized communities gives them expertise in delivering contextualized interventions that mitigate their clients' social risk factors, but it also places them at greater risk for exposure to various harms. We employed the photovoice method to illuminate how the lived experiences of CHWs working, residing, or both in Baltimore City, Maryland, dovetail with facets of their jobs. In partnership with our sixteen predominantly racial and ethnic minoritized study participants, we surfaced the ways in which CHWs negotiated and subsequently leveraged experiences with social risk factors rooted in structural racism to shape their approach to intervention delivery for structurally vulnerable communities. We also uncovered several occupational hazards that participants faced as a function of their identities. Our findings underscore the need to embed antiracist principles in the fabric of policies and practices that directly affect the CHW workforce.

Minimal Exposure Times for Irreversible Euthanasia with Carbon Dioxide in Mice and Rats.

When using an anesthetic overdose to euthanize laboratory rodents, a secondary method of euthanasia is recommended to ensure that the apparent death is irreversible. This secondary method usually is accomplished through the collection of tissues that are required to complete the research project. However, frequently laboratory rodents must be euthanized because they cannot be used for studies; in these cases, caretakers must perform a secondary method of euthanasia. Performing physical methods of euthanasia, even on unconscious rodents, can contribute to compassion fatigue in these persons. The current study was designed based on existing literature regarding minimal exposure times for preweanling rats and mice euthanized with carbon dioxide. The study evaluated the minimal time that adult rats and mice must remain in 100% carbon dioxide for death to be irreversible on removal. Adult rats (14 stocks and strains) and mice (more than 40 stocks and strains) were euthanized using a 50% volume per minute displacement rate of carbon dioxide for 2 min. The cages were then left undisturbed for predetermined times, ranging from 0 to almost 12 min. Upon removal from the cage, the animals were stimulated to determine whether they could be resuscitated. If an animal recovered, it was euthanized by using a physical method of euthanasia, and a duration that was 30 s longer than the previous predetermined time was assessed using other animals. The study demonstrated that exposure times of at least 3 min in carbon dioxide reliably result in irreversible euthanasia of mice but that exposure times of at least 10.5 min in carbon dioxide were required to ensure irreversible euthanasia of rats. Although an irreversible death can be attained with carbon dioxide, the use of appropriate species-specific exposure times is critical.

Evaluation of Carbon Dioxide Euthanasia of Female Sprague Dawley Rats Alone or With Unfamiliar Conspecifics.

Most studies evaluating methods of euthanasia to date have focused on the euthanasia of individual animals. However, larger chambers are commonly used to euthanize multiple cages of animals at once. This study evaluated the use of a commercially available system for euthanasia of 1, 2, or 4 cages containing an individual female Sprague-Dawley rat using volume per minute displacement rates (VDR/min) of either 25% or 50% of 100% carbon dioxide. Animal wellbeing was assessed based on physiologic changes (serum noradrenaline and corticosterone) and behavioral assessments (relative frequency of rearing, line crossing, and grooming). The 25% VDR/min was associated with a significantly longer time to loss of consciousness, but this was not associated with significant physiologic or behavioral changes. The 50% VDR/min treatment group was associated with significant increases in the relative frequency of movement from 1 side of the cage to the other. Increases in the relative frequency of rears were detected in the 25% VDR/min treatment group when 2 or 4 rats were in the chamber as compared with a single rat in the chamber. The absence of significant physiologic changes suggest that the behavioral changes may have been associated with the novelty of the euthanasia experience rather than with distress. The location of the cage within the chamber did not significantly affect any of the measured parameters at either 25% or 50% VDR/min. These data suggest that groups of rats euthanized in these chambers are not experiencing decreases in their welfare.

Gender of Authors in Laboratory Animal Medicine and Science in 2 Peer-Reviewed U. S. Journals.

Multiple recent surveys have examined the prevalence of female first or senior authors on publications for various scientific and medical disciplines. First and senior authorships are significant achievements for purposes of professional advancement, especially in academia. Such surveys can also provide information regarding diversity and inclusion. In this report, we present the findings of a survey performed to assess how frequently female contributors were first or senior authors in 2 of the most widely-circulated peer-reviewed journals of laboratory animal medicine and science in the United States; data were collected at 3 time points over a recent 20-y span. These data were then compared against estimated populations of potential female authors, as determined from membership rolls in the American Society of Laboratory Animal Practitioners and the American College of Laboratory Animal Medicine. Survey results suggest that female authors increased their representation as influential authors over time, in contrast to representation trends reported for other disciplines. However, whether this increase has mirrored the increase in women overall in the veterinary profession during this time span is unknown. In an era of greater attention and sensitivity to equity and inclusion, this survey is offered as a starting point for further conversation within the field of laboratory animal medicine and science.

Predictive Value of Grooming Behavior for Development of Dermatitis in Selectively Bred P Rats as a Model of Trichotillomania Hair Pulling Disorder.

Trichotillomania (TTM) is a body-focused repetitive disorder affecting as much as 0.5 to 2% of the population, with women four times more likely to be affected than men. This disorder causes impairment in daily function and significant distress. A potential animal model for this disorder is the inbred C57BL/6J mouse which displays clinical signs and behavioral characteristics similar to those described for people affected by this disorder. Because alcohol-preferring P rats also display similar clinical signs and behavioral characteristics, it was hypothesized that this selectively bred stock could be an additional animal model. In this study, 112 female P rats were recorded on digital media for 15 min after being sprayed with a mist of water and assessed for grooming patterns-oral, manual, and scratching. Significant elevations in scratching and oral grooming behavior were predictive of the future development of skin lesions. These findings suggest that P rats may be an additional model to study TTM, with the advantage of increased genetic variation (i.e., non-inbred) which mirrors the human population. The use of this model may help to identify preventative and therapeutic interventions for humans and other animals with similar body-focused repetitive disorders.

Effectiveness of the Glass Bead Sterilizer for Sterilizing Surgical Instruments.

Survival rodent surgery requires the use of sterile instruments for each animal, which can be challenging when performing multiple surgeries on batches of animals. Glass bead sterilizers (GBS) are widely considered to facilitate this practice by sterilizing the tips of the instruments between animals. However, other disciplines have raised questions about the efficacy of the GBS, especially when used with surgical tools that have grooves or ridges that may contain organic debris. In this study, we evaluated the efficacy of the GBS to sterilize instruments commonly used in rodent surgery by intentionally contaminating a selection of instruments with a standardized bacterial broth inoculated with Staphylococcus aureus and Escherichia coli. As expected, a simple ethanol wipe was ineffective in sterilizing instruments in all treatment groups. An ethanol wipe followed by GBS was effective in sterilizing 82.5% (99 of 120) of the instruments. Our study suggests that the GBS may not be effective for consistent sterilization of surgical instruments.

Honoring Dr. Shalon Irving, A Champion for Health Equity.

Shalon Irving's 2017 death brought national attention to maternal mortality among Black women in the US. This essay remembers her life and legacy.

Wellbeing of Mice Euthanized with Carbon Dioxide in Their Home Cage as Compared with an Induction Chamber.

The AVMA Guidelines on Euthanasia state that, to decrease potential distress of animals, the home cage should be used for the euthanasia of mice. The current study evaluated this recommendation by comparing behavioral and physiologic changes in ICR and SJL mice that were euthanized by using a 30% volume per minute displacement rate of 100% CO2 in either their home cage or an induction chamber. Blood samples were collected to assess blood glucose, serum corticosterone, and serum noradrenaline as markers of physiologic wellbeing. Behavioral assessment was performed (with emphasis on behaviors including rearing, jumping, sniffing at the gas inlet, and grooming) from the introduction of gas to the estimated time to loss of consciousness (i. e., the time period when the animal would be expected to experience pain or distress). Despite significant differences between mouse strains, no significant differences were detected in the physiologic or behavioral parameters assessed when comparing the home cage with the induction chamber. This finding suggests that- from the perspective of a mouse-either the home cage or an induction chamber can be used for induction of anesthesia with CO2 during the euthanasia procedure.

Evaluation of Treatment Options for Ulcerative Dermatitis in the P Rat.

Rotational outbred adult rats, phenotypically selected to prefer drinking alcohol ("P" rats) frequently present with selfinflicted wounds and ulcerative dermatitis, similar to that seen in C57BL/6 mice. Historically, veterinary interventions used to address this clinical condition have included triple antibiotic ointment (TABO), Columbia wound powder (CPW), nail trims, or plastic tubes that allow affected animals to hide. More recent studies have suggested that nail trims are the most successful intervention in mice, but this has not been evaluated previously in rats. In this study, we evaluated nail trims in rats and also tested whether placing a pumice stone in the cage would reduce the need for nail trims to reduce self-inflicted wounds. Our hypothesis was that interacting with the pumice stone would dull/trim the rats' nails without causing stress or illness and allow the wounds time to heal. We used 66 P rats that were assigned to 1 of 6 treatment groups (pumice stone, TABO, CWP, huts, nail trims, and an untreated control group) of 11 rats each. Rats were transferred to this study from a colony of experimentally naïve animals that had evidence of dermatitis. The wounds were photographed and measured for 12 wk at 2 wk intervals. At the end of the study, representative skin samples from the site of the wound were collected for histopathologic evaluation of inflammation. Our data showed no significant differences in the inflammation scores. The rats treated with nail trims healed significantly more often than did all of the other treatment groups. This suggests that nail trims are the most effective intervention for treating self-inflicted wounds in P rats.

Intraperitoneal catheter placement for pharmacological imaging studies in conscious mice.

Imaging studies that use rodents sometimes involve intraperitoneal administration of pharmacological compounds. To facilitate such studies, the authors developed a simple and easily mastered technique for placing an intraperitoneal catheter in a conscious mouse. This technique eliminates the need to remove the animal from the scanner to administer a drug through the intraperitoneal route.

Isoflurane and Carbon Dioxide Elicit Similar Behavioral Responses in Rats.

Euthanasia in rodents is an ongoing topic of debate due to concerns regarding the aversive nature of gases with anesthetic properties such as carbon dioxide (CO2) and isoflurane. The aim of this study was to expand upon previously published work evaluating the aversiveness of CO2 by introducing an isoflurane treatment group in parallel. Aversion was tested using a forced exposure setup and an aversion-avoidance setup. In the first part of the study, 12 naïve female Sprague-Dawley rats were exposed during four consecutive days, once to each of four treatments: isoflurane, fox urine, oxygen, and CO2. In the second part of the study, 24 naïve female Sprague-Dawley rats and 12 rats from the first experiment were exposed to CO2, isoflurane, or both gases. In the forced exposure study, there were no significant differences between CO2 and isoflurane treatments except in line crosses. Overall, rats were more active in the isoflurane and CO2 treatments compared to the control groups, suggesting that isoflurane and CO2 are similarly aversive. In the aversion-avoidance study, rats previously exposed to isoflurane left the dark chamber significantly earlier compared to naïve rats during exposure to isoflurane. We also show that learned aversion to isoflurane is sustained for at least 15 days after initial exposure. Given this result, we suggest that CO2 is superior to isoflurane when euthanizing rodents with prior exposure to isoflurane. Overall, these results confirm previous studies which suggest that care should be taken when considering the serial use of isoflurane as an anesthetic.

The Impact of Social and Behavioral Factors on Reproducibility in Terrestrial Vertebrate Models.

The use of animal models remains critical in preclinical and translational research. The reliability of the animal models and aspects of their validity is likely key to effective translation of findings to medicine. However, despite considerable uniformity in animal models brought about by control of genetics, there remain a number of social as well as innate and acquired behavioral characteristics of laboratory animals that may impact on research outcomes. These include the effects of strain and genetics, age and development, sex, personality and affective states, and social factors largely brought about by housing and husbandry. In addition, aspects of the testing environment may also influence research findings. A number of considerations resulting from the animals' innate and acquired behavioral characteristics as well as their social structures are described. Suggestions for minimizing the impact of these factors on research are provided.

Review of Rodent Euthanasia Methods.

The optimal choice of euthanasia method for laboratory rodents depends on a number of factors, including the scientific goals of the study, the need to minimize animal pain and/or distress, applicable guidelines and laws, the training and proficiency of personnel, and the safety and emotional needs of the personnel performing the euthanasia. This manuscript aims to provide guidance to researchers so they may select the method of euthanasia that results in minimal experimental confounds, such as the creation of artifact and alteration of tissues and analytes. Specific situations addressed include euthanasia of large numbers of rodents and euthanasia of neonates. Recent literature supports the notion of significant strain-dependent differences in response to euthanasia methods such as CO2 inhalation. To assist researchers in selecting a strain-appropriate method of euthanasia, the authors present a summary of methodologies for assessing the effectiveness of euthanasia techniques, including elements and parameters for a scoring rubric to assess them.