A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

Satellite and in situ cyanobacteria monitoring: Understanding the impact of monitoring frequency on management decisions.

Cyanobacterial harmful algal blooms (cyanoHABs) in reservoirs can be transported to downstream waters via scheduled discharges. Transport dynamics are difficult to capture in traditional cyanoHAB monitoring, which can be spatially disparate and temporally discontinuous. The introduction of satellite remote sensing for cyanoHAB monitoring provides opportunities to detect where cyanoHABs occur in relation to reservoir release locations, like canal inlets. The study objectives were to assess (1) differences in reservoir cyanoHAB frequencies as determined by in situ and remotely sensed data and (2) the feasibility of using satellite imagery to identify conditions associated with release-driven cyanoHAB export. As a representative case, Lake Okeechobee and the St. Lucie Estuary (Florida, USA), which receives controlled releases from Lake Okeechobee, were examined. Both systems are impacted by cyanoHABs, and the St. Lucie Estuary experienced states of emergency for extreme cyanoHABs in 2016 and 2018. Using the European Space Agency's Sentinel-3 OLCI imagery processed with the Cyanobacteria Index (CIcyano), cyanoHAB frequencies across Lake Okeechobee from May 2016-April 2021 were compared to frequencies from in situ data. Strong agreement was observed in frequency rankings between the in situ and remotely sensed data in capturing intra-annual variability in bloom frequencies across Lake Okeechobee (Kendall's tau = 0.85, p-value = 0.0002), whereas no alignment was observed when evaluating inter-annual variation (Kendall's tau = 0, p-value = 1). Further, remotely sensed observations revealed that cyanoHABs were highly frequent near the inlet to the canal connecting Lake Okeechobee to the St. Lucie Estuary in state-of-emergency years, a pattern not evident from in situ data alone. This study demonstrates how remote sensing can complement traditional cyanoHAB monitoring to inform reservoir release decision making.

Search for Campylobacter spp. Reveals High Prevalence and Pronounced Genetic Diversity of Arcobacter butzleri in Floodwater Samples Associated with Hurricane Florence in North Carolina, USA.

In September 2018, Hurricane Florence caused extreme flooding in eastern North Carolina, USA, a region highly dense in concentrated animal production, especially swine and poultry. In this study, floodwater samples (n = 96) were collected as promptly post-hurricane as possible and for up to approximately 30 days and selectively enriched for Campylobacter using Bolton broth enrichment and isolation on modified charcoal cefoperazone deoxycholate agar (mCCDA) microaerobically at 42°C. Only one sample yielded Campylobacter, which was found to be Campylobacter jejuni with the novel sequence type 2866 (ST-2866). However, the methods employed to isolate Campylobacter readily yielded Arcobacter from 73.5% of the floodwater samples. The Arcobacter isolates failed to grow on Mueller-Hinton agar at 25, 30, 37, or 42°C microaerobically or aerobically but could be readily subcultured on mCCDA at 42°C microaerobically. Multilocus sequence typing of 112 isolates indicated that all were Arcobacter butzleri The majority (85.7%) of the isolates exhibited novel sequence types (STs), with 66 novel STs identified. Several STs, including certain novel ones, were detected in diverse waterbody types (channel, isolated ephemeral pools, floodplain) and from multiple watersheds, suggesting the potential for regionally dominant strains. The genotypes were clearly partitioned into two major clades, one with high representation of human and ruminant isolates and another with an abundance of swine and poultry isolates. Surveillance of environmental waters and food animal production systems in this animal agriculture-dense region is needed to assess potential regional prevalence and temporal stability of the observed A. butzleri strains as well as their potential association with specific types of food animal production.IMPORTANCE Climate change and associated extreme weather events can have massive impacts on the prevalence of microbial pathogens in floodwaters. However, limited data are available on foodborne zoonotic pathogens such as Campylobacter or Arcobacter in hurricane-associated floodwaters in rural regions with intensive animal production. With a high density of intensive animal production as well as pronounced vulnerability to hurricanes, eastern North Carolina presents unique opportunities in this regard. Our findings revealed widespread incidence of the emerging zoonotic pathogen Arcobacter butzleri in floodwaters from Hurricane Florence. We encountered high and largely unexplored diversity while also noting the potential for regionally abundant and persistent clones. We noted pronounced partitioning of the floodwater genotypes into two source-associated clades. The data will contribute to elucidating the poorly understood ecology of this emerging pathogen and highlight the importance of surveillance of floodwaters associated with hurricanes and other extreme weather events for Arcobacter and other zoonotic pathogens.

Revealing Biotic and Abiotic Controls of Harmful Algal Blooms in a Shallow Subtropical Lake through Statistical Machine Learning.

Harmful algal blooms are a growing human and environmental health hazard globally. Eco-physiological diversity of the cyanobacteria genera that make up these blooms creates challenges for water managers tasked with controlling the intensity and frequency of blooms, particularly of harmful taxa (e.g., toxin producers, N2 fixers). Compounding these challenges is the ongoing debate over the efficacy of nutrient management strategies (phosphorus-only versus nitrogen and phosphorus), which increases decision-making uncertainty. To improve our understanding of how different cyanobacteria respond to nutrient levels and other biophysical factors, we analyzed a unique 17 year data set comprising monthly observations of cyanobacteria genera and zooplankton abundances, water quality, and flow in a bloom-impacted, subtropical, flow-through lake in Florida (United States). Using the Random Forests machine learning algorithm, an ensemble modeling approach, we characterized and quantified relationships among environmental conditions and five dominant cyanobacteria genera. Results highlighted nonlinear relationships and critical thresholds between cyanobacteria genera and environmental covariates, the potential for hydrology and temperature to limit the efficacy of cyanobacteria bloom management actions, and the importance of a dual nutrient management strategy for reducing bloom risk in the long term.

Assessing the utility of shellfish sanitation monitoring data for long-term estuarine water quality analysis.

Regular testing of coastal waters for fecal coliform bacteria by shellfish sanitation programs could provide data to fill large gaps in existing coastal water quality monitoring, but research is needed to understand the opportunities and limitations of using these data for inference of long-term trends. In this study, we analyzed spatiotemporal trends from multidecadal fecal coliform concentration observations collected by a shellfish sanitation program, and assessed the feasibility of using these monitoring data to infer long-term water quality dynamics. We evaluated trends in fecal coliform concentrations for a 20-year period (1999-2021) using data collected from spatially fixed sampling sites (n = 466) in North Carolina (USA). Findings indicated that shellfish sanitation data can be used for long-term water quality inference under relatively stationary management conditions, and that salinity trends can be used to investigate management-driven bias in fecal coliform observations collected in a particular area.

Short-term forecasting of fecal coliforms in shellfish growing waters.

This study sought to develop models for predicting near-term (1-3 day) fecal contamination events in coastal shellfish growing waters. Using Random Forest regression, we (1) developed fecal coliform (FC) concentration models for shellfish growing areas using watershed characteristics and antecedent hydrologic and meteorologic observations as predictors, (2) tested the change in model performance associated when forecasted, as opposed to measured, rainfall variables were used as predictors, and (3) evaluated model predictor importance in relation to shellfish sanitation management criteria. Models were trained to 10 years of coastal FC measurements (n = 1285) for 5 major shellfish management areas along the Florida (USA) coast. Model performance varied between the 5 management areas with R2 ranging from 0.36 to 0.72. Antecedent precipitation variables were among the most important predictors in the day-of forecast models in all management areas. When forecasted rainfall was included in the models, wind components became increasingly important.

Reconstructing the historical expansion of industrial swine production from Landsat imagery.

In the USA, historical data on the period over which industrial swine farms have operated are usually only available at the county scale and released every 5 years via the USDA Census of Agriculture, leaving the history of the swine industry and its potential legacy effects on the environment poorly understood. We developed a changepoint-based workflow that recreates the construction timelines of swine farms, specifically by identifying the construction years of swine manure lagoons from historical Landsat 5 imagery for the period of 1984 to 2012. The study focused on the Coastal Plain of North Carolina, a major pork-producing state in the USA. The algorithm successfully predicted the year of swine waste lagoon construction (+ /- 1 year) with an accuracy of approximately 94% when applied to the study area. By estimating the year of construction of 3405 swine waste lagoons in NC, we increased the resolution of available information on the expansion of swine production from the county scale to spatially-explicit locations. We further analyzed how the locations of swine waste lagoons changed in proximity to water resources over time, and found a significant increase in swine waste lagoon distances to the nearest water feature across the period of record.

Hurricanes, El Niño and harmful algal blooms in two sub-tropical Florida estuaries: Direct and indirect impacts.

Future increases in the intensity of hurricanes and El Niño periods predicted by climate change models have focused attention on their role in stimulating harmful algal blooms (HABs). A series of hurricanes that recently impacted Florida (USA) provided a unique opportunity to explore the relationships between hurricanes, El Niño and HABs in two Florida estuaries subject to repeated intense ecosystem disruptive HABs, the Indian River Lagoon and the St. Lucie Estuary. The roles that hurricanes and El Niño play in contributing to HAB events are examined in the context of key structural and functional features of each estuary and their watersheds, including morphology, water residence time and hydrology, such as the influence of Lake Okeechobee discharges into the St. Lucie Estuary. The most direct impact was the increase in rainfall associated with hurricanes and El Niño, resulting in enhanced nutrient loads which drive HABs in the Indian River Lagoon and Lake Okeechobee. Major HABs in Lake Okeechobee also present an indirect threat of freshwater HAB blooms in the St. Lucie Estuary via mandated discharges from the lake into the estuary during high rainfall periods. Conversely, during the absence of HABs in Lake Okeechobee, short water residence times produced by discharges into the St. Lucie Estuary can result in lower bloom intensities.

Apoptotic susceptibility to DNA damage of pluripotent stem cells facilitates pharmacologic purging of teratoma risk.

Pluripotent stem cells have been the focus of bioengineering efforts designed to generate regenerative products, yet harnessing therapeutic capacity while minimizing risk of dysregulated growth remains a challenge. The risk of residual undifferentiated stem cells within a differentiated progenitor population requires a targeted approach to eliminate contaminating cells prior to delivery. In this study we aimed to validate a toxicity strategy that could selectively purge pluripotent stem cells in response to DNA damage and avoid risk of uncontrolled cell growth upon transplantation. Compared with somatic cell types, embryonic stem cells and induced pluripotent stem cells displayed hypersensitivity to apoptotic induction by genotoxic agents. Notably, hypersensitivity in pluripotent stem cells was stage-specific and consistently lost upon in vitro differentiation, with the mean half-maximal inhibitory concentration increasing nearly 2 orders of magnitude with tissue specification. Quantitative polymerase chain reaction and Western blotting demonstrated that the innate response was mediated through upregulation of the BH3-only protein Puma in both natural and induced pluripotent stem cells. Pretreatment with genotoxic etoposide purged hypersensitive pluripotent stem cells to yield a progenitor population refractory to teratoma formation upon transplantation. Collectively, this study exploits a hypersensitive apoptotic response to DNA damage within pluripotent stem cells to decrease risk of dysregulated growth and augment the safety profile of transplant-ready, bioengineered progenitor cells.

Integrated electromyography and performance outcomes to inertial resistance exercise.

Integrated electromyography (IEMG) and performance outcomes from resistance exercise may be influenced by gender, repetition order, and contractile mode. A novel strength training apparatus employing inertial resistance operates unlike standard exercise equipment and may therefore evoke different IEMG and performance outcomes. Subjects performed 3-set, 10-repetition calf press workouts on an inertial device while IEMG and flywheel velocity were recorded. Dependent variables were examined with 2 (men, women) x 2 (first vs. 10th repetition) x 2 (concentric, eccentric) analyses of variance. Performance outcomes showed gender-by-repetition and gender-by-contractile-mode interactions, with men's 10th-repetition and men's concentric data, respectively, causing these effects. Medial gastrocnemius (MG) IEMG showed a gender-by-repetition interaction resulting from men's first-repetition data. Greater 10th-repetition performance despite higher first-repetition MG IEMG may result from heightened triceps surae elastic energy utilization and/or maintained cross-bridges during transitions from lengthening-to-shortening actions. Inertial strength training may improve performance outcomes without additional motor unit recruitment.

Inclusion of eccentric actions on net caloric cost resulting from isoinertial resistance exercise.

Net O(2) uptake was measured from maximal-effort 3-set, 8-repetition seated leg press protocols on an isoinertial ergometer. Subjects (25 women, 9 men) did 2 workouts each exerting concentric-eccentric (CE) and concentric-only (CO) knee extensor forces to measure work and net caloric cost. Significant (p < 0.05) relationships between work and net caloric cost resulted from CE and CO workouts for the male, female, and total subject sample. Two-way repeated-measures analyses of variance showed CE workouts resulted in significantly higher work but not net caloric cost and values. CE workouts likely relied on the knee extensors series elastic element to perform an additional approximately 3,600 J of eccentric work at no additional net caloric cost. Unlike other exercise modes, maximal-effort eccentric actions on the isoinertial ergometer, as done in the current study, provide no additional net caloric cost and is thus safe to administer to populations in whom metabolic cost is a concern.