Effect of the Communities that HEAL intervention on receipt of behavioral therapies for opioid use disorder: A cluster randomized wait-list controlled trial.

BACKGROUND: The U.S. opioid overdose crisis persists. Outpatient behavioral health services (BHS) are essential components of a comprehensive response to opioid use disorder and overdose fatalities. The Helping to End Addiction Long-Term® (HEALing) Communities Study developed the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths in 67 communities in Kentucky, Ohio, New York, and Massachusetts through the implementation of evidence-based practices (EBPs), including BHS. This paper compares the rate of individuals receiving outpatient BHS in Wave 1 intervention communities (n = 34) to waitlisted Wave 2 communities (n = 33). METHODS: Medicaid data included individuals ≥18 years of age receiving any of five BHS categories: intensive outpatient, outpatient, case management, peer support, and case management or peer support. Negative binomial regression models estimated the rate of receiving each BHS for Wave 1 and Wave 2. Effect modification analyses evaluated changes in the effect of the CTH intervention between Wave 1 and Wave 2 by research site, rurality, age, sex, and race/ethnicity. RESULTS: No significant differences were detected between intervention and waitlisted communities in the rate of individuals receiving any of the five BHS categories. None of the interaction effects used to test the effect modification were significant. CONCLUSIONS: Several factors should be considered when interpreting results-no significant intervention effects were observed through Medicaid claims data, the best available data source but limited in terms of capturing individuals reached by the intervention. Also, the 12-month evaluation window may have been too brief to see improved outcomes considering the time required to stand-up BHS. TRIAL REGISTRATION: Clinical Trials.gov http://www. CLINICALTRIALS: gov: Identifier: NCT04111939.

Grapevine Microbiota Reflect Diversity among Compartments and Complex Interactions within and among Root and Shoot Systems.

Grafting connects root and shoot systems of distinct individuals, bringing microbial communities of different genotypes together in a single plant. How do root system and shoot system genotypes influence plant microbiota in grafted grapevines? To address this, we utilized clonal replicates of the grapevine 'Chambourcin', growing ungrafted and grafted to three different rootstocks in three irrigation treatments. Our objectives were to (1) characterize the microbiota (bacteria and fungi) of below-ground compartments (roots, adjacent soil) and above-ground compartments (leaves, berries), (2) determine how rootstock genotype, irrigation, and their interaction influences grapevine microbiota in different compartments, and (3) investigate abundance of microorganisms implicated in the late-season grapevine disease sour rot (Acetobacterales and Saccharomycetes). We found that plant compartment had the largest influence on microbial diversity. Neither rootstock genotype nor irrigation significantly influenced microbial diversity or composition. However, differential abundance of bacterial and fungal taxa varied as a function of rootstock and irrigation treatment; in particular, Acetobacterales and Saccharomycetes displayed higher relative abundance in berries of grapevines grafted to '1103P' and 'SO4' rootstocks and varied across irrigation treatments. This study demonstrates that grapevine compartments retain distinct microbiota and identifies associations between rootstock genotypes, irrigation treatment, and the relative abundance of agriculturally relevant microorganisms in the berries.

Physicians' rhetorical strategies for motivating HPV vaccination.

RATIONALE: Receiving a healthcare provider's recommendation is a well-documented predictor of human papillomavirus (HPV) vaccination, and yet recommendations remain understudied and undertheorized. OBJECTIVE: To qualitatively describe strategies providers use to motivate HPV vaccination. METHOD: We surveyed a national sample of 771 U.S. primary care physicians. Data came from an open-ended item that assessed physicians' perspectives on the most effective thing they could say to persuade parents to get HPV vaccine for their 11- to 12-year-old children. Using a standardized codebook and two independent coders, we conducted a thematic analysis to identify rhetorical strategies underlying physicians' responses. RESULTS: We identified two sets of strategies for motivating HPV vaccination. One set drew parents' attention to specific actors or vaccine characteristics. Physicians using these strategies asked parents to consider their children's individual risk in the short-term, named specific diseases that could be prevented, emphasized the novelty of HPV vaccine as a cancer prevention tool, and gave their personal endorsement for HPV vaccination. In contrast, the second set of strategies was more distancing and impersonal. Physicians using these strategies referenced future risk, described cancer prevention in general terms, framed HPV vaccine as similar to other vaccines, and shared organizational endorsements for HPV vaccination. Across these two sets of strategies, a tension emerged between the goals of engaging parents' perceptions of HPV as a threat to their children versus framing HPV vaccination as a normative standard of care. CONCLUSIONS: Our findings suggest that theoretical frameworks, such as Construal Level Theory, may be helpful for positioning provider recommendations in the broader literature on persuasive communication. By identifying competing approaches to motivating HPV vaccination, this study lays the groundwork for future research to test the acceptability and impact of strategies for recommending routine preventive care.

A new method for extracting DNA from the grape berry surface, beginning in the vineyard.

Isolating DNA from microbes on the surface of a grape berry is a challenge due to their adhesion to the thick berry skin and cuticle, making studies of the grape microbiome challenging. We developed a field-to-lab DNA extraction procedure that starts in the vineyard, disrupts the grape berry surface while en route to the lab through agitation, and efficiently extracts microbial DNA from the surface of the grape. It is cost effective and utilizes commonly available laboratory chemicals with low toxicity (Table 1). This protocol allows researchers to extract DNA from the grape berry surface in the field, therefore undergoing minimal manipulation of those microbiomes before DNA extraction.

The epiphytic microbiota of sour rot-affected grapes differs minimally from that of healthy grapes, indicating causal organisms are already present on healthy berries.

Sour rot is a disease complex produced by an interaction between grape berries and various species of yeast and acetic acid bacteria in the presence of Drosophila fruit flies. While yeast and bacteria are consistently found on healthy grape berries worldwide, we explored whether the composition of these epiphytic communities differed depending on the presence or absence of sour rot symptoms. Using high-throughput sequencing, we characterized the microbiome of sour rot-affected grapes from two geographical areas across two years. In 2015 and 2016, both healthy and sour rot-affected berries were collected from commercial and research vineyards in Geneva, NY and commercial vineyards in Tasmania, AUS. In this experiment, all associated organisms grouped together primarily by location, and not by presence/absence of symptoms or cultivar. The predominant difference between asymptomatic and symptomatic samples, regardless of location, was the abundance of Acetobacter species, which were significantly more plentiful in the symptomatic samples. Yeast genera such as Candida, Hanseniaspora, Pichia and Saccharomyces were abundant in both sets of samples, but varied by region. The consistent presence of yeast species and the increased abundance of acetic acid-generating bacteria is consistent with our understanding of their etiological role in sour rot development. In 2016, diseased grapes also were collected from vineyards in Fredonia, NY, and Modesto, CA. Consistent with our comparison study, all associated organisms again grouped together primarily by location. Yeast genera such as Candida, Hanseniaspora, Pichia and Saccharomyces were abundant in both sets of samples, but varied by region. The consistent presence of yeast species and the abundance of acetic acid-generating bacteria in both experiments is consistent with our understanding of their etiological role in sour rot development.

Grape Sour Rot: A Four-Way Interaction Involving the Host, Yeast, Acetic Acid Bacteria, and Insects.

Sour rot, a disease affecting berries of cultivated Vitis spp. worldwide, has not been clearly defined. Reported symptoms of the disease include browning of the berry skin, oozing of disintegrated berry pulp, and the smell of acetic acid, all in the presence of fruit flies (Drosophila spp.). We determined acetic acid concentrations in multiple collections of symptomatic berries, isolated and identified microbes from them, and inoculated commonly isolated organisms into healthy berries with and without concurrent exposure to wild-type or axenic Drosophila melanogaster. Coinoculations combining one of several yeasts (Metschnikowia spp., Pichia spp., and a Saccharomyces sp.) plus an acetic acid bacterium (an Acetobacter sp. and Gluconobacter spp.) reproduced sour rot symptoms, defined here as decaying berries with a loss of turgor and containing acetic acid at a minimum of 0.83 g/liter, based on observed field levels. Symptoms developed only in the presence of D. melanogaster, either wild type or axenic, indicating a nonmicrobial contribution of these insects in addition to a previously suggested microbial role. We conclude that sour rot is the culmination of coinfection by various yeasts, which convert grape sugars to ethanol, and bacteria that oxidize the ethanol to acetic acid, and that this process is mediated by Drosophila spp.

Why is announcement training more effective than conversation training for introducing HPV vaccination? A theory-based investigation.

BACKGROUND: Improving healthcare providers' communication about HPV vaccination is critical to increasing uptake. We previously demonstrated that training providers to use presumptive announcements to introduce HPV vaccination improved uptake, whereas training them to use participatory conversations had no effect. To understand how communication training changed provider perceptions and communication practices, we evaluated intermediate outcomes and process measures from our randomized clinical trial, with a particular focus on identifying mechanisms that might explain the announcement training's impact. METHODS: In 2015, a physician educator delivered 1-h in-clinic HPV vaccination recommendation trainings at 20 primary care clinics in North Carolina serving 11,578 patients age 11 or 12. Clinics were randomized to receive training to use "announcements" that presume parents are ready to vaccinate or "conversations" that invite dialog about vaccination. Training participants were 83 HPV vaccine providers. Pre- and post-training surveys assessed constructs from the theory of planned behavior (TPB), including providers' attitudes and subjective norms about HPV vaccination and their perceived behavioral control to recommend HPV vaccination. Surveys also assessed providers' perceptions of the announcement and conversation communication strategies. RESULTS: Both trainings improved TPB-related constructs, including providers' positive attitudes toward HPV vaccination, subjective norms, and perceived behavioral control to recommend the vaccine (all p < .001, Cohen's d = .62-.90). Furthermore, in both trainings, the amount of time providers reported needing to discuss HPV vaccination with parents decreased from pre-training to 1-month follow-up (mean = 3.8 vs. 3.2 min, p = .01, d = .28). However, announcement trainings outperformed conversation trainings on other measures. For example, providers who received announcement training more often reported that the communication strategy saved them time, was easy to use, helped them promote HPV vaccination as routine care, and increased HPV vaccination coverage in their clinics (all p < .05; d = .44-.60). CONCLUSIONS: Both announcement and conversation trainings improved providers' HPV vaccine-related perceptions. However, providers viewed announcements as easier to use and more effective, which may help to explain the success of this training approach. Future provider communication interventions should consider implementation outcomes, including acceptability, alongside more traditional TPB constructs. TRIAL REGISTRATION: clinicaltrials.gov, NCT02377843 . Registered on February 27, 2015.

Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial.

OBJECTIVE: Improving provider recommendations is critical to addressing low human papillomavirus (HPV) vaccination coverage. Thus, we sought to determine the effectiveness of training providers to improve their recommendations using either presumptive "announcements" or participatory "conversations." METHODS: In 2015, we conducted a parallel-group randomized clinical trial with 30 pediatric and family medicine clinics in central North Carolina. We randomized clinics to receive no training (control), announcement training, or conversation training. Announcements are brief statements that assume parents are ready to vaccinate, whereas conversations engage parents in open-ended discussions. A physician led the 1-hour, in-clinic training. The North Carolina Immunization Registry provided data on the primary trial outcome: 6-month coverage change in HPV vaccine initiation (≥1 dose) for adolescents aged 11 or 12 years. RESULTS: The immunization registry attributed 17 173 adolescents aged 11 or 12 to the 29 clinics still open at 6-months posttraining. Six-month increases in HPV vaccination coverage were larger for patients in clinics that received announcement training versus those in control clinics (5.4% difference, 95% confidence interval: 1.1%-9.7%). Stratified analyses showed increases for both girls (4.6% difference) and boys (6.2% difference). Patients in clinics receiving conversation training did not differ from those in control clinics with respect to changes in HPV vaccination coverage. Neither training was effective for changing coverage for other vaccination outcomes or for adolescents aged 13 through 17 (n = 37 796). CONCLUSIONS: Training providers to use announcements resulted in a clinically meaningful increase in HPV vaccine initiation among young adolescents.

Messages to Motivate Human Papillomavirus Vaccination: National Studies of Parents and Physicians.

BACKGROUND: Physician communication about human papillomavirus (HPV) vaccine is a key determinant of uptake. To support physician communication, we sought to identify messages that would motivate HPV vaccination. METHODS: From 2014 to 2015, we surveyed national samples of parents of adolescents ages 11 to 17 (n = 1,504) and primary care physicians (n = 776). Parents read motivational messages, selected from nine longer messages developed by the Centers for Disease Control and Prevention and six brief messages developed by the study team. Parents indicated whether each message would persuade them to get HPV vaccine for their adolescents. Physicians read the brief messages and indicated whether they would use them to persuade parents to get HPV vaccine for 11- to 12-year-old children. RESULTS: The highest proportion of parents (65%) and physicians (69%) found this brief message to be persuasive: "I strongly believe in the importance of this cancer-preventing vaccine for [child's name]." Parents disinclined to vaccinate were most receptive to messages with information about HPV infection being common, cancers caused by HPV, and HPV vaccine effectiveness. Parents' endorsement did not vary by race/ethnicity, education, child age, or child sex (all P > 0.05). CONCLUSIONS: Our national surveys of parents and physicians identified messages that could motivate HPV vaccination, even among parents disinclined to vaccinate their children. The lack of difference across demographic subgroups in parental endorsement may suggest that these messages can be used across these subgroups. IMPACT: Our findings support physicians' use of these messages with parents to help motivate uptake of this important cancer-preventing vaccine. Cancer Epidemiol Biomarkers Prev; 25(10); 1383-91. ©2016 AACR.

Quality of physician communication about human papillomavirus vaccine: findings from a national survey.

BACKGROUND: Improving the quality of physicians' recommendations for human papillomavirus (HPV) vaccination is critical to addressing low coverage. Thus, we sought to describe HPV vaccine communication practices among primary care physicians. METHODS: Pediatricians and family physicians (n = 776) completed our national online survey in 2014. We assessed the quality of their HPV vaccine recommendations on strength of endorsement (i.e., saying the vaccine is important), timeliness (recommending it by ages 11-12), consistency (recommending it routinely vs. using a risk-based approach), and urgency (recommending same-day vaccination). RESULTS: A sizeable minority of physicians reported that they do not strongly endorse HPV vaccine (27%) or deliver timely recommendations for girls (26%) or boys (39%). Many physicians (59%) used a risk-based approach to recommending HPV vaccine, and only half (51%) usually recommended same-day vaccination. Overall recommendation quality was lower among physicians who were uncomfortable talking about HPV vaccine or who believed parents did not value it. Quality was higher among physicians who began discussions by saying the child was due for HPV vaccine versus giving information or eliciting questions. CONCLUSION: Many physicians in our national sample reported recommending HPV vaccine inconsistently, behind schedule, or without urgency. These practices likely contribute to under-immunization among adolescents, and may convey ambivalence to parents. IMPACT: As one of the first studies to assess multiple aspects of recommendation quality, these findings can inform the many state and national initiatives that aim to improve communication about HPV vaccine so as to address the persistent underuse of a powerful tool for cancer prevention.

Physician communication about adolescent vaccination: How is human papillomavirus vaccine different?

BACKGROUND: Low human papillomavirus (HPV) vaccination coverage stands in stark contrast to our success in delivering other adolescent vaccines. To identify opportunities for improving physicians' recommendations for HPV vaccination, we sought to understand how the communication context surrounding adolescent vaccination varies by vaccine type. METHODS: A national sample of 776 U.S. physicians (53% pediatricians, 47% family medicine physicians) completed our online survey in 2014. We assessed physicians' perceptions and communication practices related to recommending adolescent vaccines for 11- and 12-year-old patients. RESULTS: About three-quarters of physicians (73%) reported recommending HPV vaccine as highly important for patients, ages 11-12. More physicians recommended tetanus, diphtheria, and acellular pertussis (Tdap) (95%) and meningococcal vaccines (87%, both p<0.001) as highly important for this age group. Only 13% of physicians perceived HPV vaccine as being highly important to parents, which was far fewer than perceived parental support for Tdap (74%) and meningococcal vaccines (62%, both p<0.001). Physicians reported that discussing HPV vaccine took almost twice as long as discussing Tdap. Among physicians with a preferred order for discussing adolescent vaccines, most (70%) discussed HPV vaccine last. CONCLUSIONS: Our findings suggest that primary care physicians perceived HPV vaccine discussions to be burdensome, requiring more time and engendering less parental support than other adolescent vaccines. Perhaps for this reason, physicians in our national study recommended HPV vaccine less strongly than other adolescent vaccines, and often chose to discuss it last. Communication strategies are needed to support physicians in recommending HPV vaccine with greater confidence and efficiency.