Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study.

BACKGROUND: The health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user's primary care physician (PCP). OBJECTIVE: This study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. METHODS: Researchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient's primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. RESULTS: Our analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. CONCLUSIONS: This study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process

Dissolved organic nutrient uptake by riverine phytoplankton varies along a gradient of nutrient enrichment

The concentration of dissolved organic matter (DOM) in freshwaters is increasing in large areas of the world. In addition to carbon, DOM contains nitrogen and phosphorus and there is growing concern that these organic nutrients may be bioavailable and contribute to eutrophication. However, relatively few studies have assessed the potential for dissolved organic nitrogen (DON) or dissolved organic phosphorus (DOP) compounds to be bioavailable to natural river phytoplankton communities at different locations or times. Temporal and spatial variations in uptake, relative to environmental characteristics were examined at six riverine sites in two contrasting catchments in the UK. This study also examined how the uptake by riverine phytoplankton of four DON and four DOP compounds commonly found in rivers, varied with concentration. Total nitrogen (TN) and phosphorus (TP) concentrations, the proportion of inorganic nutrient species, and nutrient limitation varied temporally and spatially, as did the potential for DON and DOP uptake. All eight of the DOM compounds tested were bioavailable, but to different extents. Organic nutrient use depended on the concentration of the organic compound supplied, with simple compounds (urea and glucose-6-phosphate) supporting algal growth even at very low concentrations. DON use was negatively correlated with the TN and ammonia concentration and DOP use was negatively correlated with soluble reactive phosphorus (SRP) and dissolved organic carbon (DOC) concentration. The evidence indicates that DOM in rivers has been overlooked as a potential source of nutrients to phytoplankton and therefore as an agent of eutrophication

Freshwater umbrella - the effects of nitrogen deposition on freshwaters in the UK

In upland areas of the UK located away from direct human disturbance through agriculture, industrial activities and urban pollution, atmospheric pollution poses one of the major threats to the chemical and biological quality of lakes and streams. One of the most important groups of pollutants is nitrogen (N) compounds, including oxidised forms of N called NO_{x}, generated mainly by fossil fuel combustion especially in motor vehicles, and reduced forms of N (ammonia gas or dissolved ammonium compounds) generated mainly from agricultural activities and livestock. These nitrogen compounds may dissolve in rain or soilwater to form acids, or may be taken up as nutrients by plants and soil microbes in upland catchments, and then subsequently released in acid form associated with nitrate leaching at a later date. It is well established that nitrate leaching contributes to acidification of upland waters, with damage to aquatic ecosystems including plants, invertebrates and fish. However it has recently been suggested that nitrate leaching may also be associated with nutrient enrichment of upland waters that contain biological communities adapted to very low nutrient levels. Furthermore, important interactions have been found elsewhere between acid deposition and leaching of dissolved organic carbon (DOC) which has been found to be increasing in many upland waters of the northern hemisphere

Nitrogen processes in aquatic ecosystems

Executive summary Nature of the problem (science/management/policy) • Freshwater ecosystems play a key role in the European nitrogen (N) cycle, both as a reactive agent that transfers, stores and processes N loadings from the atmosphere and terrestrial ecosystems, and as a natural environment severely impacted by the increase of these loadings. Approaches • This chapter is a review of major processes and factors controlling N transport and transformations for running waters, standing waters, groundwaters and riparian wetlands. Key findings/state of knowledge • The major factor controlling N processes in freshwater ecosystems is the residence time of water, which varies widely both in space and in time, and which is sensitive to changes in climate, land use and management. • The effects of increased N loadings to European freshwaters include acidification in semi-natural environments, and eutrophication in more disturbed ecosystems, with associated loss of biodiversity in both cases. • An important part of the nitrogen transferred by surface waters is in the form of organic N, as dissolved organic N (DON) and particulate organic N (PON). This part is dominant in semi-natural catchments throughout Europe and remains a significant component of the total N load even in nitrate enriched rivers. • In eutrophicated standing freshwaters N can be a factor limiting or co-limiting biological production, and control of both N and phosphorus (P) loading is oft en needed in impacted areas, if ecological quality is to be restored. Major uncertainties/challenges • The importance of storage and denitrifi cation in aquifers is a major uncertainty in the global N cycle, and controls in part the response of catchments to land use or management changes. In some aquifers, the increase of N concentrations will continue for decades even if efficient mitigation measures are implemented now. • Nitrate retention by riparian wetlands has oft en been highlighted. However, their use for mitigation must be treated with caution, since their effectiveness is difficult to predict, and side effects include increased DON emissions to adjacent open waters, N2O emissions to the atmosphere, and loss of biodiversity. • In fact, the character and specific spatial origins of DON are not fully understood, and similarly the quantitative importance of indirect N2O emissions from freshwater ecosystems as a result of N leaching losses from agricultural soils is still poorly known at the regional scale. • These major uncertainties remain due to the lack of adequate monitoring (all forms of N at a relevant frequency), especially – but not only – in the southern and eastern EU countries. Recommendations (research/policy) • The great variability of transfer pathways, buffering capacity and sensitivity of the catchments and of the freshwater ecosystems calls for site specific mitigation measures rather than standard ones applied at regional to national scale. • The spatial and temporal variations of the N forms, the processes controlling the transport and transformation of N within freshwaters, require further investigation if the role of N in influencing freshwater ecosystem health is to be better understood, underpinning the implementation of the EU Water Framework Directive for European freshwaters

Do early warning indicators consistently predict nonlinear change in long-term ecological data?

1. Anthropogenic pressures, including climate change, are causing nonlinear changes in ecosystems globally. The development of reliable early warning indicators (EWIs) to predict these changes is vital for the adaptive management of ecosystems and the protection of biodiversity, natural capital and ecosystem services. Increased variance and autocorrelation are potential early warning indicators and can be readily estimated from ecological time series. Here, we undertook a comprehensive test of the consistency between early warning indicators and nonlinear abundance change across species, trophic levels and ecosystem types. 2. We tested whether long-term abundance time series of 55 taxa (126 data sets) across multiple trophic levels in marine and freshwater ecosystems showed (i) significant nonlinear change in abundance ‘turning points’ and (ii) significant increases in variance and autocorrelation (‘early warning indicators’). For each data set, we then quantified the prevalence of three cases: true positives (early warning indicators and associated turning point), false negatives (turning point but no associated early warning indicators) and false positives (early warning indicators but no turning point). 3. True positives were rare, representing only 9% (16 of 170) of cases using variance, and 13% (19 of 152) of cases using autocorrelation. False positives were more prevalent than false negatives (53% vs. 38% for variance; 47% vs. 40% for autocorrelation). False results were found in every decade and across all trophic levels and ecosystems. 4. Time series that contained true positives were uncommon (8% for variance; 6% for autocorrelation), with all but one time series also containing false classifications. Coherence between the types of early warning indicators was generally low with 43% of time series categorized differently based on variance compared to autocorrelation. 5. Synthesis and applications. Conservation management requires effective early warnings of ecosystem change using readily available data, and variance and autocorrelation in abundance data have been suggested as candidates. However, our study shows that they consistently fail to predict nonlinear change. For early warning indicators to be effective tools for preventative management of ecosystem change, we recommend that multivariate approaches of a suite of potential indicators are adopted, incorporating analyses of anthropogenic drivers and process-based understanding

Effects of brownification and warming on algal blooms, metabolism and higher trophic levels in productive shallow lake mesocosms

An increase of dissolved organic carbon (DOC) in inland waters has been reported across the northern temperate region but the effects of this on whole lake ecosystems, often combined with other anthropogenic stressors like nutrient inputs and warming, are poorly known. The effects of these changes on different component of the ecosystem were assessed in an experiment using twenty-four large (3000L) outdoor mesocosms simulating shallow lakes. Two different temperature regimes (ambient and ambient +4 °C) combined with three levels of organic matter (OM, added as filtered peaty water), simulating the DOC increase that is predicted to take place over the next 4 to 21 years were used. Neither temperature nor OM had significant effects on net ecosystem production, respiration or gross primary production. Phytoplankton chlorophyll a concentration was not significantly affected by warming, however in summer, autumn and winter it was significantly higher in mesocosms receiving intermediate OM levels (July–Feb DOC concentrations 2–6 mg L−1). Summer cyanobacterial blooms were highest in intermediate, and lowest in the highest OM treatments. OM concentration also influenced total macroinvertebrate abundance which was greater in spring and summer in mesocosms with intermediate and high OM. Fish abundance was not significantly affected by OM concentration, but abundance was greater in ambient (55 fish subsample−1) compared to heated mesocosms (17 fish subsample−1) and maximum abundance occurred two weeks later compared to heated mesocosms. The results suggest that changes in OM may have a greater effect on shallow lakes than temperature and that phytoplankton, especially cyanobacteria, benefit from intermediate OM concentrations, therefore, nuisance algal blooms might increase in relatively clear shallow eutrophic lakes where DOC concentrations increase

Inorganic carbon physiology underpins macroalgal responses to elevated CO2

Beneficial effects of CO2 on photosynthetic organisms will be a key driver of ecosystem change under ocean acidification. Predicting the responses of macroalgal species to ocean acidification is complex, but we demonstrate that the response of assemblages to elevated CO2 are correlated with inorganic carbon physiology. We assessed abundance patterns and a proxy for CO2:HCO3- use (\u3b413C values) of macroalgae along a gradient of CO2 at a volcanic seep, and examined how shifts in species abundance at other Mediterranean seeps are related to macroalgal inorganic carbon physiology. Five macroalgal species capable of using both HCO3- and CO2 had greater CO2 use as concentrations increased. These species (and one unable to use HCO3-) increased in abundance with elevated CO2 whereas obligate calcifying species, and non-calcareous macroalgae whose CO2 use did not increase consistently with concentration, declined in abundance. Physiological groupings provide a mechanistic understanding that will aid us in determining which species will benefit from ocean acidification and why

Diurnal changes in seawater carbonate chemistry speciation at increasing atmospheric carbon dioxide

Natural variability in seawater pH and associated carbonate chemistry parameters is in part driven by biological activities such as photosynthesis and respiration. The amplitude of these variations is expected to increase with increasing seawater carbon dioxide (CO2) concentrations in the future, because of simultaneously decreasing buffer capacity. Here, we address this experimentally during a diurnal cycle in a mesocosm CO2 perturbation study. We show that for about the same amount of dissolved inorganic carbon (DIC) utilized in net community production diel variability in proton (H+) and CO2 concentrations was almost three times higher at CO2 levels of about 675 ± 65 in comparison with levels of 310 ± 30 μatm. With a simple model, adequately simulating our measurements, we visualize carbonate chemistry variability expected for different oceanic regions with relatively low or high net community production. Since enhanced diurnal variability in CO2 and proton concentration may require stronger cellular regulation in phytoplankton to maintain respective gradients, the ability to adjust may differ between communities adapted to low in comparison with high natural variability