Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial.

BACKGROUND: Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS: We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION: This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Unmet Needs of Male Caregivers of Children and Youth with Special Health Care Needs.

OBJECTIVES: The caregiving experiences and unique health needs of male caregivers of children and youth with special health care needs (CYSHCN) are not well described. This study seeks to understand potential unmet health needs and attitudes toward supportive resources from the perspective of a sample of male caregivers of CYSHCN. METHODS: This mixed-methods study recruited a convenience sample of 30 men with CYSHCN who receive care for a chronic medical condition from primary care medical homes in Pennsylvania. We conducted semi-structured interviews (SSI), administered quantitative surveys to caregivers, and produced a thematic analysis. The SSI explored the health needs of male caregivers, assessed attitudes toward and preferences regarding supportive resources, and garnered their advice to other caregivers regarding parenting and health care system navigation. RESULTS: Participants' median age is 41 years (IQR: 33, 44), and most (80%) reside full time with their CYSHCN. Most male caregivers deprioritized their own emotional, mental, and physical health needs to support the needs of their families. Many male caregivers articulated interest in seeking emotionally supportive resources (not time-intensive). They advised other male caregivers to remain involved in the medical care and wellbeing of their CYSCHN and to openly seek and receive emotional support despite the daily challenges they face. CONCLUSIONS FOR PRACTICE: Male caregivers of CYSHCN experience intense daily stress and express the need for emotionally supportive resources. Programs designed to facilitate such support may benefit from flexible formats (time and location) and involve male caregivers of CYSHCN as both facilitators and participants.

Technical note: Bovine adipocyte and preadipocyte co-culture as an efficient adipogenic model.

Reductionist studies of adipose tissue biology require reliable in vitro adipocyte culturing models. Current protocols for adipogenesis induction in stromal vascular fraction-derived preadipocytes require extended culturing periods and have low adipogenic rates. We compared the adipogenic efficiency of a 7-d co-culture model of visceral (VIS) and subcutaneous (SC) stromal vascular fraction-derived preadipocytes with mature adipocytes with a 14-d standard adipocyte differentiation protocol. We obtained preadipocytes and mature adipocytes from SC and VIS adipose tissue of nonlactating, nongestating Holstein cows (n = 6). Adipogenesis induction was performed using a standard protocol for 7 (SD7; control) or 14 d (SD14), and a co-culture model for 7 d (CC7). Culture conditions, including medium composition, were the same for all treatments. For CC7, 900 primary adipocytes/cm2 were placed in 0.4-µm transwell inserts and co-cultured with preadipocytes for adipogenesis induction. Both CC7 and SD14 similarly stimulated gene expression of adipogenic genes such as ADIPOQ, CEBPA, and CEBPB in VIS and SC. The CC7 increased triacylglycerol accumulation compared with SD14 and SD7. CC7 augmented triacylglycerol accumulation by 40- and 16-fold in SC and VIS compared with 22- and 4-fold increment in SD14, respectively. Lipolytic responses to 2-h ß-adrenergic stimulation with 1 µM isoproterenol were higher in CC7 and SD14 than SD7 in SC; CC7 increased glycerol release compared with SD7 in VIS but SD7 and SD14 had similar responses. Overall, CC7 was more efficient in inducing adipogenesis in preadipocytes from VIS and SC than SD14. Furthermore, CC7 stimulated similar lipolysis and lipogenic responses than SD14 but in a shorter time. The adipogenic approach of co-culturing preadipocytes with mature adipocytes will improve the use of reductionist models to study adipocyte physiology in dairy cows and the assessment of pharmacological or nutritional interventions for enhancing dairy cow health and production.