COVID-19 Vaccine Hesitancy Among Patients with Inflammatory Bowel Diseases at a Diverse Safety Net Hospital.

BACKGROUND AND AIMS: Patients with inflammatory bowel disease (IBD) and underrepresented minorities (URMs) historically have below average vaccination rates. URMs have increased morbidity and mortality from COVID-19. We surveyed IBD patients to assess COVID vaccination attitudes, particularly among URMs. METHODS: In May and June 2021, all 822 adult patients with IBD, medically homed at a tertiary IBD referral center and safety net hospital, and with access to the electronic patient portal, were sent an electronic survey assessing their attitudes regarding COVID-19 vaccination. An additional 115 without access to the patient portal were contacted by phone. Demographic and clinical data were recorded. The primary outcome was vaccination hesitancy, defined as: likely will become vaccinated later this year, but not immediately; unsure if they will get the vaccine; or do not want the vaccine. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) of factors associated with vaccination intent. RESULTS: The mean age was 46.6 years (SD 15.1). 210/1029 patients responded to the survey: 150/822 (18.2%) electronically and 60/115 (52.2%) by phone. Overall vaccine hesitancy rate was 11.9%, significantly higher in younger (aOR for 10-year increments, 0.64; 95% confidence interval [CI], 0.46-0.90, p = 0.011), Hispanic (aOR, 7.67; 95% CI, 2.99-21.3, p < 0.0002), and Black patients (aOR, 3.52; 95% CI 1.11-11.1, p = 0.050). Safety concerns were the most cited reasons for vaccine hesitancy. CONCLUSIONS: URM patients were more vaccine hesitant. Future studies should further explore factors leading to lower vaccination rates among these groups and strategies to improve COVID-19 vaccination rates.

Risk Factors for Development of Hypocalcemia in Patients With Cancer Treated With Bone-Modifying Agents.

BACKGROUND: This retrospective analysis describes the prevalence of and risk factors associated with the development of hypocalcemia in patients with cancer receiving bone-modifying agents (BMAs) as supportive care. PATIENTS AND METHODS: Patients with cancer treated with an intravenous or subcutaneous BMA, including pamidronate, zoledronic acid, or denosumab, at a tertiary care/safety net hospital in 2005 through 2015 were included in this retrospective review. We reviewed the medical records for predictive clinical and laboratory parameters and for patient outcomes. RESULTS: A total of 835 patients with cancer received at least one dose of a BMA during the specified time frame; 205 patients (25%) developed hypocalcemia of CTCAE grade ≥1 within 8 weeks of BMA initiation, 18 of whom (8.8%) had grade ≥3, and 3 patients died as a result. Multivariate analysis showed that patients with hematologic malignancy (odds ratio [OR], 1.956; P=.025), bone metastases (OR, 2.443; P=.017), inpatient status (OR, 2.592; P<.001), and deficient baseline vitamin D levels (OR, 2.546; P<.023) were more likely to develop hypocalcemia. Hypercalcemia before BMA administration (OR, 0.474; P=.032) was protective. CONCLUSIONS: Certain patient populations, including those with hematologic malignancies and/or bone metastases, warrant closer monitoring of calcium levels while receiving BMAs because of the high rate of hypocalcemia. Low pretreatment vitamin D levels are associated with the development of hypocalcemia. These data support close monitoring of calcium levels in patients with cancer receiving BMAs, in addition to adequate repletion of vitamin D before initiation of BMAs when possible.

Correction to: Occurrence of mental illness following prenatal and early childhood exposure to tetrachloroethylene (PCE)-contaminated drinking water: a retrospective cohort study.

Following publication of the original article [1], the author reported that, because of a programming error, incorrect sentences and incorrect Table 3 has been published. The correct sentences and Table 3 are shown below.

Renal Interstitial Fibrosis: An Imperfect Predictor of Kidney Disease Progression in Some Patient Cohorts.

BACKGROUND: The extent of interstitial fibrosis on kidney biopsy is regarded as a prognostic indicator and guide to treatment. Patients with extensive fibrosis are assigned to supportive treatments with the expectation that they have advanced beyond the point at which immunosuppressive or other disease-modifying therapies would be of benefit. Our study highlights some of the limitations of using interstitial fibrosis to predict who will develop end-stage renal disease (ESRD). METHODS: Analysis of 434 consecutive renal biopsies performed between 2001 and 2012 at a single center. We assessed the influence of various clinical factors along with fibrosis as predictors of ESRD and dialysis-free survival in various patient groups. RESULTS: Interstitial fibrosis performed well overall as a predictor of progression to dialysis. On average, patients with >50% fibrosis progressed more rapidly than those with either 25-49 or 0-24% fibrosis with a median time to dialysis of 1.2, 6.5 and >10 years, respectively. In contrast, interstitial fibrosis was of less value as a predictor of disease progression in a subset of cases that included patients over the age of 70 and those with diabetic nephropathy on biopsy. Surprisingly, 13.9% of patients with normal renal function had 25-49% fibrosis and 5% had more than 50% fibrosis on biopsy, and 5 years after undergoing biopsy 21% of patients with >50% fibrosis still remained dialysis free. CONCLUSION: Renal fibrosis is an imperfect prognostic indicator for the development of ESRD and caution should be exercised in applying it too rigidly, especially in elderly or diabetic patients.

Lifestyle and career satisfaction among US-based oral and maxillofacial surgeons: Results of a nationwide survey.

OBJECTIVE: This study aims to investigate overall career satisfaction rate amongst US-based oral and maxillofacial surgeons (OMSs) and to evaluate possible predictors of professional stress and quality of life. STUDY DESIGN: Members of the American Association of Oral and Maxillofacial Surgeons were invited to complete an online survey-based assessment. Descriptive statistics were computed; univariate analysis was performed to identify predictors for satisfaction. RESULTS: The overall response rate was 29%. Most of respondents were male (88.6%), aged >45 years (71.7%), married (91.7%), and working at private and/or group-based practices (55.9%) for >15 years (66.6%). Most surgeons 91.3% reported being satisfied with their career with 84.9% willing to choose a career in OMS again. No significant difference was noted in satisfaction rates between academic and non-academic surgeons. On univariate analysis, no demographic characteristic was predictive of satisfaction. CONCLUSIONS: Reportedly, 91.3% of US-based OMSs have a significant degree of career satisfaction, and a majority would choose the specialty as their profession again.

A Brief Measure of Fidelity for Mindfulness Programs: Development and Evaluation of the Concise Fidelity for Mindfulness-Based Interventions Tool.

Background: Mindfulness research and clinical programs are widespread, and it is important that mindfulness-based interventions are delivered with fidelity, or as intended, across settings. The MBI:TAC is a comprehensive system for assessing teacher competence, yet it can be complex to implement. A standardized, simple fidelity/engagement tool to address treatment delivery is needed. Objective: We describe the development, evaluation, and outcomes of a brief, practical tool for assessing fidelity and engagement in online mindfulness-based programs. The tool contains questions about session elements such as meditation guidance and group discussion, and questions about participant engagement and technology-based barriers to engagement. Methods: The fidelity rating tool was developed and tested in OPTIMUM, Optimizing Pain Treatment in Medical settings Using Mindfulness. The OPTIMUM study is a 3-site pragmatic randomized trial of group medical visits and adapted mindfulness-based stress reduction for primary care patients with chronic low back pain, delivered online. Two trained study personnel independently rated 26 recorded OPTIMUM sessions to determine inter-rater reliability of the Concise Fidelity for Mindfulness-Based Interventions (CoFi-MBI) tool. Trained raters also completed the CoFi-MBI for 105 sessions. Raters provided qualitative data via optional open text fields within the tool. Results: Inter-rater agreement was 77-100% for presence of key session components, and 69-88% for Likert ratings of participant engagement and challenges related to technology, with discrepancies only occurring within 2 categories: 'very much' and 'quite a bit'. Key session components occurred as intended in 94-100% of the 105 sessions, and participant engagement was rated as 'very much' or 'quite a bit' in 95% of the sessions. Qualitative analysis of rater comments revealed themes related to engagement challenges and technology failures. Conclusion: The CoFi-MBI provides a practical way to assess basic adherence to online delivery of mindfulness session elements, participant engagement, and extent of technology obstacles. Optional text can guide strategies to improve engagement and reduce technology barriers.

Demographic predictors of lack of current mental health treatment among university students with a schizophrenia spectrum disorder.

AIM: To identify the demographic predictors of lack of current mental health (MH) treatment among university students with a schizophrenia spectrum disorder (SSD). METHODS: Adult university students with a self-identified diagnosis of an SSD (schizophreniform, schizophrenia, schizoaffective disorder) were identified from the 2019-2020 Healthy Minds Study survey. In this study, pertinent demographic factors included age, race/ethnicity, sex assigned at birth, gender identity, sexual orientation, parental education, financial stress, and employment. Multivariable modelling was used to investigate the demographic predictors of lack of current psychotherapy treatment, no current antipsychotic use, and lack of any MH treatment (defined as concurrent lack of psychotherapy and antipsychotic treatment). RESULTS: Of the 135 included students with a SSD, the median age was 23 years old and 79 (58.5%) were assigned female at birth. Fifty-five participants (40.7%) lacked any current MH treatment. In fully adjusted models, lack of current MH treatment was associated with working more than 20 h per week (OR 2.9 [1.2-7.1], p = 0.02). No current antipsychotic use was associated with Hispanic/Latino race/ethnicity (OR 4.2 (1.2-14.5), p = 0.04). Lack of current psychotherapy treatment was associated with cisgender male identity (OR 5.5 [2.0-15.2], p < 0.01), working greater than 20 hours per week (OR 6.5 [2.2-19.2], p < 0.01), and having one or more structural or attitudinal barriers to care (OR = 4.6 [1.5-13.9], p < 0.01). CONCLUSIONS: The demographic predictors of lack of current MH treatment varied between psychotherapy and antipsychotic use, suggesting university health centres should consider interventions targeting several at-risk populations to increase treatment use among students with a SSD.

ASCA IgG and CBir antibodies are associated with the development of Crohn's disease and fistulae following ileal pouch-anal anastomosis.

BACKGROUND: For ulcerative colitis (UC) patients undergoing ileal pouch-anal anastomosis (IPAA), postoperative complications include chronic pouchitis and development of Crohn's disease (CD) of the pouch. AIMS: The aim of this study was to determine if serologic markers obtained postoperatively are associated with the development of complications in UC patients after IPAA. METHODS: A retrospective chart review was conducted of UC patients with IPAA were tested for expression of serologic markers. Complications abstracted from medical records included postoperative fistula, CD of the pouch, chronic pouchitis, and diversion or excision of the pouch. RESULTS: 142 patients were enrolled, 44 of whom developed complications. Positive serologic profiles for ASCA IgG and anti-CBir1 markers were found to be associated with the development of any complication, (P = 0.017 and P = 0.002, respectively). A positive anti-CBir1 test was also found to be associated with CD of the pouch and/or fistula formation (P < 0.001). Similarly, both ASCA IgG and anti-CBir1 titers were significantly associated with postoperative IPAA complications (P = 0.034 and P = 0.001, respectively), and anti-CBir1 titers were associated with CD of the pouch and/or fistula formation (P < 0.001). Complications developed after a median follow-up of 216 months (range 1-264). CONCLUSIONS: ASCA IgG and anti-CBir1 markers were associated with the development of complications after IPAA, specifically fistulae and/or CD of the pouch. The ability to identify patients at high risk for adverse outcomes may allow for early aggressive therapy, which may decrease the rate of pouch failure. A prospective study of patients with preoperative serology is ongoing.

Occurrence of mental illness following prenatal and early childhood exposure to tetrachloroethylene (PCE)-contaminated drinking water: a retrospective cohort study.

BACKGROUND: While many studies of adults with solvent exposure have shown increased risks of anxiety and depressive disorders, there is little information on the impact of prenatal and early childhood exposure on the subsequent risk of mental illness. This retrospective cohort study examined whether early life exposure to tetrachloroethylene (PCE)-contaminated drinking water influenced the occurrence of depression, bipolar disorder, post-traumatic stress disorder, and schizophrenia among adults from Cape Cod, Massachusetts. METHODS: A total of 1,512 subjects born between 1969 and 1983 were studied, including 831 subjects with both prenatal and early childhood PCE exposure and 547 unexposed subjects. Participants completed questionnaires to gather information on mental illnesses, demographic and medical characteristics, other sources of solvent exposure, and residences from birth through 1990. PCE exposure originating from the vinyl-liner of water distribution pipes was assessed using water distribution system modeling software that incorporated a leaching and transport algorithm. RESULTS: No meaningful increases in risk ratios (RR) for depression were observed among subjects with prenatal and early childhood exposure (RR: 1.1, 95% CI: 0.9-1.4). However, subjects with prenatal and early childhood exposure had a 1.8-fold increased risk of bipolar disorder (N = 36 exposed cases, 95% CI: 0.9-1.4), a 1.5-fold increased risk post-traumatic stress disorder (N = 47 exposed cases, 95% CI: 0.9-2.5), and a 2.1-fold increased risk of schizophrenia (N = 3 exposed cases, 95% CI: 0.2-20.0). Further increases in the risk ratio were observed for bipolar disorder (N = 18 exposed cases, RR; 2.7, 95% CI: 1.3-5.6) and post-traumatic stress disorder (N = 18 exposed cases, RR: 1.7, 95% CI: 0.9-3.2) among subjects with the highest exposure levels. CONCLUSIONS: The results of this study provide evidence against an impact of early life exposure to PCE on the risk of depression. In contrast, the results provide support for an impact of early life exposure on the risk of bipolar disorder and post-traumatic stress disorder. The number of schizophrenia cases was too small to draw reliable conclusions. These findings should be confirmed in investigations of other similarly exposed populations.

Individual-level space-time analyses of emergency department data using generalized additive modeling.

BACKGROUND: Although daily emergency department (ED) data is a source of information that often includes residence, its potential for space-time analyses at the individual level has not been fully explored. We propose that ED data collected for surveillance purposes can also be used to inform spatial and temporal patterns of disease using generalized additive models (GAMs). This paper describes the methods for adapting GAMs so they can be applied to ED data. METHODS: GAMs are an effective approach for modeling spatial and temporal distributions of point-wise data, producing smoothed surfaces of continuous risk while adjusting for confounders. In addition to disease mapping, the method allows for global and pointwise hypothesis testing and selection of statistically optimum degree of smoothing using standard statistical software. We applied a two-dimensional GAM for location to ED data of overlapping calendar time using a locally-weighted regression smoother. To illustrate our methods, we investigated the association between participants' address and the risk of gastrointestinal illness in Cape Cod, Massachusetts over time. RESULTS: The GAM space-time analyses simultaneously smooth in units of distance and time by using the optimum degree of smoothing to create data frames of overlapping time periods and then spatially analyzing each data frame. When resulting maps are viewed in series, each data frame contributes a movie frame, allowing us to visualize changes in magnitude, geographic size, and location of elevated risk smoothed over space and time. In our example data, we observed an underlying geographic pattern of gastrointestinal illness with risks consistently higher in the eastern part of our study area over time and intermittent variations of increased risk during brief periods. CONCLUSIONS: Spatial-temporal analysis of emergency department data with GAMs can be used to map underlying disease risk at the individual-level and view changes in geographic patterns of disease over time while accounting for multiple confounders. Despite the advantages of GAMs, analyses should be considered exploratory in nature. It is possible that even with a conservative cutoff for statistical significance, results of hypothesis testing may be due to chance. This paper illustrates that GAMs can be adapted to measure geographic trends in public health over time using ED data.

Characterizing Interprofessional Collaboration and Referral to Mindfulness-Based Stress Reduction Programs.

Background: In 2017, the American College of Physicians (ACP) designated Mindfulness-Based Stress Reduction (MBSR), an eight-week group program, as first-line non-pharmacological treatment for chronic low back pain. However, interprofessional collaboration between mindfulness instructors and Primary Care Providers (PCP) remains largely unknown. Objective: We developed a survey to assess communication between mindfulness instructors and PCPs, identify predictors of referral to MBSR, and determine areas where interventions could increase patient access to MBSR. Methods: The 25-question survey was sent via email to PCPs at the Division of General Internal Medicine, University of Pittsburgh, PA, the Piedmont Health Services Family Medicine Section, Chapel Hill, NC, the Boston Medical Center General Internal Medicine and Family Medicine Sections, Boston, MA, and the UMass Memorial Medical Center Family Medicine Section, Worcester, MA. We used descriptive statistics and logistic regression to analyze the data. Results: Among 118 eligible respondents, 85 (72.0%) were female PCPs, mean age was approximately 41.5±10.1, and the majority (65.2%) had been in medical practice ≤10 years. Of these PCPs, 83 (70.1%) reported familiarity with MBSR (95% CI: 62.1, 78.5), and 49 (59.0%) of them referred patients at least yearly. Of those who referred, 8 (16.3%) reported collaboration with mindfulness instructors. PCPs who were quite a bit or very much familiar with MBSR had 5.10 (1.10, 22.50) times the odds (P=.03), and those who were 50 years or younger had 3.30 times the odds (P=.04) of referring patients to MBSR. Frequency of PCPs' personal practice of mindfulness was not significantly associated with referrals (P=.30). Conclusion: This is the first study to assess interprofessional collaboration between mindfulness instructors and PCPs. Suggestions for a potential integrative health care model are included; further studies on methods to augment communication and education are warranted to improve the referral process and ultimately increase accessibility and utilization of mindfulness-based programs.

Affinity for risky behaviors following prenatal and early childhood exposure to tetrachloroethylene (PCE)-contaminated drinking water: a retrospective cohort study.

BACKGROUND: Many studies of adults with acute and chronic solvent exposure have shown adverse effects on cognition, behavior and mood. No prior study has investigated the long-term impact of prenatal and early childhood exposure to the solvent tetrachloroethylene (PCE) on the affinity for risky behaviors, defined as smoking, drinking or drug use as a teen or adult. OBJECTIVES: This retrospective cohort study examined whether early life exposure to PCE-contaminated drinking water influenced the occurrence of cigarette smoking, alcohol consumption, and drug use among adults from Cape Cod, Massachusetts. METHODS: Eight hundred and thirty-one subjects with prenatal and early childhood PCE exposure and 547 unexposed subjects were studied. Participants completed questionnaires to gather information on risky behaviors as a teenager and young adult, demographic characteristics, other sources of solvent exposure, and residences from birth through 1990. PCE exposure was estimated using the U.S. EPA's water distribution system modeling software (EPANET) that was modified to incorporate a leaching and transport model to estimate PCE exposures from pipe linings. RESULTS: Individuals who were highly exposed to PCE-contaminated drinking water during gestation and early childhood experienced 50-60% increases in the risk of using two or more major illicit drugs as a teenager or as an adult (Relative Risk (RR) for teen use = 1.6, 95% CI: 1.2-2.2; and RR for adult use = 1.5, 95% CI: 1.2-1.9). Specific drugs for which increased risks were observed included crack/cocaine, psychedelics/hallucinogens, club/designer drugs, Ritalin without a prescription, and heroin (RRs:1.4-2.1). Thirty to 60% increases in the risk of certain smoking and drinking behaviors were also seen among highly exposed subjects. CONCLUSIONS: The results of this study suggest that risky behaviors, particularly drug use, are more frequent among adults with high PCE exposure levels during gestation and early childhood. These findings should be confirmed in follow-up investigations of other exposed populations.

The design and methods of the OPTIMUM study: A multisite pragmatic randomized clinical trial of a telehealth group mindfulness program for persons with chronic low back pain.

Mindfulness-based stress reduction (MBSR) is an evidence-based non-pharmacological approach for chronic low back pain (cLBP), yet it is not readily available or reimbursable within primary care clinics. Primary care providers (PCPs) who wish to avoid prescribing opioids and other medications typically have few options for their cLBP patients. We present the protocol of a pragmatic clinical trial entitled OPTIMUM (Optimizing Pain Treatment In Medical settings Using Mindfulness). OPTIMUM is offered online via telehealth and includes medical group visits (MGV) with a PCP and a mindfulness meditation intervention modeled on MBSR for persons with cLBP. In diverse health-care settings in the US, such as a safety net hospital, federally qualified health centers, and a large academic health system, 450 patients will be assigned randomly to the MGV + MBSR or to usual PCP care alone. Participants will complete self-report surveys at baseline, following the 8-week program, and at 6- and 12-month follow-up. Health care utilization data will be obtained through electronic health records and via brief monthly surveys completed by participants. The primary outcome measure is the PEG (Pain, enjoyment, and general activity) at the 6-month follow-up. Additionally, we will assess psychological function, healthcare resource use, and opioid prescriptions. This trial, which is part of the NIH HEAL Initiative, has the potential to enhance primary care treatment of cLBP by combining PCP visits with a non-pharmacological treatment modeled on MBSR. Because it is offered online and integrated into primary care, it is expected to be scalable and accessible to underserved patients. Clinical Trials.gov: NCT04129450.

Spatial analysis of learning and developmental disorders in upper Cape Cod, Massachusetts using generalized additive models.

The spatial variability of three indicators of learning and developmental disability (LDD) was assessed for Cape Cod, Massachusetts. Maternal reports of receiving special education services, attention deficit hyperactivity disorder, and educational attainment were available for a birth cohort from 1969-1983. Using generalized additive models and residential history, maps of the odds of LDD were produced that also controlled for known risk factors. While results were not statistically significant, they suggest that children living in certain parts of Cape Cod were more likely to have a LDD. The spatial variation may be due to variation in the physical and social environment.

A novel confidence interval for a single proportion in the presence of clustered binary outcome data.

Estimating the precision of a single proportion via a 100(1-α)% confidence interval in the presence of clustered data is an important statistical problem. It is necessary to account for possible over-dispersion, for instance, in animal-based teratology studies with within-litter correlation, epidemiological studies that involve clustered sampling, and clinical trial designs with multiple measurements per subject. Several asymptotic confidence interval methods have been developed, which have been found to have inadequate coverage of the true proportion for small-to-moderate sample sizes. In addition, many of the best-performing of these intervals have not been directly compared with regard to the operational characteristics of coverage probability and empirical length. This study uses Monte Carlo simulations to calculate coverage probabilities and empirical lengths of five existing confidence intervals for clustered data across various true correlations, true probabilities of interest, and sample sizes. In addition, we introduce a new score-based confidence interval method, which we find to have better coverage than existing intervals for small sample sizes under a wide range of scenarios.

Diversity, Equity, and Inclusiveness in Medicine and Cardiology: Next Steps for JAHA.

We, the Editors of the Journal of the American Heart Association, sincerely regret the publication of the article "Diversity, Inclusion, and Equity: Evolution of Race and Ethnicity Considerations for the Cardiology Workforce in the United States of America From 1969 to 2019".1 We are aware that the publication of this flawed and biased article has caused a great deal of unnecessary pain and anguish to a number of parties, and reflects extremely poorly on us. We fully support the retraction of this article.

Reproductive and developmental health effects of prenatal exposure to tetrachloroethylene-contaminated drinking water.

Tetrachloroethylene (PCE) is a common contaminant in both occupational and community settings. High exposure levels in the workplace have been shown to have adverse impacts on reproduction and development but few epidemiological studies have examined these effects at the lower levels commonly seen in community settings. We were presented with a unique opportunity to examine the reproductive and developmental effects of prenatal exposure to PCE-contaminated drinking water resulting from the installation of vinyl-lined water pipes in Massachusetts and Rhode Island from the late 1960s through 1980. This review describes the methods and findings of two community-based epidemiological studies, places their results in the context of the existing literature, and describes the strengths and challenges of conducting epidemiological research on a historical pollution episode. Our studies found that prenatal exposure to PCE-contaminated drinking water is associated with delayed time-to-pregnancy, and increased risks of placental abruption, stillbirths stemming from placental dysfunction, and certain birth defects. No associations were observed with pregnancy loss, birth weight, and gestational duration. Important strengths of this research included the availability of historical data on the affected water systems, a relatively high exposure prevalence and wide range of exposure levels, and little opportunity for recall bias and confounding. Challenges arose mainly from the retrospective nature of the exposure assessments. This research highlights the importance of considering pregnant women and their developing fetuses when monitoring, regulating, and remediating drinking water contaminants.

Prenatal exposure to tetrachloroethylene-contaminated drinking water and the risk of congenital anomalies: a retrospective cohort study.

BACKGROUND: Prior animal and human studies of prenatal exposure to solvents including tetrachloroethylene (PCE) have shown increases in the risk of certain congenital anomalies among exposed offspring. OBJECTIVES: This retrospective cohort study examined whether PCE contamination of public drinking water supplies in Massachusetts influenced the occurrence of congenital anomalies among children whose mothers were exposed around the time of conception. METHODS: The study included 1,658 children whose mothers were exposed to PCE-contaminated drinking water and a comparable group of 2,999 children of unexposed mothers. Mothers completed a self-administered questionnaire to gather information on all of their prior births, including the presence of anomalies, residential histories and confounding variables. PCE exposure was estimated using EPANET water distribution system modeling software that incorporated a fate and transport model. RESULTS: Children whose mothers had high exposure levels around the time of conception had an increased risk of congenital anomalies. The adjusted odds ratio of all anomalies combined among children with prenatal exposure in the uppermost quartile was 1.5 (95% CI: 0.9, 2.5). No meaningful increases in the risk were seen for lower exposure levels. Increases were also observed in the risk of neural tube defects (OR: 3.5, 95% CI: 0.8, 14.0) and oral clefts (OR 3.2, 95% CI: 0.7, 15.0) among offspring with any prenatal exposure. CONCLUSION: The results of this study suggest that the risk of certain congenital anomalies is increased among the offspring of women who were exposed to PCE-contaminated drinking water around the time of conception. Because these results are limited by the small number of children with congenital anomalies that were based on maternal reports, a follow-up investigation should be conducted with a larger number of affected children who are identified by independent records.

Matching Our Mission: A Strategic Plan to Create a Diverse Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Increasing the number of underrepresented minority (URM) physicians improves access and quality of care. URMs are more likely to practice primary care and work in underserved communities. The racial and ethnic diversity of family physicians lags behind the general population. To create a more diverse residency, the Boston Medical Center Family Medicine Residency Program (BMCFMRP) developed, implemented, and evaluated a strategic plan for diversity recruitment. METHODS: In academic year (AY) 2014-2015, we set goals to increase the number of URM applicants and the percentage of matched URMs. From 2014-2017, we implemented an intervention focused on: (1) increasing outreach to URM candidates, (2) revising interviews to minimize bias, and (3) analyzing recruitment data. RESULTS: From 2014-2017, the total number of URM applicants increased by 80% (61 to 110). Evaluating recruitment trends from 2010-2017, there was a statistically significant increase (P<0.001) in the percentage of URM applicants from 13.3% (29 of 218 total applicants) to 19.9% (110 of 402). There was also a significant increase (P=0.029) in the percentage of matched URMs. Before the intervention, the percentage ranged from 0% to 20% (2011: 0% [n=0/6], 2014: 0% [n=0/10], 2013: 20% [n=2/10]). During the intervention, the percentage ranged from 25% to 50% (2017: 25% [n=3/12], 2016: 50% [n=6/12]). CONCLUSIONS: The implementation of a strategic plan for diversity recruitment increased the number of URM applicants and the percentage of URMs matching into the BMCFMRP. Additional research is needed to determine if these strategies produce similar results in residency programs at other institutions and in other medical specialties.