High Rates of Missed HIV Testing Among Oral PrEP Users in the United States From 2018-2021: A National Assessment on Compliance With HIV Testing Recommendations of the CDC PrEP Guidelines.

Background: The US Centers for Disease Control and Prevention recommends HIV testing every 3 months in oral PrEP users. We performed a national assessment of HIV testing compliance among oral PrEP users. Methods: We analyzed 408 910 PrEP prescriptions issued to 39 809 PrEP users using a national insurance claims database that contained commercial and Medicaid claims. We identified PrEP use based on pharmacy claims and outpatient diagnostic coding. We evaluated the percentage of PrEP prescription refills without HIV testing (identified by CPT codes) within the prior 3, 6, and 12 months using time to event methods. We performed subgroup and multivariate analyses by age, gender, race, insurance type, and geography. Results: Of 39 809 persons, 36 197 were commercially insured, 3612 were Medicaid-insured, and 96% identified as male; the median age (interquartile range) was 34 (29-44) years, and the Medicaid-insured PrEP users were 24% Black/African American, 44% White, and 9% Hispanic/Latinx. Within the prior 3, 6, and 12 months, respectively, the percentage of PrEP prescription fills in individuals without HIV Ag/Ab testing was 34.3% (95% CI, 34.2%-34.5%), 23.8% (95% CI, 23.7%-23.9%), and 16.6% (95% CI, 16.4%-16.7%), and the percentage without any type of HIV test was 25.8% (95% CI, 25.6%-25.9%), 14.6% (95% CI, 14.5%-14.7%), and 7.8% (95% CI, 7.7%-7.9%). Conclusions: Approximately 1 in 3 oral PrEP prescriptions were filled in persons who had not received an HIV Ag/Ab test within the prior 3 months, with evidence of health disparities. These findings inform clinical PrEP monitoring efforts and compliance with national HIV testing guidance to monitor PrEP users.

Collecting baleen whale blow samples by drone: A minimally intrusive tool for conservation genetics.

In coastal British Columbia, Canada, marine megafauna such as humpback whales (Megaptera novaeangliae) and fin whales (Balaenoptera physalus velifera) have been subject to a history of exploitation and near extirpation. While their populations have been in recovery, significant threats are posed to these vulnerable species by proposed natural resource ventures in this region, in addition to the compounding effects of anthropogenic climate change. Genetic tools play a vital role in informing conservation efforts, but the associated collection of tissue biopsy samples can be challenging for the investigators and disruptive to the ongoing behaviour of the targeted whales. Here, we evaluate a minimally intrusive approach based on collecting exhaled breath condensate, or respiratory 'blow' samples, from baleen whales using an unoccupied aerial system (UAS), within Gitga'at First Nation territory for conservation genetics. Minimal behavioural responses to the sampling technique were observed, with no response detected 87% of the time (of 112 UAS deployments). DNA from whale blow (n = 88 samples) was extracted, and DNA profiles consisting of 10 nuclear microsatellite loci, sex identification and mitochondrial (mt) DNA haplotypes were constructed. An average of 7.5 microsatellite loci per individual were successfully genotyped. The success rates for mtDNA and sex assignment were 80% and 89% respectively. Thus, this minimally intrusive sampling method can be used to describe genetic diversity and generate genetic profiles for individual identification. The results of this research demonstrate the potential of UAS-collected whale blow for conservation genetics from a remote location.

Evaluating novel biodegradable polymer matrix fertilizers for nitrogen-efficient agriculture.

Enhanced efficiency fertilizers (EEFs) can reduce nitrogen (N) losses in temperate agriculture but are less effective in the tropics. We aimed to design a new EEF and evaluate their performance in simple-to-complex tests with tropical soils and crops. We melt-extruded urea at different loadings into biodegradable polymer matrix composites using biodegradable polyhydroxyalkanoate (PHA) or polybutylene adipate-co-terephthalate (PBAT) polymers with urea distributed throughout the pellet. These contrast with commercially coated EEF that have a polymer-coated urea core. We hypothesized that matrix fertilizers would have an intermediate N release rate compared to fast release from urea or slow release from coated EEF. Nitrogen release rates in water and sand-soil columns confirmed that the matrix fertilizer formulations had a more progressive N release than a coated EEF. A more complex picture emerged from testing sorghum [Sorghum bicolor (L.) Moench] grown to maturity in large soil pots, as the different formulations resulted in minor differences in plant N accumulation and grain production. This confirms the need to consider soil interactions, microbial processes, crop physiology, and phenology for evaluating fertilizer performance. Promisingly, crop δ15N signatures emerged as an integrated measure of efficacy, tracking likely N conversions and losses. The three complementary evaluations combine the advantages of standardized high-throughput screening and more resource-intensive and realistic testing in a plant-soil system. We conclude that melt-blended biodegradable polymer matrix fertilizers show promise as EEF because they can be designed toward more abiotically or more microbially driven N release by selecting biopolymer type and N loading rate.

Public Health Students' Perspectives on the Future of Public Health Education.

Our society faces an uncertain future and the field of public health will have an important role to play in shaping this future. This article introduces the special issue The Future of Health Education & Behavior which is focused on perspectives and research led by student authors. Our call for papers encouraged student perspectives that envisioned, challenged, and critiqued the future for health education and behavior. We summarize the articles included in this issue which cover topics such as gaps or future directions for public health training programs, perspectives on pressing issues facing our society, and empirical articles on critical public health topics. Many of the articles in the special issue point boldly to a future that more directly and critically confronts systems of oppression and moves away from a traditional emphasis on individual-level behaviors. These articles can help our field evolve and adapt to fully address the most pressing issues of our time.

Combination Effects of Integrin-linked Kinase and Abelson Kinase Inhibition on Aberrant Mitosis and Cell Death in Glioblastoma Cells.

In cancer cells, inhibition of integrin-linked kinase (ILK) increases centrosome declustering causing mitotic arrest and cell death. Yet, not all cancer cells are susceptible to anti-ILK treatment alone. We investigate a combination drug strategy targeting ILK and another oncogenic kinase, Abelson kinase (ABL). Drug-concentration viability assays (i.e., MTT assays) indicate that ILK and ABL inhibitors in combination decreased the viability of glioblastoma cells over the ILK drug QLT-0267 alone. Combination strategies also increased aberrant mitoses and cell death over QLT-0267 alone. This was evident from an increase in mitotic arrest, apoptosis and a sub-G1 peak following FAC analysis. In vitro, ILK and ABL localized to the centrosome and the putative ILK kinase domain was important for this localization. Increased levels of cytosolic ABL are associated with its transformative abilities. ILK inhibitor effects on survival correlated with its ability to decrease cytosolic ABL levels and inhibit ABL's localization to mitotic centrosomes in glioblastoma cells. ILK inhibitor effects on ABL's centrosomal localization were reversed by the proteasomal inhibitor MG132 (a drug that inhibits ABL degradation). These results indicate that ILK regulates ABL at mitotic centrosomes and that combination treatments targeting ILK and ABL are more effective then QLT-0267 alone at decreasing the survival of dividing glioblastoma cells.

The "Ins and Outs" of Prostate Specific Membrane Antigen (PSMA) as Specific Target in Prostate Cancer Therapy.

Prostate-specific membrane antigen (PSMA) is expressed in epithelial cells of the prostate gland and is strongly upregulated in prostatic adenocarcinoma, with elevated expression correlating with metastasis, progression, and androgen independence. Because of its specificity, PSMA is a major target of prostate cancer therapy; however, detectable levels of PSMA are also found in other tissues, especially in salivary glands and kidney, generating bystander damage of these tissues. Antibody target therapy has been used with relative success in reducing tumor growth and prostate specific antigen (PSA) levels. However, since antibodies are highly stable in plasma, they have prolonged time in circulation and accumulate in organs with an affinity for antibodies such as bone marrow. For that reason, a second generation of PSMA targeted therapeutic agents has been developed. Small molecules and minibodies have had promising clinical trial results, but concerns about their specificity had arisen with side effects due to accumulation in salivary glands and kidneys. Herein we study the specificity of small molecules and minibodies that are currently being clinically tested. We observed a high affinity of these molecules for PSMA in prostate, kidney and salivary gland, suggesting that their effect is not prostate specific. The search for specific prostate target agents must continue so as to optimally treat patients with prostate cancer, while minimizing deleterious effects in other PSMA expressing tissues.

Feasibility and Acceptability: Narrative Writing with Caregivers in Pediatric Critical Care.

Background: Pediatric intensive care unit (PICU) admissions are caregiver stressors with potential long-term impact. Writing interventions have shown health benefits, although not yet with parents writing during their child's PICU admission. Objective: The study objective was to quantify intervention acceptability and feasibility and to qualitatively examine written texts. Design: This is a proof-of-concept three-arm randomized trial. Setting and Subjects: Subjects were legal caregivers ≥18 years, able to read and write English, and of children ≤18 years in a U.S. PICU for ≥1 day. Measurements: Treatment Acceptability Questionnaire, enrollment rates, completed encounters, and qualitative thematic analysis. Results: Acceptability was high (49% enrollment; mean [standard deviation] Treatment Acceptability Questionnaire scores: M = 24.8 [2.4]). Feasibility was 100% scheduled-to-completed sessions. Thematic analysis revealed two themes (people and relationships); texts were more cognitive than emotional. Conclusions: Caregivers, provided resources and supported by a narrative medicine facilitator, are likely to engage in expressive writing. The intervention warrants subsequent development.

Examining Illness through Pediatric Poetry and Prose: A Mixed Methods Study.

The purpose of this mixed-methods retrospective study was to characterize the linguistic and narrative properties of texts generated by hospitalized pediatric patients who are experiencing significant illnesses. These young writers voluntarily participated in a narrative intervention through a program at a children's hospital that serves diverse urban and rural populations. The primary aim was to use interpretive theoretical analysis and linguistic analysis to test the following hypotheses: (1) hospital-generated texts have linguistic characteristics consistent with texts written to improve health outcomes; (2) stories told by pediatric patients through poetry and prose can be classified using Frank's illness narrative types, serving as a starting point to situate caregivers into the pediatric writer's world in a moment in time; (3) pediatric stories are authentic stories that yield important insights about patients and their relationships with others despite lacking formal narrative elements (e.g., plot) and form.

Knowledge translation approaches and practices in Indigenous health research: A systematic review.

Knowledge translation (KT) is a critical component of any applied health research. Indigenous Peoples' health research and KT largely continues to be taught, developed, designed, regulated, and conducted in ways that do not prioritize local Indigenous Peoples' ways of sharing knowledges. This review was governed and informed by Indigenous health scholars, Knowledge Guardians, and Elders. Our systematic review focused on answering, what are the promising and wise practices for KT in the Indigenous health research field? Fifty-one documents were included after screening published literature from any country and grey literature from what is now known as Canada. This included contacting 73 government agencies at the federal, territorial, and provincial levels that may have funded Indigenous health research. Only studies that: a) focused on Indigenous Peoples' health and wellness; b) documented knowledge sharing activities and rationale; c) evaluated the knowledge sharing processes or outcomes; and d) printed in English were included and appraised using the Well Living House quality appraisal tool. The analysis was completed using an iterative and narrative synthesis approach. Our systematic review protocol has been published elsewhere. We highlight and summarize the varied aims of Indigenous health research KT, types of KT methodologies and methods used, effectiveness of KT efforts, impacts of KT on Indigenous Peoples' health and wellness, as well as recommendations and lessons learned. Few authors reported using rigorous KT evaluation or disclosed their identity and relationship with the Indigenous communities involved in research (i.e. self-locate). The findings from this review accentuate, reiterate and reinforce that KT is inherent in Indigenous health research processes and content, as a form of knowing and doing. Indigenous health research must include inherent KT processes, if the research is by, for, and/or with Indigenous Peoples.

Fin whales of the Great Bear Rainforest: Balaenoptera physalus velifera in a Canadian Pacific fjord system.

Fin whales (Balaenoptera physalus) are widely considered an offshore and oceanic species, but certain populations also use coastal areas and semi-enclosed seas. Based upon fifteen years of study, we report that Canadian Pacific fin whales (B. p. velifera) have returned to the Kitimat Fjord System (KFS) in the Great Bear Rainforest, and have established a seasonally resident population in its intracoastal waters. This is the only fjord system along this coast or elsewhere in which fin whales are known to occur regularly with strong site fidelity. The KFS was also the only Canadian Pacific fjord system in which fin whales were commonly found and killed during commercial whaling, pointing to its long-term importance. Traditional knowledge, whaling records, and citizen science databases suggest that fin whales were extirpated from this area prior to their return in 2005-2006. Visual surveys and mark-recapture analysis documented their repopulation of the area, with 100-120 whales using the fjord system in recent years, as well as the establishment of a seasonally resident population with annual return rates higher than 70%. Line transect surveys identified the central and outer channels of the KFS as the primary fin whale habitat, with the greatest densities occurring in Squally Channel and Caamaño Sound. Fin whales were observed in the KFS in most months of the year. Vessel- and shore-based surveys (27,311 km and 6,572 hours of effort, respectively) indicated regular fin whale presence (2,542 detections), including mother-calf pairs, from June to October and peak abundance in late August-early September. Seasonal patterns were variable year-to-year, and several lines of evidence indicated that fin whales arrived and departed from the KFS repeatedly throughout the summer and fall. Additionally, we report on the population's social network and morphometrics. These findings offer insights into the dynamics of population recovery in an area where several marine shipping projects are proposed. The fin whales of the Great Bear Rainforest represent a rare exception to general patterns in this species' natural history, and we highlight the importance of their conservation.

Algae biofertilisers promote sustainable food production and a circular nutrient economy - An integrated empirical-modelling study.

Agriculture has radically changed the global nitrogen (N) cycle and is heavily dependent on synthetic N-fertiliser. However, the N-use efficiency of synthetic fertilisers is often only 50% with N-losses from crop systems polluting the biosphere, hydrosphere and atmosphere. To address the large carbon and energy footprint of N-fertiliser synthesis and curb N-pollution, new technologies are required to deliver enhanced energy efficiency, decarbonisation and a circular nutrient economy. Algae fertilisers (AF) are an alternative to synthetic N-fertiliser (SF). Here microalgae were used as biofertiliser for spinach production. AF production was evaluated using life-cycle analyses. Over 4 weeks, AF released 63.5% of N as bioavailable ammonium and nitrate, and 25% of phosphorous (P) as phosphate to the growth substrate; SF released 100% N and 20% P. To maximise crop N-use and minimise N-leaching, we explored AF and SF dose-response-curves with spinach in glasshouse conditions. AF-grown spinach produced 36% less biomass than SF-grown plants due to AF's slower and linear N-release; SF exhibited 5-times higher N-leaching than AF. Optimised AF:SF blends yielded greater synchrony between N-release and crop-uptake, boosting crop yields and minimising N-loss. Additional benefits of AF included greener leaves, lower leaf nitrate concentration, and higher microbial diversity and water holding capacity of the growth substrate. An integrated techno-economic and life-cycle-analysis of scaled-up microalgae systems (+/- wastewater) normalised to the application dose showed that replacing the most effective SF-dose with AF lowered the annual carbon footprint of fertiliser production from 3.644 kg CO2 m-2 (C-producing) to -6.039 kg CO2 m-2 (C-assimilation). N-loss from growth substrate was lowered by 54%. Embodied energy for AF:SF blends could be reduced by 29% when cultivating microalgae on wastewater. Conclusions: (i) microalgae offer a sustainable alternative to synthetic N-fertiliser for spinach production and potentially other crop systems, (ii) microalgae biofertilisers support the circular-nutrient-economy and several UN-Sustainable-Development-Goals.

Treatment Integrity Failures during Timeout from Play.

Timeout is an effective behavior-reduction strategy with considerable generality. However, little is known about how timeout is implemented under natural conditions, or how errors in implementation impact effectiveness. During Experiment 1, we observed teachers implementing timeout during play to evaluate how frequently the teachers implemented timeout following target behavior (omission errors) and other behaviors (commission errors) for four children. Teachers rarely implemented timeout; thus, omission errors were frequent, but commission errors rarely occurred. During Experiment 2, we used a reversal design to compare timeout implemented with 0% omission integrity, 100% integrity, and the level of omission integrity observed to occur during Experiment 1 for two of the participants. Timeout implemented with reduced-integrity decreased problem behavior relative to baseline, suggesting that infrequent teacher implementation of timeout may have been sufficient to reduce problem behavior.

Harnessing Augmented Reality and CT to Teach First-Year Medical Students Head and Neck Anatomy.

RATIONALE AND OBJECTIVES: Three-dimensional (3D) visualization has been shown to benefit new generations of medical students and physicians-in-training in a variety of contexts. However, there is limited research directly comparing student performance after using 3D tools to those using two-dimensional (2D) screens. MATERIALS AND METHODS: A CT was performed on a donated cadaver and a 3D CT hologram was created. A total of 30 first-year medical students were randomly assigned into two groups to review head and neck anatomy in a teaching session that incorporated CT. The first group used an augmented reality headset, while the second group used a laptop screen. The students were administered a five-question anatomy test before and after the session. Two-tailed t-tests were used for statistical comparison of pretest and posttest performance within and between groups. A feedback survey was distributed for qualitative data. RESULTS: Pretest vs. posttest comparison of average percentage of questions answered correctly demonstrated both groups showing significant in-group improvement (p < 0.05), from 59% to 95% in the augmented reality group, and from 57% to 80% in the screen group. Between-group analysis indicated that posttest performance was significantly better in the augmented reality group (p = 0.022, effect size = 0.73). CONCLUSION: Immersive 3D visualization has the potential to improve short-term anatomic recall in the head and neck compared to traditional 2D screen-based review, as well as engage millennial learners to learn better in anatomy laboratory. Our findings may reflect additional benefit gained from the stereoscopic depth cues present in augmented reality-based visualization.

Social robots as treatment agents: Pilot randomized controlled trial to deliver a behavior change intervention.

Social robots are increasingly demonstrating effectiveness as low-intensity behavior change agents. Key targets for these behavioral interventions include daily lifestyle behaviors with significant health consequences, such as the consumption of high-calorie foods and drinks ('snacks'). A pilot randomized controlled trial using a stepped-wedge design was conducted to determine the efficacy of a motivational intervention by an autonomous robot, to help reduce high-calorie snacks. Twenty-six adults were randomized to receive Immediate or 4-week Delayed treatment, with assessments at Baseline and Weeks 4 and 8. The treatment comprised motivation enhancement and self-management training using mental imagery (Functional Imagery Training). A significant condition by time effect for snack episode reduction was obtained, F(2, 32.06) = 4.30, p = .022. The Immediate condition significantly reduced snacking between Baseline and Week 4 (d = -1.06), while the Delayed condition did not (d = -0.08). Immediate participants maintained their improvement between Weeks 4 and 8 (d = -0.18), and Delayed participants then showed a significant fall (d = -1.42). Overall, 'Immediate' participants decreased their snack episodes by 54% and 'Delayed' decreased by 62% from Baseline to Week 8, and an average weight reduction of 4.4 kg was seen across over the first 2 weeks of treatment. Four weeks after starting the intervention, both conditions had significant increases in perceived confidence to control snack intake for time duration, specific scenarios and emotional states (d = 0.61 to 1.42). Working alliance was significantly correlated with reduced snack episodes. The pilot's results appear to suggest that the robot-delivered intervention may be as effective as a human clinician delivering a similar intervention. The robot-delivered pilot achieved similar snack episode reduction in the first four weeks (FIT-R, 55%) when compared with the human-delivered version by a trained clinician (FIT-H, 49%). Overall, the results provide preliminary evidence for an autonomous social robot to deliver a low-intensity treatment on dietary intake without the need for human intervention. Future trials should extend the deployment of the robot-delivered intervention protocol to other low-intensity behavioral outcomes.

Glucose time in range and peripheral neuropathy in type 2 diabetes mellitus and chronic kidney disease.

​OBJECTIVE: Compared with hemoglobin A1c (HbA1c), continuous glucose monitoring (CGM) may better capture risk of diabetes complications in patients with chronic kidney disease (CKD), including diabetic peripheral neuropathy (DPN). We hypothesized that glucose time in range (TIR), measured by CGM, is associated with DPN symptoms among participants with type 2 diabetes mellitus (type 2 DM) and moderate-to-severe CKD. ​RESEARCH DESIGN AND METHODS: We enrolled 105 people with type 2 DM treated with insulin or sulfonylurea, 81 participants with CKD (estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2) and 24 matched control participants with eGFR ≥60 mL/min/1.73 m2. Each participant wore a CGM for two 6-day periods. Calculated glycemic measures included TIR (glucose 70-180 mg/dL) and glucose management indicator (GMI). DPN symptoms were assessed using the Michigan Neuropathy Screening Instrument (MNSI) questionnaire, with a positive MNSI score defined as ≥2 symptoms. ​RESULTS: Participants with CKD had a mean age of 68 years, diabetes duration 20 years, eGFR 38 mL/min/1.73 m2 and HbA1c 7.8%, 61 mmol/mol. Sixty-two participants reported ≥2 DPN symptoms, 51 (63%) with CKD and 11 (46%) controls. Less TIR and higher GMI were associated with higher risk of MNSI questionnaire score ≥2 (OR 1.25 (95% CI 1.02 to 1.52) per 10% lower TIR, and OR 1.79 (95% CI 1.05 to 3.04) per 1% higher GMI, adjusting for age, gender and race). Similar results were observed when analyses were restricted to participants with CKD. In contrast, there was no significant association of HbA1c with DPN symptoms. ​CONCLUSIONS: Symptoms of DPN were common among participants with long-standing type 2 DM and CKD. Lower TIR and higher GMI were associated with DPN symptoms.

Psychosocial Health Interventions by Social Robots: Systematic Review of Randomized Controlled Trials.

BACKGROUND: Social robots that can communicate and interact with people offer exciting opportunities for improved health care access and outcomes. However, evidence from randomized controlled trials (RCTs) on health or well-being outcomes has not yet been clearly synthesized across all health domains where social robots have been tested. OBJECTIVE: This study aimed to undertake a systematic review examining current evidence from RCTs on the effects of psychosocial interventions by social robots on health or well-being. METHODS: Medline, PsycInfo, ScienceDirect, Scopus, and Engineering Village searches across all years in the English language were conducted and supplemented by forward and backward searches. The included papers reported RCTs that assessed changes in health or well-being from interactions with a social robot across at least 2 measurement occasions. RESULTS: Out of 408 extracted records, 27 trials met the inclusion criteria: 6 in child health or well-being, 9 in children with autism spectrum disorder, and 12 with older adults. No trials on adolescents, young adults, or other problem areas were identified, and no studies had interventions where robots spontaneously modified verbal responses based on speech by participants. Most trials were small (total N=5 to 415; median=34), only 6 (22%) reported any follow-up outcomes (2 to 12 weeks; median=3.5) and a single-blind assessment was reported in 8 (31%). More recent trials tended to have greater methodological quality. All papers reported some positive outcomes from robotic interventions, although most trials had some measures that showed no difference or favored alternate treatments. CONCLUSIONS: Controlled research on social robots is at an early stage, as is the current range of their applications to health care. Research on social robot interventions in clinical and health settings needs to transition from exploratory investigations to include large-scale controlled trials with sophisticated methodology, to increase confidence in their efficacy.

Accumulated reinforcers increase academic responding and suppress problem behavior for students with Attention-Deficit Hyperactivity Disorder.

We compared rates of academic responses and problem behavior during mathematics with distributed and accumulated reinforcer arrangements for 3 students with Attention-Deficit Hyperactivity Disorder who engaged in chronic, severe problem behavior. All 3 students engaged in more academic responding and less problem behavior when reinforcers accumulated throughout the session, relative to conditions in which reinforcers were distributed throughout the session or withheld completely. We then conducted concurrent-chain analyses to evaluate student preference for the reinforcer arrangements. Two students preferred distributed reinforcers, even though this arrangement continued to produce problem behavior. One student preferred accumulated reinforcers. Our data replicate previous findings regarding the efficacy of accumulated-reinforcer arrangements, but suggest that students do not always prefer the most efficacious reinforcer arrangement.

Hypoglycemia in People with Type 2 Diabetes and CKD.

BACKGROUND AND OBJECTIVES: Among people with diabetes mellitus, CKD may promote hypoglycemia through altered clearance of glucose-lowering medications, decreased kidney gluconeogenesis, and blunted counter-regulatory response. We conducted a prospective observational study of hypoglycemia among 105 individuals with type 2 diabetes treated with insulin or a sulfonylurea using continuous glucose monitors. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS: We enrolled 81 participants with CKD, defined as eGFR<60 ml/min per 1.73 m2, and 24 control participants with eGFR≥60 ml/min per 1.73 m2 frequency-matched on age, duration of diabetes, hemoglobin A1c, and glucose-lowering medications. Each participant wore a continuous glucose monitor for two 6-day periods. We examined rates of sustained level 1 hypoglycemia (<70 mg/dl) and level 2 hypoglycemia (<54 mg/dl) among participants with CKD. We then tested differences compared with control participants as well as a second control population (n=73) using Poisson and linear regression, adjusting for age, sex, and race. RESULTS: Over 890 total days of continuous glucose monitoring, participants with CKD were observed to have 255 episodes of level 1 hypoglycemia, of which 68 episodes reached level 2 hypoglycemia. Median rate of hypoglycemic episodes was 5.3 (interquartile range, 0.0-11.7) per 30 days and mean time spent in hypoglycemia was 28 (SD 37) minutes per day. Hemoglobin A1c and the glucose management indicator were the main clinical correlates of time in hypoglycemia (adjusted differences 6 [95% confidence interval, 2 to 10] and 13 [95% confidence interval, 7 to 20] fewer minutes per day per 1% higher hemoglobin A1c or glucose management indicator, respectively). Compared with control populations, participants with CKD were not observed to have significant differences in time in hypoglycemia (adjusted differences 4 [95% confidence interval, -12 to 20] and -12 [95% confidence interval, -29 to 5] minutes per day). CONCLUSIONS: Among people with type 2 diabetes and moderate to severe CKD, hypoglycemia was common, particularly with tighter glycemic control, but not significantly different from groups with similar clinical characteristics and preserved eGFR.

Rates of Cardiac Rhythm Abnormalities in Patients with CKD and Diabetes.

BACKGROUND AND OBJECTIVES: Cardiac arrhythmias increase mortality and morbidity in CKD. We evaluated the rates of subclinical arrhythmias in a population with type 2 diabetes and patients with moderate to severe CKD who were not on dialysis. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS: This is a prospective observational study, using continuous ambulatory cardiac monitors to determine the rate of atrial and ventricular arrhythmias, as well as conduction abnormalities in this group. RESULTS: A total of 38 patients (34% women), with mean eGFR of 38±13 ml/min per 1.73 m2, underwent ambulatory cardiac monitoring for 11.2±3.9 days. The overall mean rate of any cardiac arrhythmia was 88.8 (95% confidence interval [95% CI], 27.1 to 184.6) episodes per person-year (PY). A history of cardiovascular disease was associated with a higher rate of detected arrhythmia (rate ratio, 5.87; 95% CI, 1.37 to 25.21; P<0.001). The most common arrhythmia was atrial fibrillation, which was observed in two participants with known atrial fibrillation and was a new diagnosis in four patients (11%), none of whom experienced symptoms. Overall, atrial fibrillation episodes occurred at a rate of 37.6 (95% CI, 2.4 to 112.3) per PY. Conduction abnormalities were found in eight patients (21%), a rate of 26.5 (95% CI, 4.2 to 65.5) per PY. Rates of ventricular arrhythmias were low (14.5 per PY; 95% CI, 4.3 to 32.0) and driven by premature ventricular contractions. CONCLUSIONS: Cardiac rhythm abnormalities are common in patients with diabetes with moderate to severe CKD not requiring dialysis. Rates of atrial fibrillation are high and episodes are asymptomatic. Future studies are needed to determine the role of screening and upstream therapy of cardiac arrhythmias in this group.

Without management interventions, endemic wet-sclerophyll forest is transitioning to rainforest in World Heritage listed K'gari (Fraser Island), Australia.

Wet-sclerophyll forests are unique ecosystems that can transition to dry-sclerophyll forests or to rainforests. Understanding of the dynamics of these forests for conservation is limited. We evaluated the long-term succession of wet-sclerophyll forest on World Heritage listed K'gari (Fraser Island)-the world's largest sand island. We recorded the presence and growth of tree species in three 0.4 hectare plots that had been subjected to selective logging, fire, and cyclone disturbance over 65 years, from 1952 to 2017. Irrespective of disturbance regimes, which varied between plots, rainforest trees recruited at much faster rates than the dominant wet-sclerophyll forest trees, narrowly endemic species Syncarpia hillii and more common Lophostemon confertus. Syncarpia hillii did not recruit at the plot with the least disturbance and recruited only in low numbers at plots with more prominent disturbance regimes in the ≥10 cm at breast height size. Lophostemon confertus recruited at all plots but in much lower numbers than rainforest trees. Only five L. confertus were detected in the smallest size class (<10 cm diameter) in the 2017 survey. Overall, we find evidence that more pronounced disturbance regimes than those that have occurred over the past 65 years may be required to conserve this wet-sclerophyll forest, as without intervention, transition to rainforest is a likely trajectory. Fire and other management tools should therefore be explored, in collaboration with Indigenous landowners, to ensure conservation of this wet-sclerophyll forest.