Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for internal medicine subspecialty fellows.

BACKGROUND: Case tracking (following-up prior patient encounters) can help inform future clinical decisions and supplement experiential learning. Internal medicine subspecialty fellows see a high volume of patients and need to become subject matter experts within a short time frame, yet little is known about their specific needs and motivations around case tracking. OBJECTIVE: The objective of this study was to explore internal medicine subspecialty fellows' motivations, preferences, and practices around case tracking. METHODS: We conducted interviews with internal medicine subspecialty fellows at a single academic medical center during the 2022-2023 academic year. Interviews were analyzed using qualitative content analysis. RESULTS: 22 fellows were interviewed for our study. We found that most fellows engaged in case tracking with lists in the electronic health record (EHR). Fellows primarily tracked cases of clinical uncertainty and patients with specific diseases or conditions of interest. Fellows sought information on patients' health outcomes, results, and clinical notes. Motivations for tracking were predominantly related to curiosity, professional growth, and development of practice patterns. Barriers to case tracking included time, challenges maintaining patient lists, losing track of patients, and lack of motivation to develop and maintain an organized system. CONCLUSIONS: Internal medicine subspecialty fellows engaged in and valued case tracking as a way to supplement their experiential learning. Our study highlighted their current practices, motivations, preferences, and challenges related to case tracking. We plan to use these findings to help develop an EHR-embedded dashboard to facilitate case tracking among subspecialty fellows.

Skills, Not Just Knowledge: Infectious Diseases Fellows' Recommendations Regarding Antimicrobial Stewardship Training.

BACKGROUND: Antimicrobial stewardship (AS) is an important topic in infectious diseases (ID) training, yet many ID fellowships lack formal training, and little is known about fellows' learning preferences. METHODS: We conducted 24 in-depth interviews with ID fellows across the United States during 2018 and 2019 to explore their experiences with and preferences for AS education during fellowship. Interviews were transcribed, deidentified, and analyzed to identify themes. RESULTS: Fellows had variable exposure to AS before and during fellowship, which impacted their knowledge about and attitude toward stewardship as a career; however, all fellows expressed the importance of learning general stewardship principles during fellowship. Some fellows' training included mandatory stewardship lectures and/or rotations, but most fellows felt their primary stewardship learning occurred through informal experiences in the clinical setting, such as holding the antimicrobial approval pager. Fellows expressed a preference for a standardized, structured curriculum that included in-person practical, interactive discussions with multidisciplinary faculty along with the opportunity to practice and apply their skills; however, they emphasized that time needed to be set aside for those educational activities. Although they wanted to learn the evidence and rationale for stewardship recommendations, they especially wanted training in and feedback on how to communicate stewardship recommendations to other health professionals, particularly in the setting of conflict. CONCLUSIONS: ID fellows believe that standardized AS curricula should be included in their fellowship training, and they prefer structured, practical, and interactive learning experiences.

Sinus inflammation and chronic rhinosinusitis are associated with a diagnosis of new onset asthma in the following year.

BACKGROUND: Chronic rhinosinusitis (CRS) and asthma commonly co-occur. No studies have leveraged large samples needed to formally address whether preexisting CRS is associated with new onset asthma over time. METHODS: We evaluated whether prevalent CRS [identified in two ways: validated text algorithm applied to sinus computerized tomography (CT) scan or two diagnoses] was associated with new onset adult asthma in the following year. We used electronic health record data from Geisinger from 2008 to 2019. For each year we removed persons with any evidence of asthma through the end of the year, then identified those with new diagnosis of asthma in the following year. Complementary log-log regression was used to adjust for confounding variables (e.g., sociodemographic, contact with the health system, comorbidities), and hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 35,441 persons were diagnosed with new onset asthma and were compared to 890,956 persons who did not develop asthma. Persons with new onset asthma tended to be female (69.6%) and younger (mean [SD] age 45.9 [17.0] years). Both CRS definitions were associated (HR, 95% CI) with new onset asthma, with 2.21 (1.93, 2.54) and 1.48 (1.38, 1.59) for CRS based on sinus CT scan and two diagnoses, respectively. New onset asthma was uncommonly observed in persons with a history of sinus surgery. CONCLUSION: Prevalent CRS identified with two complementary approaches was associated with a diagnosis of new onset asthma in the following year. The findings may have clinical implications for the prevention of asthma.

Associations between PM2.5 and O3 exposures and new onset type 2 diabetes in regional and national samples in the United States.

BACKGROUND: Exposure to particulate matter ≤2.5 µm in diameter (PM2.5) and ozone (O3) has been linked to numerous harmful health outcomes. While epidemiologic evidence has suggested a positive association with type 2 diabetes (T2D), there is heterogeneity in findings. We evaluated exposures to PM2.5 and O3 across three large samples in the US using a harmonized approach for exposure assignment and covariate adjustment. METHODS: Data were obtained from the Veterans Administration Diabetes Risk (VADR) cohort (electronic health records [EHRs]), the Reasons for Geographic and Racial Disparities in Stroke (REGARDS) cohort (primary data collection), and the Geisinger health system (EHRs), and reflect the years 2003-2016 (REGARDS) and 2008-2016 (VADR and Geisinger). New onset T2D was ascertained using EHR information on medication orders, laboratory results, and T2D diagnoses (VADR and Geisinger) or report of T2D medication or diagnosis and/or elevated blood glucose levels (REGARDS). Exposure was assigned using pollutant annual averages from the Downscaler model. Models stratified by community type (higher density urban, lower density urban, suburban/small town, or rural census tracts) evaluated likelihood of new onset T2D in each study sample in single- and two-pollutant models of PM2.5 and O3. RESULTS: In two pollutant models, associations of PM2.5, and new onset T2D were null in the REGARDS cohort except for in suburban/small town community types in models that also adjusted for NSEE, with an odds ratio (95% CI) of 1.51 (1.01, 2.25) per 5 µg/m3 of PM2.5. Results in the Geisinger sample were null. VADR sample results evidenced nonlinear associations for both pollutants; the shape of the association was dependent on community type. CONCLUSIONS: Associations between PM2.5, O3 and new onset T2D differed across three large study samples in the US. None of the results from any of the three study populations found strong and clear positive associations.

Strong and consistent associations of precedent chronic rhinosinusitis with risk of non-cystic fibrosis bronchiectasis.

BACKGROUND: Chronic rhinosinusitis (CRS) and bronchiectasis commonly co-occur, but most prior studies were not designed to evaluate temporality and causality. OBJECTIVES: In a sample representing the general population in 37 counties in Pennsylvania, and thus the full spectrum of sinonasal and relevant lung diseases, we aimed to evaluate the temporality and strength of associations of CRS with non-cystic fibrosis bronchiectasis. METHODS: We completed case-control analyses for each of 3 primary bronchiectasis case finding methods. We used electronic health records to identify CRS and bronchiectasis with diagnoses, procedure orders, and/or specific text in sinus or chest computerized tomography scan radiology reports. The controls never had any indication of bronchiectasis and were frequency-matched to the 3 bronchiectasis groups on the basis of age, sex, and encounter year. There were 5,329 unique persons with bronchiectasis and 33,363 without bronchiectasis in the 3 analyses. Important co-occurring conditions were identified with diagnoses, medication orders, and encounter types. Logistic regression was used to evaluate associations (odds ratios [ORs] and 95% CIs) of CRS with bronchiectasis while adjusting for confounding variables. RESULTS: In adjusted analyses, CRS was consistently and strongly associated with all 3 bronchiectasis definitions. The strongest associations for CRS (ORs and 95% CIs) were those that were based on the text of sinus computerized tomography scan reports; the associations were generally stronger for CRS without nasal polyps (eg, OR = 4.46 [95% CI = 2.09-9.51] for diagnosis-based bronchiectasis). On average, CRS was identified more than 6 years before bronchiectasis. CONCLUSION: Precedent CRS was strongly and consistently associated with increased risk of bronchiectasis.

Evaluation of the Infectious Diseases Society of America's Core Antimicrobial Stewardship Curriculum for Infectious Diseases Fellows.

BACKGROUND: Antimicrobial stewardship (AS) programs are required by Centers for Medicare and Medicaid Services and should ideally have infectious diseases (ID) physician involvement; however, only 50% of ID fellowship programs have formal AS curricula. The Infectious Diseases Society of America (IDSA) formed a workgroup to develop a core AS curriculum for ID fellows. Here we study its impact. METHODS: ID program directors and fellows in 56 fellowship programs were surveyed regarding the content and effectiveness of their AS training before and after implementation of the IDSA curriculum. Fellows' knowledge was assessed using multiple-choice questions. Fellows completing their first year of fellowship were surveyed before curriculum implementation ("pre-curriculum") and compared to first-year fellows who complete the curriculum the following year ("post-curriculum"). RESULTS: Forty-nine (88%) program directors and 105 (67%) fellows completed the pre-curriculum surveys; 35 (64%) program directors and 79 (50%) fellows completed the post-curriculum surveys. Prior to IDSA curriculum implementation, only 51% of programs had a "formal" curriculum. After implementation, satisfaction with AS training increased among program directors (16% to 68%) and fellows (51% to 68%). Fellows' confidence increased in 7/10 AS content areas. Knowledge scores improved from a mean of 4.6 to 5.1 correct answers of 9 questions (P = .028). The major hurdle to curriculum implementation was time, both for formal teaching and for e-learning. CONCLUSIONS: Effective AS training is a critical component of ID fellowship training. The IDSA Core AS Curriculum can enhance AS training, increase fellow confidence, and improve overall satisfaction of fellows and program directors.

The association of unconventional natural gas development with diagnosis and treatment of internalizing disorders among adolescents in Pennsylvania using electronic health records.

BACKGROUND: Unconventional natural gas development (UNGD) introduces physical and psychosocial hazards into communities, which could contribute to psychosocial stress in adolescents and an increased risk of internalizing disorders, common and impactful health outcomes. OBJECTIVES: To evaluate associations between a 180-day composite UNGD activity metric and new onset of internalizing disorders, overall and separately for anxiety and depressive disorders, and effect modification by sex. METHODS: We used a nested case-control design from 2008 to 2016 in 38 Pennsylvania counties using electronic health records from adolescent Geisinger subjects. Cases were defined by at least two diagnoses or medication orders indicating new onset of an internalizing disorder, and controls frequency-matched 4:1 on age, sex, and year. To evaluate associations, we used generalized estimating equations, with logit link, robust standard errors, and an exchangeable correlation structure within community. RESULTS: We identified 7,974 adolescents (65.9% female, mean age 15.0 years) with new onset internalizing disorders. There were no associations when we used data from the entire study period. When restricted to years with higher UNGD activity (2010-2016), comparing the highest to lowest quartile, UNGD activity was associated (odds ratio [95% confidence level]) with new onset internalizing disorders (1.15 [1.06, 1.25]). Associations were slightly stronger for depressive disorders. Associations were only present in females (p = 0.009). DISCUSSION: This is the first epidemiologic study of UNGD in relation to adolescent mental health, an important health outcome in a potentially susceptible group to the environmental and community impacts of UNGD. UNGD activity was associated with new onset internalizing disorders in females in this large sample in an area of active UNGD.

Urban-Rural Differences in Health Care Utilization and COVID-19 Outcomes in Patients With Type 2 Diabetes.

INTRODUCTION: Two studies in Pennsylvania aimed to determine whether community type and community socioeconomic deprivation (CSD) 1) modified associations between type 2 diabetes (hereinafter, diabetes) and COVID-19 hospitalization outcomes, and 2) influenced health care utilization among individuals with diabetes during the COVID-19 pandemic. METHODS: The hospitalization study evaluated a retrospective cohort of patients hospitalized with COVID-19 through 2020 for COVID-19 outcomes: death, intensive care unit (ICU) admission, mechanical ventilation, elevated D-dimer, and elevated troponin level. We used adjusted logistic regression models, adding interaction terms to evaluate effect modification by community type (township, borough, or city census tract) and CSD. The utilization study included patients with diabetes and a clinical encounter between 2017 and 2020. Autoregressive integrated moving average time-series models evaluated changes in weekly rates of emergency department and outpatient visits, hemoglobin A1c (HbA1c) laboratory tests, and antihyperglycemic medication orders from 2018 to 2020. RESULTS: In the hospitalization study, of 2,751 patients hospitalized for COVID-19, 1,020 had diabetes, which was associated with ICU admission and elevated troponin. Associations did not differ by community type or CSD. In the utilization study, among 93,401 patients with diabetes, utilization measures decreased in March 2020. Utilization increased in July, and then began to stabilize or decline through the end of 2020. Changes in HbA1c tests and medication order trends during the pandemic differed by community type and CSD. CONCLUSION: Diabetes was associated with selected outcomes among individuals hospitalized for COVID-19, but these did not differ by community features. Utilization trajectories among individuals with diabetes during the pandemic were influenced by community type and CSD and could be used to identify individuals at risk of gaps in diabetes care.

Human Immunodeficiency Virus Training Pathways in Residency: A National Survey of Curricula and Outcomes.

BACKGROUND: The Ending the HIV Epidemic initiative, which aims to decrease the annual incidence of HIV infections in the United States (US) by 90% over the next decade, will require growth of a limited HIV provider workforce. Existing HIV training pathways within Family Medicine (FM) and Internal Medicine (IM) residency programs may address the shortage of HIV medical providers, but their curricula and outcomes have not previously been assessed. METHODS: We identified HIV residency pathways via literature review, Internet search, and snowball sampling and designed a cross-sectional study of existing HIV pathways in the US. This survey of pathway directors included 33 quantitative items regarding pathway organization, curricular content, graduate outcomes, and challenges. We used descriptive statistics to summarize responses. RESULTS: Twenty-five residency programs with dedicated HIV pathways in the US were identified (14 FM and 11 IM), with most located in the West and Northeast. All 25 (100%) pathway directors completed the survey. Since 2006, a total of 228 residents (77 FM and 151 IM) have graduated from these HIV pathways. Ninety (39%) of 228 pathway graduates provide primary care to persons with HIV (PWH). CONCLUSIONS: HIV pathways are effective in graduating providers who can care for PWH, but generally are not located in nor do graduates practice in the geographic areas of highest need. Our findings can inform quality improvement for existing programs, development of new pathways, and workforce development strategies. Specifically, expanding pathways in regions of greatest need and incentivizing pathway graduates to work in these regions could augment the HIV workforce.

Guiding Academic Clinician Educators at Research-Intensive Institutions: a Framework for Chairs, Chiefs, and Mentors.

Department chairs and division chiefs at research-intensive academic medical centers often find mentoring clinician educators challenging. These faculty constitute the majority of academic physicians. Supporting excellent clinician educators is key to ensuring high-quality patient care and developing tomorrow's physicians. Little has been written for leaders on strategies to advance academic clinician educators' career success. We present a framework to guide chairs, chiefs, and mentors seeking to address clinician educator retention and satisfaction in academic medical centers.

Risk factors for Lyme disease stage and manifestation using electronic health records.

BACKGROUND: Little is known about risk factors for early (e.g., erythema migrans) and disseminated Lyme disease manifestations, such as arthritis, neurological complications, and carditis. No study has used both diagnoses and free text to classify Lyme disease by disease stage and manifestation. METHODS: We identified Lyme disease cases in 2012-2016 in the electronic health record (EHR) of a large, integrated health system in Pennsylvania. We developed a rule-based text-matching algorithm using regular expressions to extract clinical data from free text. Lyme disease cases were then classified by stage and manifestation using data from both diagnoses and free text. Among cases classified by stage, we evaluated individual, community, and health care variables as predictors of disseminated stage (vs. early) disease using Poisson regression models with robust errors. Final models adjusted for sociodemographic factors, receipt of Medical Assistance (i.e., Medicaid, a proxy for low socioeconomic status), primary care contact, setting of diagnosis, season of diagnosis, and urban/rural status. RESULTS: Among 7310 cases of Lyme disease, we classified 62% by stage. Overall, 23% were classified using both diagnoses and text, 26% were classified using diagnoses only, and 13% were classified using text only. Among the staged diagnoses (n = 4530), 30% were disseminated stage (762 arthritis, 426 neurological manifestations, 76 carditis, 95 secondary erythema migrans, and 76 other manifestations). In adjusted models, we found that persons on Medical Assistance at least 50% of time under observation, compared to never users, had a higher risk (risk ratio [95% confidence interval]) of disseminated Lyme disease (1.20 [1.05, 1.37]). Primary care contact (0.59 [0.54, 0.64]) and diagnosis in the urgent care (0.22 [0.17, 0.29]), compared to the outpatient setting, were associated with lower risk of disseminated Lyme disease. CONCLUSIONS: The associations between insurance payor, primary care status, and diagnostic setting with disseminated Lyme disease suggest that lower socioeconomic status and less health care access could be linked with disseminated stage Lyme disease. Intervening on these factors could reduce the individual and health care burden of disseminated Lyme disease. Our findings demonstrate the value of both diagnostic and narrative text data to identify Lyme disease manifestations in the EHR.

Neighborhood Characteristics and Cardiovascular Biomarkers in Middle-Aged and Older Adults: the Baltimore Memory Study.

Neighborhood greenness has been linked to better cardiovascular health, but little is known about its association with biomarkers related to cardiovascular risk. Adverse neighborhood conditions, such as disorder and socioeconomic disadvantage, are associated with higher cardiovascular biomarker levels, but these relationships may differ in neighborhoods with more greenness. This study evaluated cross-sectional associations of validated measures of neighborhood greenness, disorder, and socioeconomic disadvantage with cardiovascular biomarkers in middle-aged and older adults living in Baltimore City. The sample included 500 adults, aged 57-79 years, enrolled in the Baltimore Memory Study and living in Baltimore City during 2009-2010. Multi-level log-gamma regressions examined associations between the three neighborhood characteristics and seven cardiovascular biomarkers. Models additionally evaluated the effect modification by neighborhood greenness on associations of neighborhood disorder and socioeconomic disadvantage with the biomarkers. Adjusting for covariates and neighborhood greenness, greater neighborhood disorder was associated with higher C-reactive protein (exp ß = 1.21, SE = 0.11, p = 0.035) and serum amyloid A (exp ß = 1.28, SE = 0.12, p = 0.008), while greater neighborhood socioeconomic disadvantage was associated with higher tumor necrosis factor alpha (exp ß = 1.24, SE = 0.12, p = 0.019). Higher neighborhood greenness was associated with lower soluble vascular cell adhesion molecule-1, accounting for disorder (exp ß = 0.70, SE = 0.10, p = 0.010) and socioeconomic disadvantage (exp ß = 0.73, SE = 0.10, p = 0.025). There was no evidence of effect modification among neighborhood characteristics. The findings suggest that neighborhood effects on cardiovascular health may be mediated through cardiovascular biomarker levels, and that socioeconomic disadvantage, disorder, and greenness may each be important features of neighborhoods.

Proximity to freshwater blue space and type 2 diabetes onset: the importance of historical and economic context.

Salutogenic effects of living near aquatic areas (blue space) remain underexplored, particularly in non-coastal and non-urban areas. We evaluated associations of residential proximity to inland freshwater blue space with new onset type 2 diabetes (T2D) in central and northeast Pennsylvania, USA, using medical records to conduct a nested case-control study. T2D cases (n=15,888) were identified from diabetes diagnoses, medication orders, and laboratory test results and frequency-matched on age, sex, and encounter year to diabetes-free controls (n=79,435). We calculated distance from individual residences to the nearest lake, river, tributary, or large stream, and residence within the 100-year floodplain. Logistic regression models adjusted for community socioeconomic deprivation and other confounding variables and stratified by community type (townships [rural/suburban], boroughs [small towns], city census tracts). Compared to individuals living ≥1.25 miles from blue space, those within 0.25 miles had 8% and 17% higher odds of T2D onset in townships and boroughs, respectively. Among city residents, T2D odds were 38-39% higher for those living 0.25 to <0.75 miles from blue space. Residing within the floodplain was associated with 16% and 14% higher T2D odds in townships and boroughs. A post-hoc analysis demonstrated patterns of lower residential property values with nearer distance to the region's predominant waterbody, suggesting unmeasured confounding by socioeconomic disadvantage. This may explain our unexpected findings of higher T2D odds with closer proximity to blue space. Our findings highlight the importance of historic and economic context and interrelated factors such as flood risk and lack of waterfront development in blue space research.

Clinical outcomes and serologic response in solid organ transplant recipients with COVID-19: A case series from the United States.

The coronavirus disease 2019 (COVID-19) pandemic caused by SARS coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality for patients and stressed healthcare systems worldwide. The clinical features, disease course, and serologic response of COVID-19 among immunosuppressed patients such as solid organ transplant (SOT) recipients, who are at presumed risk for more severe disease, are not well characterized. We describe our institutional experience with COVID-19 among 10 SOT patients, including the clinical presentation, treatment modalities, and outcomes of 7 renal transplant recipients, 1 liver transplant recipient, 1 heart transplant recipient, and 1 lung transplant recipient. In addition, we report the serologic response in SOT recipients, documenting a positive IgG response in all 7 hospitalized patients. We also review the existing literature on COVID-19 in SOT recipients to consolidate the current knowledge on COVID-19 in the SOT population for the transplant community.

Radiologic sinus inflammation and symptoms of chronic rhinosinusitis in a population-based sample.

BACKGROUND: Chronic rhinosinusitis (CRS) epidemiology has been largely studied using symptom-based case definitions, without assessment of objective sinus findings. OBJECTIVE: To describe radiologic sinus opacification and the prevalence of CRS, defined by the co-occurrence of symptoms and sinus opacification, in a general population-based sample. METHODS: We collected questionnaires and sinus CT scans from 646 participants selected from a source population of 200 769 primary care patients. Symptom status (CRSS ) was based on guideline criteria, and objective radiologic inflammation (CRSO ) was based on the Lund-Mackay (L-M) score using multiple L-M thresholds for positivity. Participants with symptoms and radiologic inflammation were classified as CRSS+O . We performed negative binomial regression to assess factors associated with L-M score and logistic regression to evaluate factors associated with CRSS+O . Using weighted analysis, we calculated estimates for the source population. RESULTS: The proportion of women with L-M scores ≥ 3, 4, or 6 (CRSO ) was 11.1%, 9.9%, and 5.7%, respectively, and 16.1%, 14.6%, and 8.7% among men. The respective proportion with CRSS+O was 1.7%, 1.6%, and 0.45% among women and 8.8%, 7.5%, and 3.6% among men. Men had higher odds of CRSS+O compared to women. A greater proportion of men (vs women) had any opacification in the frontal, anterior ethmoid, and sphenoid sinuses. CONCLUSION: In a general population-based sample in Pennsylvania, sinus opacification was more common among men than in women and opacification occurred in different locations by sex. Male sex, migraine headache, and prior sinus surgery were associated with higher odds of CRSS+O .

Management and clinical outcomes after lung transplantation in patients with pre-transplant Mycobacterium abscessus infection: A single center experience.

BACKGROUND: Preoperative Mycobacterium abscessus infection is often considered a contraindication to lung transplantation because of its association with poor outcomes after transplant. Detailed strategies for bridging to transplant, post-operative management, and data regarding outcomes are lacking. METHODS: We reviewed outcomes in subjects with M abscessus infection who underwent lung transplantation between 2010 and 2018 at the University of California San Francisco. M abscessus infection was defined by American Thoracic Society (ATS) criteria. Data collected included age, FEV1 , BMI, LAS, antibiotic regimens, and other management decisions. Time to chronic lung allograft dysfunction (CLAD) and survival were also assessed. RESULTS: Of 387 lung transplant recipients, seven were infected with M abscessus at the time of listing. All received multiple antibiotics before transplant. While all subjects converted to smear negative for acid-fast bacilli before listing, five of the seven remained culture-positive at the time of transplant. After transplant, subjects received a median of 6 months of a multi-antibiotic regimen. One subject developed a post-operative M abscessus soft tissue infection that was treated medically. Six of the seven subjects survived the observation period; one died unrelated to M abscessus. Time to CLAD and survival were similar to a contemporary comparator group of CF transplant recipients. CONCLUSION: Lung transplant recipients with M abscessus infection have a low incidence of recurrent infection, excellent survival, and freedom from CLAD when an aggressive management and surveillance strategy is utilized. Given these findings, M abscessus infection may not be considered a contraindication to lung transplantation.

Unconventional natural gas development and adverse birth outcomes in Pennsylvania: The potential mediating role of antenatal anxiety and depression.

BACKGROUND: Studies have reported associations between unconventional natural gas development (UNGD) and adverse birth outcomes. None have evaluated potential mediating mechanisms. OBJECTIVES: To evaluate associations between (1) UNGD and antenatal anxiety and depression and (2) antenatal anxiety and depression and preterm birth (<37 weeks gestation) and reduced term birth weight, (3) stochastic direct and indirect effects of UNGD on preterm birth and term birth weight operating through antenatal anxiety and depression, and (4) effect modification by family-level socioeconomic status. METHODS: This retrospective cohort study included mothers without prevalent anxiety or depression at time of conception, who delivered at Geisinger in Pennsylvania between January 2009-January 2013. We assembled phase-specific UNGD activity data from public sources. Mothers were categorized as exposed (quartile 4) or unexposed (quartiles 1-3) based on average daily inverse distance-squared UNGD activity metric between conception and the week prior to anxiety or depression (cases) or the pregnancy-average daily metric (non-cases). We estimated associations with a doubly robust estimator (targeted minimum loss-based estimation) and adjusted for potential individual- and community-level confounding variables. RESULTS: Analyses included 8,371 births to 7,715 mothers, 12.2% of whom had antenatal anxiety or depression. We found 4.3 additional cases of antenatal anxiety or depression per 100 women (95% CI: 1.5, 7.0) under the scenario where all mothers lived in the highest quartile of UNGD activity versus quartiles 1-3. The risk difference appeared larger among mothers receiving Medical Assistance (indicator of low family income) compared to those who did not, 5.6 (95% CI: 0.5, 10.6) versus 2.9 (95% CI: -0.7, 6.5) additional cases of antenatal anxiety or depression per 100 women. We found no relationship between antenatal anxiety or depression and adverse birth outcomes and no mediation effect either overall or when stratifying by Medical Assistance. CONCLUSION: We observed a relationship between UNGD activity and antenatal anxiety and depression, which did not mediate the overall association between UNGD activity and adverse birth outcomes.

Peridomestic and community-wide landscape risk factors for Lyme disease across a range of community contexts in Pennsylvania.

Land use and forest fragmentation are thought to be major drivers of Lyme disease incidence and its geographic distribution. We examined the association between landscape composition and configuration and Lyme disease in a population-based case control study in the Geisinger health system in Pennsylvania. Lyme disease cases (n = 9657) were identified using a combination of diagnosis codes, laboratory codes, and antibiotic orders from electronic health records (EHRs). Controls (5:1) were randomly selected and frequency matched on year, age, and sex. We measured six landscape variables based on prior literature, derived from the National Land Cover Database and MODIS satellite imagery: greenness (normalized difference vegetation index), percent forest, percent herbaceous, forest edge density, percent forest-herbaceous edge, and mean forest patch size. We assigned landscape variables within two spatial contexts (community and ½-mile [805 m] Euclidian residential buffer). In models stratified by community type, landscape variables were modeled as tertiles and flexible splines and associations were adjusted for demographic and clinical covariates. In general, we observed positive associations between landscape metrics and Lyme disease, except for percent herbaceous, where associations differed by community type. For example, compared to the lowest tertile, individuals with highest tertile of greenness in residential buffers had higher odds of Lyme disease (odds ratio: 95% confidence interval [CI]) in townships (1.73: 1.55, 1.93), boroughs (1.70: 1.40, 2.07), and cities (3.71: 1.74, 7.92). Similarly, corresponding odds ratios (95% CI) for forest edge density were 1.34 (1.22, 1.47), 1.56 (1.33, 1.82), and 1.90 (1.13, 3.18). Associations were generally higher in residential buffers, compared to community, and in cities, compared to boroughs or townships. Our results reinforce the importance of peridomestic landscape in Lyme disease risk, particularly measures that reflect human interaction with tick habitat. Linkage of EHR data to public data on residential and community context may lead to new health system-based approaches for improving Lyme disease diagnosis, treatment, and prevention.