Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk

BackgroundAn estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described.MethodsThe Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945–1964). The study was conducted at three primary care clinics in the Bronx, New York.ResultsBoth interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P < 0.001) and 9.9% during the birth cohort period (P < 0.001).ConclusionsTwo simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.     

Best practices to optimize utilization of the National Living Donor Assistance Center for the financial assistance of living organ donors

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow‐up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs’ NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States.     

Ancient plant DNA reveals High Arctic greening during the Last Interglacial

Summer warming is driving a greening trend across the Arctic, with the potential for large-scale amplification of climate change due to vegetation-related feedbacks [Pearson et al., Nat. Clim. Chang. (3), 673–677 (2013)]. Because observational records are sparse and temporally limited, past episodes of Arctic warming can help elucidate the magnitude of vegetation response to temperature change. The Last Interglacial ([LIG], 129,000 to 116,000 y ago) was the most recent episode of Arctic warming on par with predicted 21st century temperature change [Otto-Bliesner et al., Philos. Trans. A Math. Phys. Eng. Sci. (371), 20130097 (2013) and Post et al., Sci. Adv. (5), eaaw9883 (2019)]. However, high-latitude terrestrial records from this period are rare, so LIG vegetation distributions are incompletely known. Pollen-based vegetation reconstructions can be biased by long-distance pollen transport, further obscuring the paleoenvironmental record. Here, we present a LIG vegetation record based on ancient DNA in lake sediment and compare it with fossil pollen. Comprehensive plant community reconstructions through the last and current interglacial (the Holocene) on Baffin Island, Arctic Canada, reveal coherent climate-driven community shifts across both interglacials. Peak LIG warmth featured a ∼400-km northward range shift of dwarf birch, a key woody shrub that is again expanding northward. Greening of the High Arctic—documented here by multiple proxies—likely represented a strong positive feedback on high-latitude LIG warming. Authenticated ancient DNA from this lake sediment also extends the useful preservation window for the technique and highlights the utility of combining traditional and molecular approaches for gleaning paleoenvironmental insights to better anticipate a warmer future.

The Arctic is greening as shrub biomass increases and vegetation ranges shift north in response to summer warming (1, 2). This process—one of the clearest terrestrial manifestations of climate change thus far—has major implications both for local ecosystems and for global energy balance and biogeochemical systems (3–5). In particular, taller shrubs darken otherwise snow-covered surfaces, contributing to the albedo feedback (6, 7), and enhanced evapotranspiration is expected to result in a positive greenhouse feedback (8). Shrub cover also impacts soil thermal regime, which may impact permafrost vulnerability (9–11). Because feedbacks related to Arctic greening are complex and potentially large in magnitude, estimating the extent and rate of northward shrub migration is a vital component of predicting future warming.Past warm periods serve as valuable analogs for understanding the extent of Arctic greening under well-constrained climate conditions. The Last Interglacial (LIG; Marine Isotope Stage [MIS] 5e, 129 to 116 ka [thousands of years before present]) was ∼1 °C warmer than the preindustrial period globally, but the Arctic experienced amplified warming due to higher summer insolation anomalies and positive feedbacks at high latitudes (12, 13). The Eastern Canadian Arctic and Greenland, in particular, were likely ∼4 to 8 °C warmer in summer than present (Fig. 1) (14–18). LIG sediment records from this region thus provide an archive of the vegetation response to Arctic warming at levels comparable to predicted 21^st-century climate change (19).Open in a separate windowFig. 1.Map of Baffin Island and Lake CF8 study area. The symbols represent maximum LIG temperature anomalies based on terrestrial proxy records (shape indicates proxy type) from Baffin Island and Greenland (see SI Appendix, Table S1 for metadata). The shaded regions indicate Arctic bioclimate subzones delineations (29), including modern Betula range in subzones D and E. We note that a small outlier population of Betula occurs east of the D/E boundary on Baffin Island (not captured by vegetation map resolution) (38).While most High Arctic lake basins were scraped clean by ice sheet erosion during the last glaciation and thus only contain postglacial sediments, lakes with small, low-relief catchments within regions of cold-based, slow-flowing ice were protected from erosion. Several such sites have been discovered on eastern Baffin Island, Arctic Canada and contain stratified records of multiple interglacials (20–22). Previous work from Lake CF8 on northeastern Baffin Island (Fig. 1 and SI Appendix, Fig. S1) demonstrates that its sediment record spans at least three interglacials (∼200 ka), including a substantially warmer-than-present LIG as indicated by chironomids, diatoms, and geochemical proxies (15, 23).We targeted the multi-interglacial record from Lake CF8 to assess the vegetation response to pronounced warmth during the LIG and moderate warmth during the Holocene. Pollen produced by some key shrubs and trees, including Betula (birch), is efficiently wind-transported and thus present in lake sediments far north of their ranges (24, 25). We therefore analyzed both sedimentary ancient DNA (sedaDNA), which is sourced locally from within the lake catchment and does not include pollen-derived DNA (26), and fossil pollen to generate a robust vegetation record spanning the last ∼130 ka. Taken together, DNA-inferred plant communities and pollen-inferred July air temperatures provide insight into Arctic plant range shifts under strong summer warming.     

Building Strong Research Partnerships Between Public Health and Researchers: A VA Case Study

We are in a new era of partner-based implementation research, and we need clear strategies for how to navigate this new era. Drawing on principles from community-based participatory research, the Clinical Public Health group of the Department of Veterans Affairs and the HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) forged a longstanding partnership that has improved the care of Veterans with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus. An exemplar HIV testing project epitomizes this partnership and is discussed in terms of the lessons learned as a result of our high level of collaboration around design, analysis, implementation, and dissemination across projects over the past several years. Lessons learned through this partnered testing program involve respecting different time horizons among the partners, identifying relevant research questions for both parties, designing flexible studies, engaging all partners throughout the research, and placing an emphasis on relationship building at all times. These lessons and strategies can benefit others conducting partner-based research both within the Veterans Health Administration (VA) and in other integrated healthcare systems.     

临床疑似TTP-HUS患者血浆置换治疗引起的并发症

由于采用血浆置换(PE)治疗血栓性血小板减少性紫癜溶血性尿毒综合征(TTP HUS)频率的增加,PE引起的并发症也成为制定治疗方案时需要考虑的因素。由于TTP HUS的诊断常常是不确定的,掌握PE治疗利弊之间的平衡已成为制定适当治疗方案的焦点。之前,我们于1996年～2002年间曾两次报道     

Acute intranasal osteopontin treatment in male rats following TBI increases the number of activated microglia but does not alter lesion characteristics

Intranasal recombinant osteopontin (OPN) has been shown to be neuroprotective in different models of acquired brain injury but has never been tested after traumatic brain injury (TBI). We used a model of moderate-to-severe controlled cortical impact in male adult Sprague Dawley rats and tested our hypothesis that OPN treatment would improve neurological outcomes, lesion and brain tissue characteristics, neuroinflammation, and vascular characteristics at 1 day post-injury. Intranasal OPN administered 1 hr after the TBI did not improve neurological score, lesion volumes, blood–brain barrier, or vascular characteristics. When assessing neuroinflammation, we did not observe any effect of OPN on the astrocyte reactivity but discovered an increased number of activated microglia within the ipsilateral hemisphere. Moreover, we found a correlation between edema and heme oxygenase-1 (HO-1) expression which was decreased in OPN-treated animals, suggesting an effect of OPN on the HO-1 response to injury. Thus, OPN may increase or accelerate the microglial response after TBI, and early response of HO-1 in modulating edema formation may limit the secondary consequences of TBI at later time points. Additional experiments and at longer time points are needed to determine if intranasal OPN could potentially be used as a treatment after TBI where it might be beneficial by activating protective signaling pathways.