Developing Two-Generation Approaches in Communities: Final Report from Family-Centered Community Change

The Annie E. Casey Foundation launched its Family-Centered Community Change (FCCC) initiative with a goal of integrating two-generation strategies into existing place-based community initiatives. The innovative effort, which ran from 2012 to 2019, focused on supporting local partners in three neighborhoods with low economic resources: Buffalo, New York; Columbus, Ohio; and San Antonio, Texas.Over the course of the initiative, the sites worked to promote the healthy development and academic success of children while simultaneously delivering adult services focused on parenting and financial stability. In year three, the community partners also received training and technical assistance — provided by the Casey Foundation — aimed at enhancing racial and ethnic equity and inclusion.The Urban Institute conducted a formative evaluation of this effort, which included: 1) qualitative data collection from interviews and focus groups with partner staff and participants; 2) descriptive analysis of program data; and 3) a cost study

Study protocol: a pragmatic, stepped-wedge trial of tailored support for implementing social determinants of health documentation/action in community health centers, with realist evaluation

Abstract Background National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action. Methods This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics’ implementation efforts. Discussion Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance. Trial registration clinicaltrials.gov, NCT03607617 , registration date: 7/31/2018—retrospectively registere

Structure and functional characterization of pyruvate decarboxylase from Gluconacetobacter diazotrophicus

BACKGROUND: Bacterial pyruvate decarboxylases (PDC) are rare. Their role in ethanol production and in bacterially mediated ethanologenic processes has, however, ensured a continued and growing interest. PDCs from Zymomonas mobilis (ZmPDC), Zymobacter palmae (ZpPDC) and Sarcina ventriculi (SvPDC) have been characterized and ZmPDC has been produced successfully in a range of heterologous hosts. PDCs from the Acetobacteraceae and their role in metabolism have not been characterized to the same extent. Examples include Gluconobacter oxydans (GoPDC), G. diazotrophicus (GdPDC) and Acetobacter pasteutrianus (ApPDC). All of these organisms are of commercial importance. RESULTS: This study reports the kinetic characterization and the crystal structure of a PDC from Gluconacetobacter diazotrophicus (GdPDC). Enzyme kinetic analysis indicates a high affinity for pyruvate (KM 0.06 mM at pH 5), high catalytic efficiencies, pHopt of 5.5 and Topt at 45 degrees C. The enzyme is not thermostable (T of 18 minutes at 60 degrees C) and the calculated number of bonds between monomers and dimers do not give clear indications for the relatively lower thermostability compared to other PDCs. The structure is highly similar to those described for Z. mobilis (ZmPDC) and A. pasteurianus PDC (ApPDC) with a rmsd value of 0.57 A for C? when comparing GdPDC to that of ApPDC. Indole-3-pyruvate does not serve as a substrate for the enzyme. Structural differences occur in two loci, involving the regions Thr341 to Thr352 and Asn499 to Asp503. CONCLUSIONS: This is the first study of the PDC from G. diazotrophicus (PAL5) and lays the groundwork for future research into its role in this endosymbiont. The crystal structure of GdPDC indicates the enzyme to be evolutionarily closely related to homologues from Z. mobilis and A. pasteurianus and suggests strong selective pressure to keep the enzyme characteristics in a narrow range. The pH optimum together with reduced thermostability likely reflect the host organisms niche and conditions under which these properties have been naturally selected for. The lack of activity on indole-3-pyruvate excludes this decarboxylase as the enzyme responsible for indole acetic acid production in G. diazotrophicus.IS

Implementing Peer-Based Interventions in Clinic-Based Settings: Lessons from a Multi-Site HIV Prevention with Positives Initiative

Interventions for people with HIV/AIDS became a national priority in 2003. While the importance of involving HIV-positive people in the design, delivery, and evaluation of prevention programs is widely recognized, information about how to implement peer-based services in clinic settings is sparse. The four projects described in this article implemented peer-based interventions as part of larger, multi-site Special Projects of National Significance (SPNS) initiative. Common themes reported by Project Directors/Evaluators describe the challenges and benefits of peer-based interventions across these programs, including infrastructural, clinical and research-related issues. We also discuss the benefits to Peers, researchers, and the clinics sites

Adoption of Social Determinants of Health EHR Tools by Community Health Centers

PurposeThis pilot study assessed the feasibility of implementing electronic health record (EHR) tools for collecting, reviewing, and acting on patient-reported social determinants of health (SDH) data in community health centers (CHCs). We believe it is the first such US study.MethodsWe implemented a suite of SDH data tools in 3 Pacific Northwest CHCs in June 2016, and used mixed methods to assess their adoption through July 2017. We modified the tools at clinic request; for example, we added questions that ask if the patient wanted assistance with SDH needs.ResultsSocial determinants of health data were collected on 1,130 patients during the study period; 97% to 99% of screened patients (n = 1,098) had ≥1 SDH need documented in the EHR, of whom 211 (19%) had an EHR-documented SDH referral. Only 15% to 21% of patients with a documented SDH need indicated wanting help. Examples of lessons learned on adoption of EHR SDH tools indicate that clinics should: consider how to best integrate tools into existing workflow processes; ensure that staff tasked with SDH efforts receive adequate tool training and access; and consider that timing of data entry impacts how and when SDH data can be used.ConclusionsOur results indicate that adoption of systematic EHR-based SDH documentation may be feasible, but substantial barriers to adoption exist. Lessons from this study may inform primary care providers seeking to implement SDH-related efforts, and related health policies. Far more research is needed to address implementation barriers related to SDH documentation in EHRs

Study protocol: a pragmatic, stepped-wedge trial of tailored support for implementing social determinants of health documentation/action in community health centers, with realist evaluation

Abstract Background National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action. Methods This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics’ implementation efforts. Discussion Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance. Trial registration clinicaltrials.gov, NCT03607617, registration date: 7/31/2018—retrospectively registere

Infliximab is not associated with increased risk of malignancy or hemophagocytic lymphohistiocytosis in pediatric patients with inflammatory bowel disease

BACKGROUND AND AIMS: Immunosuppressive therapy for inflammatory bowel disease (IBD) in pediatric patients is thought to increase the risk of malignancy and lymphoproliferative disorders, including hemophagocytic lymphohistiocytosis (HLH). We compared unadjusted incidence rates of malignancy and HLH in pediatric patients with IBD exposed to infliximab (IFX) with patients not exposed to biologics and calculated standardized incidence ratios (SIRs). METHODS: We collected and analyzed data from 5766 participants in a prospective study of long-term outcomes of pediatric patients with IBD (NCT00606346), from May 31, 2007 through June 30, 2016. Patients were 17 years old or younger and had Crohn's disease, ulcerative colitis, or IBD-unclassified with 24,543.0 patient-years of follow-up. We estimated incidence rates for malignancy and HLH as events/1000 patient-years of follow-up. We calculated age-, sex-, and race-adjusted SIRs, with 95% confidence intervals (CIs), using the Surveillance, Epidemiology, and End Results Program (SEER) database. RESULTS: Thirteen of the 15 patients who developed a malignancy and all 5 of the patients who developed HLH had been exposed to thiopurines; 10 patients with malignancy had also been exposed to a biologic agent. Unadjusted incidence rates showed no increased risk of malignancy (0.46/1000 patient-years) or HLH (0.0/1000 patient-years) in patients exposed to IFX as the only biologic vs those unexposed to biologics (malignancy: 1.12/1000 patient-years; HLH: 0.56/1000 patient-years). SIRs did not demonstrate an increased risk of malignancy among patients exposed to IFX (SIR, 1.69; 95% CI, 0.46-4.32) vs patients not exposed to a biologic agent (SIR, 2.17; 95% CI, 0.59-5.56), even when patients were stratified by thiopurine exposure. CONCLUSIONS: In determination of age-, sex-, and race-adjusted SIRs using data from a large clinical study and the SEER database, we found that IFX exposure did not associate with increased risk of malignancy or HLH in pediatric patients with IBD. Thiopurine exposure is an important precedent event for the development of malignancy or HLH in pediatric patients with IBD