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Objectives As community viral load ( CVL) measurements are associated with the incidence of new HIV-1 infections in a population, we hypothesized that similarly measured community drug resistance ( CDR) could predict the prevalence of transmitted drug resistance ( TDR). Methods Between 2001 and 2011, the prevalences of HIV-1 drug resistance for patients with established infection receiving HIV care (i.e. CDR) and TDR in recently infected patients were determined in San Diego. At each position in HIV-1 reverse transcriptase ( RT) and protease ( pro), drug resistance was evaluated both as the overall prevalence of resistance-associated mutations and by weighting each resistance position to the concurrent viral load of the patient and its proportion to the total viral load of the clinic ( CVL). The weighting was the proportion of the CVL associated with patients identified with resistance at each residue. Spearman ranked correlation coefficients were used to determine associations between CDR and TDR. Results We analysed 1088 resistance tests for 971 clinic patients and baseline resistance tests for 542 recently infected patients. CDR at positions 30, 46, and 88 in pro was associated with TDR between 2001 and 2011. When CDR was weighted by the viral load of patients, CDR was associated with TDR at position 103 in RT. Each of these associations was corroborated at least once using shorter measurement intervals. Conclusions Despite evaluation of a limited percentage of chronically infected patients in San Diego, CDR correlated with TDR at key resistance positions and therefore may be a useful tool with which to predict the prevalence of TDR. [ABSTRACT FROM AUTHOR]

Objective: Korean Americans have higher incidence of stomach, liver, and cervical cancer than most groups in CA, USA, and generally lower rates of cancer screening. To better target community interventions, we evaluated the cancer content in a leading Korean American newspaper, the Korea Daily, compared to a mainstream newspaper from the same metropolitan area, the Los Angeles (LA) Times. Methods: Using the online versions of each newspaper for the year 2006, we counted articles mentioning cancer and evaluated the content in a random sample of 300 articles from each newspaper. Articles were categorized by relevance of cancer content and topic(s) covered. Results: Although the LA Times had a higher proportion of articles mentioning cancer, the Korea Daily had more articles that primarily focused on cancer and addressed specific types of cancer. Articles in the Korea Daily were more likely to discuss prevention, while those in the LA Times more often focused on people, politics, or research. Conclusions: Smaller, ethnic newspapers may be more amenable to messages about prevention and appropriate places to target community-focused interventions. Practice Implications: Health practitioners should consider submitting articles to ethnic newspapers and forming partnerships with journalists to cultivate this potential. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic placed a heavy strain on the United States healthcare system. Common hospital operational performances were impacted to varying degrees by the pandemic. This study examined the healthcare operational measures during COVID-19 pandemic., Methods: This cross-sectional study examined the COVID-19 cases and death counts of 56 California counties and hospital-level utilization data of 397 hospitals in California from January 2019 to March 2021., Results: A total of 56 California counties were analysed, of which 37 counties were urban and 19 counties were rural. Average patient length of stay was positively associated with the number of intensive care unit visits by COVID-19 patients for all counties, as well as urban and rural counties separately. However, average patient length of stay was negatively associated with the number of inpatient visits by COVID-19 patients for all counties and urban counties., Conclusions: The findings suggest that, while the need for additional beds and nursing staff in intensive care units exceeded initial estimates, there were also opportunities to streamline the care process for improved efficiency in regular acute care units. The understanding of factors impacting average patient length of stay would be valuable for hospital administrators in optimizing resource allocation and utilization to balance patient outcomes with financial sustainability during disruptive events., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: The COVID-19 pandemic changed the way healthcare providers delivered most health services, including treatment for alcohol use disorder (AUD). Specialty alcohol treatment remained available through the pandemic, and within some systems treatment use increased likely due to telehealth availability. However, the field knows little about the relationship between the pandemic's expanded access to specialty alcohol treatment and alcohol use outcomes., Methods: The sample included 14,712 patients from Kaiser Permanente Northern California who screened positive for unhealthy alcohol use in primary care and had an AUD diagnosis or risked developing an AUD by reporting 5 or more heavy drinking days in a 3-month period between 1/1/2019 and 2/29/2020 (pre-pandemic). The study examined the receipt of any specialty alcohol treatment (including at least one outpatient, inpatient, or telehealth specialty treatment encounter, or pharmacotherapy prescription) from 3/1/2020 (pandemic start) to either the first completed follow-up alcohol screening or 6/20/2022 (study period end). The outcomes of alcohol use included changes in heavy drinking days, drinks per week, drinking days per week, and drinks per drinking day between the pre- and post-pandemic periods., Results: On average patients significantly decreased alcohol use across all four alcohol use measures examined, regardless of whether they received treatment. However, those who received any treatment compared to those who did not had greater reductions in alcohol use, with an additional decrease of -3.55 heavy drinking days (95 % CI = -5.93, -1.17), -3.80 drinks per week (95 % CI = -5.18, -2.42), -0.72 drinks per drinking day (95 % CI = -1.14, -0.30), and - 1.01 drinking days per week (95 % CI = -1.30, -0.72). Treatment effects were greatest among patients who exceeded both daily and weekly limits pre-pandemic, with an additional decrease of -10.75 heavy drinking days (95 % CI = -15.28, -6.21), -12.83 drinks per week (95 % CI = -16.31, -9.35), -1.67 drinks per drinking day (95 % CI = -2.19, -1.14), and -2.02 drinking days per week (95 % CI = -2.41, -1.63)., Conclusions: On average, patients decreased alcohol use during the onset of the pandemic, however, those who had any specialty alcohol treatment had significantly greater decreases, suggesting that the hybrid in-person and telehealth treatment approach was effective during the pandemic., Competing Interests: Declaration of competing interest We have nothing to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Obesity rates among children and adults continue to accelerate in the U.S., particularly among marginalized and low-income populations. Obesity prevention and reduction policies can significantly impact population health by improving environmental conditions and increasing access to health-promoting resources. Limited research has been conducted to examine state obesity policy change over time. The primary aim of this study is to examine legislative approaches used to prevent and reduce obesity in the state of California (U.S.)., Methods: We used quantitative policy surveillance methods to develop a state database of obesity-related legislation (bills, resolutions) introduced in California's legislature between 1999 and 2020. Descriptive statistics were used to examine trends of introduced and enacted policy by legislative and policy characteristics. Chi-square tests were used to determine differences in characteristics between enacted and non-enacted legislation. Legislative session and policy characteristics found to be associated with enactment were used to predict adoption in a logistic regression., Results: A total of 284 obesity-related bills and resolutions were introduced in California's legislature between 1999 and 2020 with a peak of 43 in 2005-2006. On average, 25.8 bills and resolutions were introduced each 2-year legislative cycle. Findings indicate that (a) children and schools were the most frequently specified population and setting; (b) the most common policy topics were nutrition (45%) and physical activity (33%); and (c) only 15% of legislation mentioned race/ethnicity. Overall, 24.9% of bills were enacted compared to 82.1% of resolutions adopted. Legislation to raise awareness about obesity had 5.4 times the odds of being passed compared to other topics. Yet this difference was not statistically significant in a sensitivity analysis when we excluded resolutions., Conclusions: This database can be leveraged to advance our knowledge of effective and equitable policy instruments to prevent and reduce obesity. Results reveal important policy elements that may impact legislative success, including policy topic, and contribute to a nascent evidence base for public health law research, legal epidemiology, and practice. Future work should investigate the role of policy effectiveness research and evidence on legislative policymaking., (© 2024. The Author(s).)

Importance: Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results., Objective: To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients., Design, Setting, and Participants: The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase., Intervention: Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up., Main Outcomes and Measures: The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient., Results: A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008)., Conclusions and Relevance: In this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF., Trial Registration: ClinicalTrials.gov Identifier: NCT05009225.

Importance: Telemedicine is an increasingly used yet understudied vehicle to deliver pediatric primary care. Evidence detailing downstream health care utilization after telemedicine visits is needed., Objective: To compare pediatric primary care conducted via telemedicine (video or telephone) with in-person office visits with regard to physician medication prescribing and imaging and laboratory ordering and downstream follow-up office visits, emergency department (ED) visits, and hospitalizations., Design, Setting, and Participants: This cohort study included all patients younger than 18 years who had scheduled primary care appointments with a pediatrician from January 1 to December 31, 2022, in the Kaiser Permanente Northern California health system, a large integrated health care delivery system offering in-person office visits, video visits, or telephone visits for pediatric primary care., Exposure: Pediatric primary care in-person visit, telephone visit, or video visit., Main Outcome and Measures: Rates of physician medication prescribing and imaging and laboratory ordering during an index telemedicine or office visit and rates of in-person office visits, ED visits, and hospitalizations within 7 days after the visit, adjusted for patient and clinical characteristics., Results: Of 782 596 total appointments (51.1% male) among 438 638 patients, telemedicine was used for 332 153 visits (42.4%). After adjustment, there was more medication prescribing for in-person visits (39.8%) compared with video visits (29.5%; adjusted difference, -10.3%; 95% CI, -10.6% to -10.0%) or telephone visits (27.3%; adjusted difference, -12.5%; 95% CI, -12.5% to -12.7%). There was also more laboratory ordering for in-person visits (24.6%) compared with video visits (7.8%; adjusted difference, -16.8%; 95% CI, -17.0% to -16.6%) or telephone visits (8.5%; adjusted difference, -16.2%; 95% CI, -16.3% to -16.0%). There was more imaging ordering for in-person visits (8.5%) compared with video visits (4.0%; adjusted difference, -4.5%; 95% CI, -4.6% to -4.4%) and telephone visits (3.5%; adjusted difference, -5.0%; 95% CI, -5.1% to -4.9%). After adjustment, fewer in-person follow up visits occurred for index visits that were in-person (4.3%) compared with video (14.4%; adjusted difference, 10.1%; 95% CI, 9.9%-10.3%) or telephone (15.1%; adjusted difference, 10.8%; 95% CI, 10.7%-11.0%) visits. The rate of ED visits following an in-person visit was slightly lower (1.75%) compared with after video visits (2.04%; adjusted difference, 0.29%; 95% CI, 0.21%-0.38%) or telephone visits (2.00%; adjusted difference, 0.25%; 95% CI, 0.18%-0.33%). There was no statistically significant difference in the 7-day rate of hospitalizations., Conclusions and Relevance: In this cohort study, telephone and video visits for pediatric primary care were associated with less prescribing and ordering than in-person visits. Telemedicine visits were associated with modestly higher rates of subsequent in-person visits and slightly higher rates of ED visits, and there was no difference in hospitalizations. Telemedicine appears to be a useful vehicle for health care delivery in the pediatric population, although it is not a universal substitute for in-person visits.

Objectives. To examine whether local cannabis policies and retail availability are associated with cannabis use and problematic cannabis use (PCU) among adolescents in Northern California. Methods. The sample comprised adolescents aged 13 to 17 years screened for past-year cannabis use during well-child visits in 2021. Exposures included local bans on cannabis storefront retailers, policy protectiveness, and retail proximity and density. Outcomes included self-reported past-year cannabis use and PCU diagnoses. Modified Poisson regression models adjusted for sociodemographics. Results. The sample (n = 103 134) was 51.1% male with a median age of 15 years (interquartile range [IQR] = 14-16 years); 5.5% self-reported cannabis use, and 0.3% had diagnosed PCU. Adolescents had a lower prevalence of cannabis use in jurisdictions that banned storefront retailers (adjusted prevalence rate [APR] = 0.857; 95% confidence interval [CI] = 0.814, 0.903 vs allowed), banned delivery (APR = 0.751; 95% CI = 0.710, 0.795 vs allowed), or had more policy protections (APR range = 0.705-0.800). Lower PCU prevalence was also found among those in jurisdictions that banned (vs allowed) storefront retailers (APR = 0.786; 95% CI = 0.629, 0.983) or delivery (APR = 0.783; 95% CI = 0.616, 0.996). Longer drive time and lower density of storefront retailers were associated with a lower cannabis use prevalence. Conclusions. More protective cannabis policies and less retail availability were associated with a lower prevalence of adolescent cannabis use and PCU. ( Am J Public Health . 2024;114(S8):S654-S663. https://doi.org/10.2105/AJPH.2024.307787).

Objective: Individuals with unhealthy alcohol use and comorbid depression or anxiety may be vulnerable to alcohol use escalation in times of stress such as the COVID-19 pandemic. Among a cohort of individuals with pre-pandemic unhealthy drinking, we compared changes in alcohol use by whether people had a depression or anxiety diagnosis and examined whether mental health treatment was related to these changes., Method: Using electronic health record data from Kaiser Permanente Northern California, we analyzed drinking changes during the pandemic (3/1/2020-6/30/2022) among adults identified in primary care with unhealthy alcohol use (exceeding daily/weekly recommended limits) pre-pandemic (1/1/2019-2/29/2020). Outcomes were mean changes in number of heavy drinking days (prior 3 months), drinks/week, drinks/day, and drinking days/week. Multivariable linear regression models were fit to (a) compare outcomes of patients with depression or anxiety diagnoses to those without, and (b) among patients with depression or anxiety, estimate associations between mental health treatment and outcomes., Results: The sample included 62,924 adults with unhealthy alcohol use, of whom 12,281 (19.5%) had depression or anxiety. On average, alcohol use significantly decreased across all measures during the pandemic; however, patients with depression or anxiety had greater decreases in drinks/week (adjusted mean difference [aMD] [CI] = -0.34 [-0.55, -0.12]) and drinking days/week (-0.15 [-0.20, -0.10]). No associations were found between mental health treatment and changes in drinking., Conclusions: Contrary to expectations, patients with unhealthy alcohol use and depression or anxiety decreased alcohol use more than those without depression or anxiety during COVID-19, regardless of whether they accessed mental health services.

Adaptive responses to climate change, based on heritable variation in stress tolerance, may be important for plant population persistence. It is unclear which populations will mount the strongest future adaptive responses. It may be fruitful to identify populations that have escaped trade-offs among performance traits, which can hinder adaptation. Barring strong genetic constraints, the extent of trade-offs may depend on spatial relationships among climate variables shaping different traits. Here, we test for climate-driven ecotypic variation and trade-offs among drought and freezing sensitivity, and growth, for Lemmon's willow (Salix lemmonii) in a common garden study of 90 genotypes from 38 sites in the Sierra Nevada, USA. Salix lemmonii exhibits ecotypic variation in leaf turgor loss point, a measure of drought sensitivity, from -0.95 to -0.74 MPa along a gradient of spring snowpack. We also find variation in spring freezing sensitivity with minimum May temperature. However, we find no trade-off, as the climatic gradients shaping these traits are spatially uncorrelated in our study region, despite being negatively correlated across the Sierra Nevada. Species may escape adaptive trade-offs in geographic regions where climate variables are spatially decoupled. These regions may represent valuable reservoirs of heritable adaptive phenotypic variation., (© 2024 The Author(s). New Phytologist © 2024 New Phytologist Foundation.)

Aims: This study examined differential changes in alcohol use during the COVID-19 pandemic among adults with unhealthy alcohol use., Methods: Among 62 924 adults identified with unhealthy alcohol use in primary care prepandemic (1 January 2019 to 29 February 2020), changes in alcohol use during the pandemic (1 March 2020 to 30 June 2022) were examined using electronic health record data from Kaiser Permanente Northern California. Outcomes were changes in heavy drinking days in the past three months (HDDs) and overall consumption (drinks/week), including continuous and categorical measures. Differences in outcomes by sex, age, race/ethnicity, and alcohol use disorder (AUD) were examined., Results: On average, drinking was reduced by 3.0 HDDs (in the past three months) (SD = 18.4) and 4.1 drinks/week (SD = 12.2), but women, certain age groups, White patients, and patients without AUD had smaller decreases than their counterparts. Overall, 9.1% increased, 34.4% maintained, and 56.5% decreased HDDs, and 20.2% increased, 19.8% maintained, and 60.1% decreased drinks/week. Women, patients aged ≥35 years, White patients, and patients with AUD had higher odds of increasing versus decreasing HDDs, and maintaining versus decreasing, compared to their counterparts. Patients aged 18-20 years, White patients, and patients without AUD had higher odds than their counterparts of increasing versus decreasing drinks/week. Women, patients aged 18-20 years, Asian/Pacific Islander, and Latino/Hispanic patients had higher odds of maintaining versus decreasing drinks/week., Conclusions: While alcohol use decreased overall among this sample of primary care patients with unhealthy drinking prepandemic, certain subgroups were more likely to increase drinking, suggesting a greater risk of alcohol-related problems., (© The Author(s) 2024. Medical Council on Alcohol and Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH., Method: We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models., Results: Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI., Limitations: SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor., Conclusions: HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed., Competing Interests: Declaration of competing interest The authors report no competing of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery., Objectives: The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence., Setting: Large integrated health system in Southern California with 11 surgical practices and 23 surgeons., Methods: A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey., Results: For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies., Conclusions: Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Food insecurity disproportionately affects low-income, racially marginalized, and rural communities. The COVID-19 pandemic led to higher demand for emergency food distribution, potentially impacting food pantry operations and services. Limited research exists assessing consumer nutrition environments of pantries in rural regions., Objectives: To assess the consumer nutrition environment of rural food pantries and report challenges and adaptations encountered during the pandemic., Design: A mixed-methods, cross-sectional survey., Participants/setting: Nineteen food pantry representatives from California's San Joaquin Valley were surveyed between August 2020 and June 2021. Representatives were eligible if their pantry served the general population and was open at least once a week. Nine were church-based pantries, and 10 were from other settings., Main Outcome Measures: The Nutrition Environment Food Pantry Assessment Tool (NEFPAT) measured the nutrition food environment and scored pantries as bronze (0-15), silver (16-31), or gold (32-47) categories. Eleven items were developed to explore pandemic-related challenges., Statistical Analyses Performed: Independent χ 2 tests assessed the relationship between the organization type and NEFPAT scores and food supply sources. Fisher's exact test explored associations between food pantry type, NEFPAT category, and challenges. Nonparametric tests were run on non-normally distributed data. Inductive content analysis was used to examine open-ended pandemic-related questions., Results: The nutrition environment of most pantries was suboptimal, because no pantry scored in the "gold" category based on total NEFPAT scores (median, 18 of 47). No statistically significant differences were found in the NEFPAT scores by organization type. Most pantries did not provide healthy food nudges or culturally diverse foods. Key COVID-19 challenges encountered consisted of supply- and demand-side issues, including reduced personnel, capacity, and resources, and increased client quantity and demand for food., Conclusions: Assessing the nutrition environment of rural food pantries revealed gaps and strategies for improvement, including the use of healthy nudges and increasing the availability of culturally diverse foods., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Cabernet Sauvignon from the California Paso Robles AVA was processed with a contrasting array of cap management frequencies, consisting of punch-down (PD) frequencies (0, 1, 2, and 3 PD/day) over two vintages, one of which the fruit was harvested at two contrasting maturity levels. Wines followed with up to 3 years of bottle aging for basic and phenolic chemistry, and the wines of the second harvest of 2020 were submitted to sensory analysis. There were almost non-existent effects due to the frequency of punch downs on parameters such as ethanol, pH, titratable acidity, lactic acid, and glucose + fructose. In 2019, the chromatic differences between different PD regimes were subtle, and minor effects of the punch-down frequency were observed for tannins and total phenolics. During the early stages of alcoholic fermentation, higher levels of all anthocyanin classes were observed in 1 PD wines and the lowest levels in 0 PD wines. The anthocyanin content of the wines of the first harvest (unripe) was 27% higher than that of the wines of the second harvest (ripe), but these differences disappeared after 3 years of bottle aging irrespective of the vintage and harvest date. Acylated anthocyanins were preferentially lost during aging, especially in 2019 wines and, to a lesser extent, in 2020 wines. In 2020, the polymeric pigment content of the wines of the second harvest was higher than in the wines of the first harvest, with 3 PD wines showing higher polymeric pigments and yellow hues than 0 and 2 PD wines after 3 years of bottle aging. Sensory analysis of the second harvest of the 2020 wines showed that the wines of all four PD regimes were perceived as drying, signifying they were perceived as equally astringent, which is consistent with comparable tannin levels on said wines. The perception of bitterness increased with the frequency of punch downs; thus, 3 PD wines showed the highest bitterness perception. It was concluded that in sufficiently warm fermentations and small volumes, phenolic extraction occurs regardless of fruit maturity and under conditions of minimum mixing.

Persons with HIV (PWH) experience high levels of pain. We examined the relationship of pain severity with use of cannabis and prescription opioids among PWH. This cross-sectional study evaluated associations between self-reported pain (moderate/severe vs mild/none) and cannabis and prescription opioid use in a primary care sample of PWH enrolled in an alcohol use treatment study at Kaiser Permanente, San Francisco. Prevalence ratios (PR) for moderate/severe pain associated with cannabis, opioid use, or both in the prior 30 days were obtained from Poisson regression models. Adjusted models included race/ethnicity, education, employment, HIV ribonucleic acid levels, depression, and anxiety. Overall, 614 PWH completed baseline questionnaires from May 2013 to May 2015, among whom 182/614 (29.6%) reported moderate/severe pain. The prevalence of moderate/severe pain varied by substances: 19.1% moderate/severe pain among study participants who reported neither cannabis or opioids, 30.2% for cannabis alone, 41.2% for opioids alone, and 60.9% for those reporting both substances. In adjusted models, compared with PWH who reported neither substance (reference), prevalence of moderate/severe pain was higher for those using cannabis alone (PR 1.54; 95% CI 1.13-2.09), opioids alone (PR 1.96; 95% CI 1.31-2.94), and those reporting both (PR 2.66; 95% CI 1.91-3.70). PWH who reported opioid and/or cannabis use were more likely to report moderate/severe pain compared with PWH who did not report use of these substances. To improve patient care, it is vital to assess patients' approaches to pain management including substance use and target appropriate interventions to reduce pain in PWH., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Since the coronavirus disease 2019 (COVID-19) pandemic began, telemedicine use has transformed healthcare delivery. Yet there is concern that telemedicine may widen care disparities for vulnerable populations, and patient experience data are limited., Aims: We aimed to assess patient satisfaction with hepatology-related telemedicine (telehepatology) for delivery of fatty liver disease (FLD) care in a safety-net healthcare system., Methods: Adult patients with FLD were surveyed regarding satisfaction with telehepatology. Clinical, demographic, resources, and social determinants of health (SDoH) data were collected to identify factors associated with satisfaction through multivariable modeling., Results: From June 2020 to March 2022, 220 participants were enrolled: the median age was 52 years, 37% were men, and 68% were Hispanic. One hundred nineteen (54%) had prior telehepatology experience. Overall, satisfaction was high; 70% reported being somewhat or very satisfied. On univariate analysis, Hispanic ethnicity (versus non-Hispanic, OR 0.34, 95% CI 0.1-0.9, p = 0.03) and limited access to personal cellphone/internet (OR 0.16, 95% CI 0.04-0.6, p = 0.01) were associated with lower satisfaction. On multivariable logistic regression modeling adjusted for pandemic duration, age, sex, severity of liver disease, and coexisting liver disease, Hispanic ethnicity and lack of personal cellphone/internet remained independently associated with lower telehepatology satisfaction (OR 0.24, 95% CI 0.07-0.9, p = 0.03 and OR 0.2, 95% CI 0.04-0.9, p = 0.04, respectively). The association remained statistically significant after inclusion of various SDoH in the multivariable model., Conclusions: Satisfaction with telehepatology among FLD patients in a safety-net clinical setting was high overall. However, Hispanic ethnicity and lack of personal cellphone/internet were independently associated with lower telehepatology satisfaction. A better understanding of patients' experience with telehepatology is needed to identify reasons for dissatisfaction, and in-person visits should remain an option for patients to ensure equitable care., (© 2024. The Author(s).)

The Northern California Current is a highly productive marine upwelling ecosystem that is economically and ecologically important. It is home to both commercially harvested species and those that are federally listed under the U.S. Endangered Species Act. Recently, there has been a global shift from single-species fisheries management to ecosystem-based fisheries management, which acknowledges that more complex dynamics can reverberate through a food web. Here, we have integrated new research into an end-to-end ecosystem model (i.e., physics to fisheries) using data from long-term ocean surveys, phytoplankton satellite imagery paired with a vertically generalized production model, a recently assembled diet database, fishery catch information, species distribution models, and existing literature. This spatially-explicit model includes 90 living and detrital functional groups ranging from phytoplankton, krill, and forage fish to salmon, seabirds, and marine mammals, and nine fisheries that occur off the coast of Washington, Oregon, and Northern California. This model was updated from previous regional models to account for more recent changes in the Northern California Current (e.g., increases in market squid and some gelatinous zooplankton such as pyrosomes and salps), to expand the previous domain to increase the spatial resolution, to include data from previously unincorporated surveys, and to add improved characterization of endangered species, such as Chinook salmon (Oncorhynchus tshawytscha) and southern resident killer whales (Orcinus orca). Our model is mass-balanced, ecologically plausible, without extinctions, and stable over 150-year simulations. Ammonium and nitrate availability, total primary production rates, and model-derived phytoplankton time series are within realistic ranges. As we move towards holistic ecosystem-based fisheries management, we must continue to openly and collaboratively integrate our disparate datasets and collective knowledge to solve the intricate problems we face. As a tool for future research, we provide the data and code to use our ecosystem model., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Adverse Childhood Experiences (ACEs) are very common and presently implicated in 9 out of 10 leading causes of death in the United States. Despite this fact, our mechanistic understanding of how ACEs impact health is limited. Moreover, interventions for reducing stress presently use a one-size-fits-all approach that involves no treatment tailoring or precision. To address these issues, we developed a combined cross-sectional study and randomized controlled trial, called the California Stress, Trauma, and Resilience Study (CalSTARS), to (a) characterize how ACEs influence multisystem biological functioning in adults with all levels of ACE burden and current perceived stress, using multiomics and other complementary approaches, and (b) test the efficacy of our new California Prec ision I ntervention for S tress and R e silience (PRECISE) in adults with elevated perceived stress levels who have experienced the full range of ACEs. The primary trial outcome is perceived stress, and the secondary outcomes span a variety of psychological, emotional, biological, and behavioral variables, as assessed using self-report measures, wearable technologies, and extensive biospecimens (i.e. DNA, saliva, blood, urine, & stool) that will be subjected to genomic, transcriptomic, proteomic, metabolomic, lipidomic, immunomic, and metagenomic/microbiome analysis. In this protocol paper, we describe the scientific gaps motivating this study as well as the sample, study design, procedures, measures, and planned analyses. Ultimately, our goal is to leverage the power of cutting-edge tools from psychology, multiomics, precision medicine, and translational bioinformatics to identify social, molecular, and immunological processes that can be targeted to reduce stress-related disease risk and enhance biopsychosocial resilience in individuals and communities worldwide.

Purpose: California's failed attempts to enact a statewide sugary beverage tax presents an opportunity to advance understanding of advocacy coalition behavior. We investigate the participation of advocacy coalitions in California's statewide sugar-sweetened beverage (SSB) tax policy debate., Design: Document analysis of legislative bills and newspaper articles collected in 2019., Setting: California., Method: A total of 11 SSB tax-related bills were introduced in California's legislature between 2001-2018 according to the state's legislative website. Data sources include legislative bill documents (n = 94) and newspaper articles (n = 138). Guided by the Advocacy Coalition Framework (ACF), we identify advocacy coalitions involved in California's SSB tax debate and explore strategies and arguments used to advance each coalitions' position., Results: Two coalitions (public health, food/beverage industry) were involved in California's statewide SSB tax policy debate. The public health coalition had higher member participation and referred to scientific research evidence while the industry coalition used preemption and financial resources as primary advocacy strategies. The public health coalition frequently presented messaging on the health consequences and financial benefits of SSB taxes. The industry coalition responded by focusing on the potential negative economic impact of a tax., Conclusion: Multiple attempts to enact a statewide SSB tax in California have failed. Our findings add insight into the challenges of enacting an SSB tax considering industry interference. Results can inform future efforts to pass evidence-based nutrition policies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Burning of agricultural fields is an understudied source of air pollution in rural communities in the United States. Smoke from agricultural burning contains air toxics that adversely impact respiratory health. Imperial County in southeastern California is a highly productive agricultural valley that heavily employs agricultural burning to clear post-harvest crop remnants. We related individual-level exposure to agricultural burns to parent-reported respiratory symptoms in children. We leveraged the Children's Assessing Imperial Valley Respiratory Health and the Environment (AIRE) cohort of 735 predominantly Hispanic low-income elementary school students in Imperial County. Parents reported children's respiratory health symptoms and family demographic characteristics in questionnaires collected at enrollment and in annual follow-up assessments from 2017 to 2019. Permitted agricultural burns in Imperial County from 2016 to 2019 were spatially linked to children's geocoded residential addresses. We used generalized estimating equations to evaluate prevalence differences (PDs) in respiratory symptoms with increasing exposure to agricultural burning within 3 km in the 12 months prior to each assessment. Nearly half of children (346, 49 %) lived within 3 km of at least one agricultural burn in the year prior to study enrollment. In adjusted models, each additional day of agricultural burning in the prior year was associated with a one percentage point higher prevalence of wheezing (PD 1.1 %; 95 % CI 0.2 %, 2.0 %) and higher bronchitic symptoms (PD 1.0 %; 95 % CI -0.2 %, 2.1 %). Children exposed to four or more days of burning had an absolute increased prevalence of wheezing and bronchitic symptoms of 5.9 % (95 % CI -0.3 %, 12 %) and 5.6 % (95 % CI -1.8 %, 13 %), respectively, compared to no burn exposure. Associations with wheezing were stronger among children with asthma (PD 14 %; 95 % CI -1.4 %, 29 %). To our knowledge, this is the first U.S. study of agricultural burning and children's respiratory health. This work suggests that reducing agricultural burning could improve children's respiratory health., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: State and local policies prohibiting the sales of flavored tobacco have been effective in curtailing retail availability and sales of products across the United States. Less is known about the use of flavored tobacco which could vary as a function of type of ordinance, product category, policy implementation, and other factors., Methods: The 2019-2020 California Health Interview Surveys were used to estimate flavored and non-flavored tobacco use among adults (n = 43,681) residing in a California jurisdiction with a comprehensive (n = 48), partial (n = 35), or no flavored tobacco sales restriction (FTSR) (n = 427). Multinomial logistic regression models, which accounted for clustering within jurisdictions (n = 510), were separately developed for outcomes corresponding to use of any tobacco, non-cigarette tobacco products (NCTPs), electronic nicotine delivery systems, and conventional cigarettes. Individual-level effects of policy on tobacco use were estimated due to the overlap between the survey periods and effective policy dates., Results: Approximately 22% of Californians were subject to a partial or comprehensive FTSR by December 31, 2020. Accounting for potential confounders, residents of jurisdictions with a comprehensive FTSR (vs. no ban) had 30% lower odds of using any flavored tobacco. The strongest and only statistically significant association by product category was exposure to a comprehensive FTSR and use of a flavored NCTP (aOR=0.4 (0.2, 0.8); p=0.008). Null or positive associations were primarily observed between a partial FTSR and flavored tobacco use, as well as associations between any FTSR and non-flavored tobacco use., Conclusion: Recent passage of a statewide ban in California will close gaps from the patchwork of local policies and eliminate most partial FTSR exemptions. However, state law still exempts the sales of some flavored tobacco products (e.g., hookah), leaving jurisdictions the option of enacting comprehensive FTSRs that may be more effective than partial FTSRs in reducing use of flavored tobacco., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: Flavoured tobacco control policy exemptions and electronic cigarette products may contribute to increased youth access and tobacco use disparities., Methods: We assessed public support among California Central Valley residents for four policies to regulate flavoured tobacco products and e-cigarettes. The probability-based, multimode survey was conducted with English-speaking and Spanish-speaking registered voters (n=845) across 11 counties between 13 and 18 August 2020. Weighted logistic regression analyses measured odds of policy support, adjusting for predictor variables (attitudes and beliefs) and covariates., Results: The weighted sample was 50% female and predominantly Latino (30%) or non-Hispanic white (46%); 26% had a high school education or less, and 22% an annual household income

Objectives: The use of e-cigarettes is on the rise in the United States (US). An understudied facet of e-cigarette use is the influence of social groups. The purpose of the present article is to examine the role of social groups in the use of e-cigarettes among Asian Americans. Methods: We conducted 12 semi-structured interviews of Asian Americans who use e-cigarettes living in California. Interviews were transcribed and analyzed using thematic analysis. Results: Findings showed that e-cigarette use is normalized and encouraged among peer groups and social gatherings, anecdotal success stories of their peers who were able to quit or reduce their use of combustible cigarettes using e-cigarettes were motivating, and vape shops provided a space for socialization and belonging. Conclusions: The findings illuminate that e-cigarette use is a mediator in Asian American social groups as an activity for collectivity and connection. Public health researchers and practitioners can address nicotine use or addiction among Asian Americans through group or peer targeted prevention and intervention strategies.

Background: Given workplace risks from COVID-19, California policymakers passed Senate Bill (SB) 1159 to facilitate access to workers' compensation (WC) benefits for frontline workers. However there has been no review of the available evidence needed to inform policy decisions about COVID-19 and WC., Methods: We conducted a literature review on worker and employer experiences surrounding COVID-19 and WC, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines., Results: Forty articles were included (16 about worker experiences and 24 about employer practices). Most were not about experiences and practices related to COVID-19 and WC. Worker studies indicated that paid sick leave reduced new COVID-19 cases and COVID-19 activity. Studies also found that rural agricultural and food processing workers lacked sick leave protection and faced severe housing and food insecurity. Studies on workplace health and safety indicated that healthcare workers with access to personal protective equipment had lower stress levels. Studies about employer practices found that unrestricted work in high-contact industries was associated with increased risks to at-risk workers, and with health disparities. No studies examined worker COVID-19 experiences and WC claims or benefits, job loss, retaliation, workers' medical care experiences, and return-to-work or leave practices., Conclusions: Our review identified experiences and practice related to COVID-19 and the WC system, but not specifically about WC and COVID-19 WC claims or benefits. Further research is needed to document and understand evidence underpinning the need for WC coverage for COVID-19 and to evaluate the impact of the current SB 1159 bill on WC in California., (© 2022 Wiley Periodicals LLC.)

Background: The evidence linking sugar-sweetened beverage (SSB) intake and mortality risk is conflicting, and associations between various SSB subtypes and mortality remain unclear., Objective: To examine the association between baseline SSB intake, subtypes of SSB intake, and mortality risk in women., Design: Prospective cohort study., Participants/setting: Participants of the California Teachers Study (n = 100,314; median age = 53 years) free of cardiovascular disease, cancer, and diabetes at baseline (1995-1996) were followed from 1995 to 2015. Baseline SSB intake was defined as caloric soft drinks (regular soft drinks, not diet soda), sweetened bottled waters or teas, and fruit drinks; and was derived from a self-administered food frequency questionnaire., Main Outcome Measure: Mortality was ascertained via annual linkage with state- and nationwide mortality records and the National Death Index over 20 years., Statistical Analysis: Multivariable-adjusted Cox proportional hazards models were used to generate hazard ratios (HRs) and 95% CIs for assessing associations between SSB intake and mortality. Rare/never consumers were the comparator group., Results: There were a total of 14,143 deaths over 20 years (30.5% from cardiovascular disease; 29.2% from cancer). In women who consumed ≥ 7 servings/week of SSBs at baseline (4% of participants), the multivariable-adjusted HRs were not significant for all-cause, cardiovascular disease-specific, or cancer-specific mortality. Consuming ≥ 7 servings/week of baseline caloric soft drink was associated with a higher risk of all-cause (HR = 1.26, 95% CI 1.10 to 1.46; P for trend = 0.02) and cancer-specific (HR = 1.33, 95% CI 1.08 to 1.63; P for trend = 0.08) mortality. In secondary analyses, consuming ≥ 1.5 c/day of baseline SSBs was associated with all-cause mortality (HR = 1.12, 95% CI 1.02 to 1.24; P for trend = 0.01)., Conclusions: Although the baseline frequency of total SSB intake was not significantly associated with mortality, consuming ≥ 7 servings/week of caloric soft drinks was associated with higher risk of all-cause and cancer-specific mortality. Findings support public health efforts to reduce caloric soft drink consumption., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors., Objective: We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center., Research Design: Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach., Subjects: A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0., Measures: CAHPS overall provider rating and provider communication composite (scaled 0-100)., Results: Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach., Conclusions: Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care., Objective: To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections., Design, Setting, and Participants: This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021., Exposures: Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR., Main Outcomes and Measures: The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections., Results: Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years)., Conclusions and Relevance: These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity.

Inundated wetlands can potentially sequester substantial amounts of soil carbon (C) over the long-term because of slow decomposition and high primary productivity, particularly in climates with long growing seasons. Restoring such wetlands may provide one of several effective negative emission technologies to remove atmospheric CO2 and mitigate climate change. However, there remains considerable uncertainty whether these heterogeneous ecotones are consistent net C sinks and to what degree restoration and management methods affect C sequestration. Since wetland C dynamics are largely driven by climate, it is difficult to draw comparisons across regions. With many restored wetlands having different functional outcomes, we need to better understand the importance of site-specific conditions and how they change over time. We report on 21 site-years of C fluxes using eddy covariance measurements from five restored fresh to brackish wetlands in a Mediterranean climate. The wetlands ranged from 3 to 23 years after restoration and showed that several factors related to restoration methods and site conditions altered the magnitude of C sequestration by affecting vegetation cover and structure. Vegetation established within two years of re-flooding but followed different trajectories depending on design aspects, such as bathymetry-determined water levels, planting methods, and soil nutrients. A minimum of 55% vegetation cover was needed to become a net C sink, which most wetlands achieved once vegetation was established. Established wetlands had a high C sequestration efficiency (i.e. the ratio of net to gross ecosystem productivity) comparable to upland ecosystems but varied between years undergoing boom-bust growth cycles and C uptake strength was susceptible to disturbance events. We highlight the large C sequestration potential of productive inundated marshes, aided by restoration design and management targeted to maximise vegetation extent and minimise disturbance. These findings have important implications for wetland restoration, policy, and management practitioners., Competing Interests: The authors declare no competing interest.

Introduction: Recent studies indicate low rates of follow-up colonoscopy after abnormal fecal immunochemical testing (FIT) within safety net health systems. A patient navigation (PN) program is an evidence-based strategy that has been shown to improve colonoscopy completion in private and public healthcare settings. The aim of this study was to evaluate the effectiveness of a PN program to encourage follow-up colonoscopy after abnormal FIT within a large safety net hospital system., Methods: We established an enterprisewide PN program at 5 tertiary care hospitals within the Los Angeles County Department of Health Services system in 2018. The PN assisted adult patients aged 50-75 years with an abnormal FIT to a follow-up colonoscopy within 6 months. PN activities included initiating referral for and scheduling of colonoscopy, performing reminder phone calls to patient for their upcoming colonoscopy, and following up with patients who did not attend their colonoscopy. We assess the effectiveness of the PN intervention by comparing follow-up colonoscopy rates with a period before the intervention., Results: There were 2,531 patients with abnormal FIT results (n = 1,214 in 2017 and n = 1,317 in 2018). A majority were women (55% in 2017 vs 52% in 2018) with a mean age of 60 ± 6.2 years. From a previous mean of 163 days without PN in 2017, the mean time from abnormal FIT to colonoscopy with PN improved to 113 days in 2018. The frequency of colonoscopy completion with PN increased from 40.6% (n = 493) in 2017 to 46% (n = 600) in 2018., Discussion: After the introduction of the PN program, there was a significant increase in patients undergoing follow-up colonoscopy after abnormal FIT and patients were more likely to undergo colonoscopy within the recommended 6 months., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Evaluating sediment recontamination due to storm water discharges is important when evaluating the long-term effectiveness of sediment remediation efforts at reducing biological impacts. The bioaccumulation of the heavy metals zinc, nickel, copper, cadmium, mercury, and lead and the metalloid arsenic in a clam (Macoma nasuta) was studied in surficial sediments before and after storm water inputs from Paleta Creek, California, USA, during wet seasons in 2015 to 2016 and 2016 to 2017. The bioaccumulation was compared with bulk sediment concentrations and porewater concentrations measured by diffusion gradient in thin film devices. Significant reductions in biota accumulation and porewater concentrations were observed in samples collected after storm seasons compared with before storm seasons despite bulk sediment concentrations remaining the same or increasing. This was apparently the result of the deposition of storm water contaminants in low bioavailable forms. The bioaccumulation of all the measured contaminants showed a positive significant correlation with porewater concentrations (p < 0.1, α = 0.1) and weak or no correlations with bulk sediment concentration. In conclusion, observed bulk sediment recontamination due to storm water should not be assumed to lead directly to greater biota accumulation without bioavailability assessment. Environ Toxicol Chem 2020;39:2475-2484. © 2020 SETAC., (© 2020 SETAC.)

Background: The Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA., Methods: Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL)., Results: Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed., Conclusions: In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.

Background: Practitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy., Methods: We conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood., Results: Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment., Conclusions: Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background Sugar-sweetened beverage (SSB) consumption has been associated with cardiometabolic risk. However, the association between total and type of SSB intake and incident cardiovascular disease (CVD) end points such as myocardial infarction, stroke, and revascularization is limited. Methods and Results We examined the prospective association of baseline SSB consumption with incident CVD in 106 178 women free from CVD and diabetes mellitus in the CTS (California Teachers Study), a cohort of female teachers and administrators, followed since 1995. SSBs were defined as caloric soft drinks, sweetened bottled waters or teas, and fruit drinks, and derived from a self-administered food frequency questionnaire. CVD end points were based on annual linkage with statewide inpatient hospitalization records. Cox proportional hazards models were used to assess the association between SSB consumption and incident CVD. A total of 8848 CVD incident cases were documented over 20 years of follow-up. After adjusting for potential confounders, we observed higher hazard ratios (HRs) for CVD (HR, 1.19; 95% CI, 1.06-1.34), revascularization (HR, 1.26; 95% CI, 1.04-1.54]), and stroke (HR, 1.21; 95% CI, 1.04-1.41) in women who consumed ≥1 serving per day of SSBs compared with rare/never consumers. We also observed a higher risk of CVD in women who consumed ≥1 serving per day of fruit drinks (HR, 1.42; 95% CI, 1.00-2.01 [ P trend=0.021]) and caloric soft drinks (HR, 1.23; 95% CI, 1.05-1.44 [ P trend=0.0002]), compared with rare/never consumers. Conclusions Consuming ≥1 serving per day of SSB was associated with CVD, revascularization, and stroke. SSB intake might be a modifiable dietary target to reduce risk of CVD among women.

Constructed wetlands built for water treatment often need biomass harvesting to remove nutrients from the system. Usually harvesting is done during the peak growing season to maximize the amount of nutrients removed from the system. This, however, can create huge methane fluxes that escape from plant tissues to the atmosphere. We used manual chambers and eddy covariance measurements to analyze the increase in methane emissions due to the harvesting of two common wetland species, Typha spp. and Schoenoplectus spp., in two climatically different constructed wetlands in Estonia and California. In addition, we determined the biomass nutrient and carbon concentrations from harvested biomass. We found that harvesting during the summer season, e.g. June and August, resulted in a significant release of methane at both sites. At the California site, baseline median methane emissions were 217.6 nmol m - 2  s - 1 , and harvesting resulted in increases to 395.4 nmol m - 2  s - 1 that decreased to baseline emission within three days. Footprint modeling demonstrated that the emission increases measured by eddy covariance were dominated by contributions from the cut area to the total footprint signal. At the Estonian site, harvesting resulted in methane increases of 15.9 nmol m - 2  s - 1 to 110.4 nmol m - 2  s - 1 in August. However, in September and October the emission was significantly lower. Plant biomass analyses showed clear temporal dynamics in terms of nutrient concentration, being highest in summer and lowest in winter. Our experiments indicate that the optimal time for aboveground biomass harvesting is at the end of the growing season before nutrient translocation to belowground plant structures begins coinciding with lowest methane emissions. Therefore, strategic planning of the harvest timing may help reduce greenhouse gas emissions from managed wetlands and thus improve their multi-faceted ecological benefit., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Sickle cell disease (SCD) is associated with high acute healthcare utilization. The purpose of this study was to examine whether Medicaid expansion in California increased Medicaid enrollment, increased hydroxyurea prescriptions filled, and decreased acute healthcare utilization in SCD., Methods: Individuals with SCD (≤65 years and enrolled in Medicaid for ≥6 total calendar months any year between 2011 and 2016) were identified in a multisource database maintained by the California Sickle Cell Data Collection Program. We describe trends and changes in Medicaid enrollment, hydroxyurea prescriptions filled, and emergency department (ED) visits and hospital admissions before (2011-2013) and after (2014-2016) Medicaid expansion in California., Results: The cohort included 3635 individuals. Enrollment was highest in 2014 and lowest in 2016 with a 2.8% annual decease postexpansion. Although <20% of the cohort had a hydroxyurea prescription filled, the percentage increased by 5.2% annually after 2014. The ED visit rate was highest in 2014 and decreased slightly in 2016, decreasing by 1.1% annually postexpansion. Hospital admission rates were similar during the pre- and postexpansion periods. Young adults and adults had higher ED and hospital admission rates than children and adolescents., Conclusions: Medicaid expansion does not appear to have improved enrollment or acute healthcare utilization among individuals with SCD in California. Future studies should explore whether individuals with SCD transitioned to other insurance plans or became uninsured postexpansion, the underlying reasons for low hydroxyurea utilization, and the lack of effect on hospital admissions despite a modest effect on ED visits., (© 2020 Wiley Periodicals, Inc.)

Objectives: People with HIV (PWH) have a high burden of bacterial sexually transmitted infections (STIs). We examined the relationship of alcohol and drug use and partner pre-exposure prophylaxis (PrEP) use to STI prevalence in a cohort of PWH with a history of unhealthy alcohol use., Methods: We analysed data from a primary care-based alcohol intervention study at Kaiser Permanente Northern California (KPNC). Participants were recruited between April 2013 and May 2015 and were followed for up to 24 months. We linked participant responses to questions from the 24 month follow-up interview, including alcohol and drug use and partner PrEP use, with STI test results (ie, syphilis, chlamydia, gonorrhoea) in the KPNC electronic health record. Prevalence ratios (PR) were estimated using Poisson models fitted with robust variance estimators to evaluate the association of substance use and partner use of PrEP with STIs., Results: In the analytic sample (n=465), the median age was 52 years (IQR 45-59); 67% were white; 95% were men who have sex with men. Thirty-two per cent of participants had HIV-positive partners only; 31% had HIV-negative partners with at least one on PrEP in the previous year and 37% had HIV-negative partners without any on PrEP. Twenty-three per cent reported alcohol and drug use prior to sex in the last 6 months. Eight per cent of participants had an STI. Partner PrEP use (adjusted PR (aPR) 2.99 (95% CI 1.11 to 8.08)) was independently associated with higher STI prevalence. Participants who reported use of alcohol (aPR 1.53 (0.61 to 3.83)), drugs (aPR 1.97 (0.71 to 5.51)) or both (aPR 1.93 (0.75 to 4.97)) prior to sex had a higher STI prevalence., Conclusions: The higher prevalence of STIs among PWH with unhealthy alcohol use who have partners on PrEP suggests that this subgroup may be a high-yield focus for targeted outreach, STI screening and sexual health counselling., Competing Interests: Competing interests: JM has received research grant support from Merck and has consulted on a research grant to Kaiser Permanente Northern California from Gilead Sciences. All other authors have no conflicts of interest to disclose., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Within Southern California, east Pacific green sea turtles (Chelonia mydas) forage year-round, taking advantage of diverse food resources, including seagrass, marine algae, and invertebrates. Assessing persistent organic pollutants (POP) in green turtle aggregations in the Seal Beach National Wildlife Refuge (SBNWR, n = 17) and San Diego Bay (SDB, n = 25) can help quantify contamination risks for these populations. Blood plasma was analyzed for polychlorinated biphenyls (PCBs), organochlorinated pesticides (OCPs), and polybrominated diphenyl ethers (PBDEs). PCBs and body size explained much of the separation of turtles by foraging aggregation in a principal component analysis. Turtles from SDB had significantly (p < 0.001) higher total PCBs than SBNWR turtles. Most PCBs detected in turtles were non-dioxin-like PCB congeners (153, 138, 99) that are associated with neurotoxicity. Recaptured turtles' POP levels changed significantly over time indicating significant variation in POP levels through time and space, even among adjacent foraging locations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background Sedentary behavior is pervasive, especially in older adults, and is associated with cardiometabolic disease and mortality. Relationships between cardiometabolic biomarkers and sitting time are unexplored in older women, as are possible ethnic differences. Methods and Results Ethnic differences in sitting behavior and associations with cardiometabolic risk were explored in overweight/obese postmenopausal women (n=518; mean±SD age 63±6 years; mean body mass index 31.4±4.8 kg/m 2 ). Accelerometer data were processed using validated machine-learned algorithms to measure total daily sitting time and mean sitting bout duration (an indicator of sitting behavior pattern). Multivariable linear regression was used to compare sitting among Hispanic women (n=102) and non-Hispanic women (n=416) and tested associations with cardiometabolic risk biomarkers. Hispanic women sat, on average, 50.3 minutes less/day than non-Hispanic women ( P <0.001) and had shorter (3.6 minutes less, P =0.02) mean sitting bout duration. Among all women, longer total sitting time was deleteriously associated with fasting insulin and triglyceride concentrations, insulin resistance, body mass index and waist circumference; longer mean sitting bout duration was deleteriously associated with fasting glucose and insulin concentrations, insulin resistance, body mass index and waist circumference. Exploratory interaction analysis showed that the association between mean sitting bout duration and fasting glucose concentration was significantly stronger among Hispanic women than non-Hispanic women ( P -interaction=0.03). Conclusions Ethnic differences in 2 objectively measured parameters of sitting behavior, as well as detrimental associations between parameters and cardiometabolic biomarkers were observed in overweight/obese older women. The detrimental association between mean sitting bout duration and fasting glucose may be greater in Hispanic women than in non-Hispanic women. Corroboration in larger studies is warranted.

Purpose: The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire., Methods: This study assessed SMY status in youth aged 12.5-18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as self-reported attraction to the same sex or both sexes., Results: A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n = 5,329) of respondents (N = 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6-2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth., Conclusions: This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Reflooding formerly drained peatlands has been proposed as a means to reduce losses of organic matter and sequester soil carbon for climate change mitigation, but a renewal of high methane emissions has been reported for these ecosystems, offsetting mitigation potential. Our ability to interpret observed methane fluxes in reflooded peatlands and make predictions about future flux trends is limited due to a lack of detailed studies of methanogenic processes. In this study we investigate methanogenesis in a reflooded agricultural peatland in the Sacramento Delta, California. We use the stable-and radio-carbon isotopic signatures of wetland sediment methane, ecosystem-scale eddy covariance flux observations, and laboratory incubation experiments, to identify which carbon sources and methanogenic production pathways fuel methanogenesis and how these processes are affected by vegetation and seasonality. We found that the old peat contribution to annual methane emissions was large (~30%) compared to intact wetlands, indicating a biogeochemical legacy of drainage. However, fresh carbon and the acetoclastic pathway still accounted for the majority of methanogenesis throughout the year. Although temperature sensitivities for bulk peat methanogenesis were similar between open-water (Q 10  = 2.1) and vegetated (Q 10  = 2.3) soils, methane production from both fresh and old carbon sources showed pronounced seasonality in vegetated zones. We conclude that high methane emissions in restored wetlands constitute a biogeochemical trade-off with contemporary carbon uptake, given that methane efflux is fueled primarily by fresh carbon inputs., (© 2019 John Wiley & Sons Ltd.)

To assess potential impacts on receiving systems, associated with storm water contaminants, laboratory 10-d amphipod (Eohaustorius estuarius) survival toxicity tests were performed using intact sediment cores collected from Paleta Creek (San Diego Bay, CA, USA) on 5 occasions between 2015 and 2017. The approach included deposition-associated sediment particles collected from sediment traps placed at each of 4 locations during the 2015 to 2016 wet seasons. The bioassays demonstrated wet season toxicity, especially closest to the creek mouth, and greater mortality associated with particles deposited in the wet season compared with dry season samples. Grain size analysis of sediment trap material indicated coarser sediment at the mouth of the creek and finer sediment in the outer depositional areas. Contaminant concentrations of metals (Cd, Cu, Hg, Ni, Pb, and Zn) and organic compounds (polycyclic aromatic hydrocarbons [PAHs], polychlorinated biphenyls [PCBs], and pesticides) were quantified to assess possible causes of toxicity. Contaminant concentrations were determined in the top 5 cm of sediment and porewater (using passive samplers). Whereas metals, PAHs, and PCBs were rarely detected at sufficient concentrations to elicit a response, pyrethroid pesticides were highly correlated with amphipod toxicity. Summing individual pyrethroid constituents using a toxic unit approach suggested that toxicity to E. estuarius could be associated with pyrethroids. This unique test design allowed delineation of spatial and temporal differences in toxicity, suggesting that storm water discharge from Paleta Creek may be the source of seasonal toxicity. Environ Toxicol Chem 2019;39:229-239. © 2019 SETAC., (© 2019 SETAC.)

Objectives: We characterized referral trends over time at a transgender clinic within an integrated health system in Northern California. We identified the transition-related requests of pediatric transgender and gender-nonconforming patients and evaluated differences in referrals by age group., Methods: Medical records were analyzed for all patients <18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics., Results: We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3-17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non-Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time ( P < .001). Most referrals were for requests to start cross-sex hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%)., Conclusions: The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Building Better Caregivers (BBC), a community 6-week, peer-led intervention, targets family caregivers of those with cognitive impairments. BBC was implemented in four geographically scattered areas. Self-report data were collected at baseline, 6 months, and 1 year. Primary outcome were caregiver strain and depression. Secondary outcomes included caregiver burden, stress, fatigue, pain, sleep, self-rated health, exercise, self-efficacy, and caregiver and care partner health care utilization. Paired t tests examined 6 month and 1-year improvements. General linear models examined associations between baseline and 6-month changes in self-efficacy and 12-month primary outcomes. Eighty-three participants (75% of eligible) completed 12-month data. Caregiver strain and depression improved significantly (Effect Sizes = .30 and .41). All secondary outcomes except exercise and caregiver health care utilization improved significantly. Baseline and 6-month improvements in self-efficacy were associated with improvements in caregiver strain and depression. In this pilot pragmatic study, BBC appears to assist caregivers while reducing care partner health care utilization. Self-efficacy appears to moderate these outcomes.

Importance: Visual impairment in children with brain tumors has received limited attention, as most pediatric neuro-oncology clinical trials neither require ophthalmologic evaluation on enrollment nor monitor effects of treatment on visual function during and after treatment., Objective: To investigate ophthalmology referral patterns for children with primary brain tumors, the prevalence of visual sequelae, and the association between tumor characteristics and vision-related diagnoses., Design, Setting, and Participants: This retrospective cohort study included 141 children with primary brain tumors treated at Loma Linda University Children's Hospital and Eye Institute, a university-based tertiary referral center, between January 2013 and September 2017. Data analysis was completed in March 2019., Intervention: Comprehensive ophthalmologic evaluation for children with primary brain tumors., Main Outcomes and Measures: Percentage of patients with ophthalmology evaluation, prevalence of abnormal ophthalmic findings, and their association with tumor characteristics., Results: A total of 141 children (73 [52%] male; median [range] age, 7 [0-18] years) with primary brain tumors were enrolled in this study. Seventy-three patients (41 [52%] male; median [range] age, 8 [0-17] years) never had formal ophthalmologic evaluation. Sixty-eight patients (32 [48%] male; median [range] age, 7 [0-18] years) were evaluated by 1 of 4 board-certified, fellowship-trained pediatric and/or neuro-ophthalmologists for any visual impairment over a total of 222 visits. Five-year overall survival for patients who had eye examination was not significantly different from those who did not (mean [SD] survival, 78.3% [6.2%] vs 84.9% [4.7%]). Median (range) time from tumor diagnosis to initial ophthalmologic evaluation was 9 (0-94) months. Only 10 of 68 children (15%) presented with visual symptoms at tumor diagnosis, while 61 of 68 (90%) had abnormal findings on examination, including strabismus (41 [60%]), visual acuity impairment (37 [54%]), amblyopia (26 [38%]), papilledema (24 [35%]), visual field defects (13 [19%]), optic atrophy (12 [18%]), and keratopathy (10 [15%]). Strabismus occurred more frequently in patients with posterior fossa tumors (26 of 68 in posterior fossa vs 15 of 68 in other locations; P = .02). The presence of visual field defects in patients with no visual symptoms was 15% (9 of 58). Radiation was significantly associated with amblyopia (odds ratio, 4.5; 95% CI, 1.2-15.7; P = .02)., Conclusions and Relevance: In this study, more than 50% of children with primary brain tumors were not referred for ophthalmologic evaluation. Although visual symptoms were uncommon, visual impairments occurred more frequently than previously reported. Ophthalmologic evaluation is recommended to identify and manage visual impairment and prevent permanent vision loss in children with brain tumors.

Vulnerability to embolism varies between con-generic species distributed along aridity gradients, yet little is known about intraspecific variation and its drivers. Even less is known about intraspecific variation in tissues other than stems, despite results suggesting that roots, stems and leaves can differ in vulnerability. We hypothesized that intraspecific variation in vulnerability in leaves and stems is adaptive and driven by aridity. We quantified leaf and stem vulnerability of Quercus douglasii using the optical technique. To assess contributions of genetic variation and phenotypic plasticity to within-species variation, we quantified the vulnerability of individuals growing in a common garden, but originating from populations along an aridity gradient, as well as individuals from the same wild populations. Intraspecific variation in water potential at which 50% of total embolism in a tissue is observed (P 50 ) was explained mostly by differences between individuals (&gt;66% of total variance) and tissues (16%). There was little between-population variation in leaf/stem P 50 in the garden, which was not related to site of origin aridity. Unexpectedly, we observed a positive relationship between wild individual stem P 50 and aridity. Although there is no local adaptation and only minor phenotypic plasticity in leaf/stem vulnerability in Q. douglasii, high levels of potentially heritable variation within populations or strong environmental selection could contribute to adaptive responses under future climate change., (© 2019 The Authors. New Phytologist © 2019 New Phytologist Trust.)

Major ecological realignments are already occurring in response to climate change. To be successful, conservation strategies now need to account for geographical patterns in traits sensitive to climate change, as well as climate threats to species-level diversity. As part of an effort to provide such information, we conducted a climate vulnerability assessment that included all anadromous Pacific salmon and steelhead (Oncorhynchus spp.) population units listed under the U.S. Endangered Species Act. Using an expert-based scoring system, we ranked 20 attributes for the 28 listed units and 5 additional units. Attributes captured biological sensitivity, or the strength of linkages between each listing unit and the present climate; climate exposure, or the magnitude of projected change in local environmental conditions; and adaptive capacity, or the ability to modify phenotypes to cope with new climatic conditions. Each listing unit was then assigned one of four vulnerability categories. Units ranked most vulnerable overall were Chinook (O. tshawytscha) in the California Central Valley, coho (O. kisutch) in California and southern Oregon, sockeye (O. nerka) in the Snake River Basin, and spring-run Chinook in the interior Columbia and Willamette River Basins. We identified units with similar vulnerability profiles using a hierarchical cluster analysis. Life history characteristics, especially freshwater and estuary residence times, interplayed with gradations in exposure from south to north and from coastal to interior regions to generate landscape-level patterns within each species. Nearly all listing units faced high exposures to projected increases in stream temperature, sea surface temperature, and ocean acidification, but other aspects of exposure peaked in particular regions. Anthropogenic factors, especially migration barriers, habitat degradation, and hatchery influence, have reduced the adaptive capacity of most steelhead and salmon populations. Enhancing adaptive capacity is essential to mitigate for the increasing threat of climate change. Collectively, these results provide a framework to support recovery planning that considers climate impacts on the majority of West Coast anadromous salmonids., Competing Interests: MWN is employed by a commercial contracting company, ECS Federal, Inc in support of NOAA Fisheries Office of Science and Technology. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Foraging aggregations of east Pacific green sea turtles (Chelonia mydas) inhabit the Seal Beach National Wildlife Refuge (SBNWR) and San Diego Bay (SDB), two habitats in southern California, USA, located near urbanized areas. Both juvenile and adult green turtles forage in these areas and exhibit high site fidelity, which potentially exposes green turtles to anthropogenic contaminants. We assessed 21 trace metals (TM) bioaccumulated in green turtle scute and red blood cell (RBC) samples collected from SBNWR (n = 16 turtles) and SDB (n = 20 turtles) using acid digestion and inductively coupled plasma mass spectrometry. Principal component analyses of TM composition indicate that SBNWR and SDB turtles have location-specific contaminant signatures, characterized by differences in cadmium and selenium concentrations: SBNWR turtles had significantly more cadmium and selenium in RBC and more selenium in scute samples, than SDB turtles. Cadmium and selenium concentrations in RBC had a strong positive relationship, regardless of location. SBNWR turtles had higher selenium in RBCs than previously measured in other green turtle populations globally. Due to different retention times in blood vs. scute, these results suggest that SBNWR turtles have high long- and short-term selenium exposure. Turtles from SBNWR and SDB had higher trace metal concentrations than documented in green turtle populations that inhabit non-urbanized areas, supporting the hypothesis that coastal cities can increase trace metal exposure to local green turtles. Our study finds evidence that green turtle TM concentrations can differ between urbanized habitats and that long-term monitoring of these green turtles may be necessary., (Copyright © 2019. Published by Elsevier Ltd.)