The Scope of Multimorbidity in Family Medicine: Identifying Age Patterns Across the Lifespan.

INTRODUCTION: Multimorbidity rates are both increasing in prevalence across age ranges, and also increasing in diagnostic importance within and outside the family medicine clinic. Here we aim to describe the course of multimorbidity across the lifespan. METHODS: This was a retrospective cohort study across 211,953 patients from a large northeastern health care system. Past medical histories were collected in the form of ICD-10 diagnostic codes. Rates of multimorbidity were calculated from comorbid diagnoses defined from the ICD10 codes identified in the past medical histories. RESULTS: We identify 4 main age groups of diagnosis and multimorbidity. Ages 0 to 10 contain diagnoses which are infectious or respiratory, whereas ages 10 to 40 are related to mental health. From ages 40 to 70 there is an emergence of alcohol use disorders and cardiometabolic disorders. And ages 70 to 90 are predominantly long-term sequelae of the most common cardiometabolic disorders. The mortality of the whole population over the study period was 5.7%, whereas the multimorbidity with the highest mortality across the study period was Circulatory Disorders-Circulatory Disorders at 23.1%. CONCLUSION: The results from this study provide a comparison for the presence of multimorbidity within age cohorts longitudinally across the population. These patterns of comorbidity can assist in the allocation to practice resources that will best support the common conditions that patients need assistance with, especially as the patients transition between pediatric, adult, and geriatric care. Future work examining and comparing multimorbidity indices is warranted.

Prevalence of Powassan Virus Seropositivity Among People with History of Lyme Disease and Non-Lyme Community Controls in the Northeastern United States.

Introduction: Lyme disease (LD) affects ∼476,000 people each year in the United States. Symptoms are variable and include rash and flu-like symptoms. Reasons for the wide variation in disease outcomes are unknown. Powassan virus (POWV) is a tick-borne flavivirus that causes disease ranging from asymptomatic infection to encephalitis, neurologic damage, and death. POWV and LD geographic case distributions overlap, with Ixodes species ticks as the common vectors. Clinical ramifications of coinfection or sequential infection are unknown. Objectives: This study's primary objective was to determine the prevalence of POWV-reactive antibodies in sera samples collected from previously studied cohorts of individuals with self-reported LD history residing in the Northeastern United States. As a secondary objective, we studied clinical differences between people with self-reported LD history and low versus high POWV antibody levels. Methods: We used an enzyme-linked immunosorbent assay (ELISA) to quantify IgG directed at the POWV envelope (E) protein domain III in 538 samples from individuals with self-reported LD history and 16 community controls. The samples were also tested with an ELISA assay to quantify IgG directed at the POWV NS1 protein. Results: The percentage of individuals with LD history and possible evidence of POWV exposure varied depending on the assay utilized. We found no significant difference in clinical symptoms between those with low or high POWV IgG levels in the in-house assay. Congruence of the EDIII and NS1 assays was low with only 12% of those positive in the in-house EDIII ELISA testing positive in the POWV NS1 ELISA. Conclusions: The results highlight the difficulty in flavivirus diagnostic testing, particularly in the retrospective detection of flavivirus exposure. The findings suggest that a prospective study with symptomatic patients using approved clinical testing is necessary to address the incidence and clinical implications of LD and POWV co-infection or sequential infection.

Urinary mutagenicity and bladder cancer risk in northern New England.

The etiology of bladder cancer among never smokers without occupational or environmental exposure to established urothelial carcinogens remains unclear. Urinary mutagenicity is an integrative measure that reflects recent exposure to genotoxic agents. Here, we investigated its potential association with bladder cancer in rural northern New England. We analyzed 156 bladder cancer cases and 247 cancer-free controls from a large population-based case-control study conducted in Maine, New Hampshire, and Vermont. Overnight urine samples were deconjugated enzymatically and the extracted organics were assessed for mutagenicity using the plate-incorporation Ames assay with the Salmonella frameshift strain YG1041 + S9. Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) of bladder cancer in relation to having mutagenic versus nonmutagenic urine, adjusted for age, sex, and state, and stratified by smoking status (never, former, and current). We found evidence for an association between having mutagenic urine and increased bladder cancer risk among never smokers (OR = 3.8, 95% CI: 1.3-11.2) but not among former or current smokers. Risk could not be estimated among current smokers because nearly all cases and controls had mutagenic urine. Urinary mutagenicity among never-smoking controls could not be explained by recent exposure to established occupational and environmental mutagenic bladder carcinogens evaluated in our study. Our findings suggest that among never smokers, urinary mutagenicity potentially reflects genotoxic exposure profiles relevant to bladder carcinogenesis. Future studies are needed to replicate our findings and identify compounds and their sources that influence bladder cancer risk.

The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021.

OBJECTIVE: The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR. METHODS: The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined. RESULTS: The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR. CONCLUSIONS: Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.

Prevalence and correlates of past 30-day dual-vaping of nicotine and cannabis among adolescents in five New England states.

SIGNIFICANCE: Adolescent vaping behavior includes vaping of multiple substances, including both nicotine and cannabis (dual-vaping). This study describes the prevalence and the sociodemographic correlates of past 30-day dual-vaping. METHODS: We recruited adolescents ages 13-17 from five New England states (Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire) through the Prodege online survey panel from April 2021 to August 2022. Dual-vaping was defined as vaping both nicotine and cannabis (THC and/or CBD) in the past 30-days. We analyzed the prevalence of sole-nicotine, sole-cannabis, and dual-vaping of nicotine and cannabis and used multinomial logistic regression to examine associations between sociodemographic factors and sole- and dual-vaping of nicotine and cannabis. RESULTS: The analytic sample included 2013 observations from 1858 participants (mean age 15.1 years, 46.2% female, 74.1% White, 82.2% heterosexual). Among these observations, 5.6% reported past 30-day sole-nicotine vaping, 5.5% reported sole-cannabis vaping, and 7.3% had dual-vaped. Correlates for higher odds of past 30-day dual-vaping included total social media sites used and household tobacco use, in contrast with sole-cannabis vaping, which included older age and self-reported depression (all p's <0.05). DISCUSSION: Adolescent past 30-day dual-vaping of nicotine and cannabis was more prevalent than past 30-day sole-vaping of either nicotine or cannabis alone. Future studies should continue to collect detailed data on the type of substances, besides nicotine, that adolescents are vaping.

Detection and characterization of novel luchacoviruses, genus Alphacoronavirus, in saliva and feces of meso-carnivores in the northeastern United States.

IMPORTANCE: Several coronaviruses (CoVs) have been detected in domesticated, farmed, and wild meso-carnivores, causing a wide range of diseases and infecting diverse species, highlighting their important but understudied role in the epidemiology of these viruses. Assessing the viral diversity hosted in wildlife species is essential to understand their significance in the cross-species transmission of CoVs. Our focus here was on CoV discovery in meso-carnivores in the Northeast United States as a potential "hotspot" area with high density of humans and urban wildlife. This study identifies novel alphacoronaviruses circulating in multiple free-ranging wild and domestic species in this area and explores their potential epidemiological importance based on regions of the Spike gene, which are relevant for virus-host interactions.

Raising the HPV Vaccination Rate in Rural Northern New England Using Local Opinion Leaders.

The human papillomavirus is associated with a range of cancers. A vaccine introduced in 2006 has dramatically decreased the incidence of these cancers, but Americans still experience over 47,000 new cases of HPV-related cancers each year. The situation is worse in rural areas, where vaccination rates lag the national average, making HPV a significant health disparity issue. This article lays out an evidence-based HPV vaccine-promotion strategy that will serve as part of a campaign to improve health equity in rural northern New England in a process that is repeatable and sustainable. The campaign includes the following elements: partnerships with state departments of health and trusted community opinion leaders, evidence-based storytelling, local social media, traditional media, and school-based pop-up vaccination clinics. Borrowing from marketing and social marketing frameworks and guided by public health perspectives, we begin with psychographic and geodemographic information about our target audience, followed by a discussion about relevant models, frameworks, and research related to persuasive storytelling. We conclude with the outline of a guidebook to foster the creation of persuasive stories as part of a sustainable, replicable HPV vaccination campaign.

Cancer Epidemiology in the Northeastern United States (2013-2017).

We tested the hypotheses that adult cancer incidence and mortality in the Northeast region and in Northern New England (NNE) were different than the rest of the United States, and described other related cancer metrics and risk factor prevalence. Using national, publicly available cancer registry data, we compared cancer incidence and mortality in the Northeast region with the United States and NNE with the United States overall and by race/ethnicity, using age-standardized cancer incidence and rate ratios (RR). Compared with the United States, age-adjusted cancer incidence in adults of all races combined was higher in the Northeast (RR, 1.07; 95% confidence interval [CI] 1.07-1.08) and in NNE (RR 1.06; CI 1.05-1.07). However compared with the United States, mortality was lower in the Northeast (RR, 0.98; CI 0.98-0.98) but higher in NNE (RR, 1.05; CI 1.03-1.06). Mortality in NNE was higher than the United States for cancers of the brain (RR, 1.16; CI 1.07-1.26), uterus (RR, 1.32; CI 1.14-1.52), esophagus (RR, 1.36; CI 1.26-1.47), lung (RR, 1.12; CI 1.09-1.15), bladder (RR, 1.23; CI 1.14-1.33), and melanoma (RR, 1.13; CI 1.01-1.27). Significantly higher overall cancer incidence was seen in the Northeast than the United States in all race/ethnicity subgroups except Native American/Alaska Natives (RR, 0.68; CI 0.64-0.72). In conclusion, NNE has higher cancer incidence and mortality than the United States, a pattern that contrasts with the Northeast region, which has lower cancer mortality overall than the United States despite higher incidence. Significance: These findings highlight the need to identify the causes of higher cancer incidence in the Northeast and the excess cancer mortality in NNE.

Urine pH and Risk of Bladder Cancer in Northern New England.

BACKGROUND: Acidic urine pH is associated with rapid hydrolysis of N-glucuronide conjugates of aromatic amines into metabolites that may undergo metabolism in the bladder lumen to form mutagenic DNA adducts. We previously reported that consistently acidic urine was associated with increased bladder cancer risk in a hospital-based case-control study in Spain. Here, we conducted a separate study in northern New England to replicate these findings. METHODS: In a large, population-based case-control study conducted in Maine, New Hampshire, and Vermont, we examined bladder cancer risk in relation to consistent urine pH, measured twice daily by participants over 4 consecutive days using dipsticks. In parallel, we collected spot urine samples and conducted laboratory measurements of urinary acidity using a pH meter. Unconditional logistic regression was used to estimate associations, adjusting for age, gender, race, Hispanic status, and state. Analyses were further stratified by smoking status. RESULTS: Among 616 urothelial carcinoma cases and 897 controls, urine pH consistently ≤ 6.0 was associated with increased bladder cancer risk (OR = 1.27; 95% confidence interval, 1.02-1.57), with the effect limited to ever-smokers. These findings were supported by analyses of a spot urine, with statistically significant exposure-response relationships for bladder cancer risk overall (Ptrend = 5.1×10-3) and among ever-smokers (Ptrend = 1.2×10-3). CONCLUSIONS: Consistent with a previous study in Spain, our findings suggest that acidic urine pH is associated with increased bladder cancer risk. IMPACT: Our findings align with experimental results showing that acidic urine pH, which is partly modifiable by lifestyle factors, is linked to hydrolysis of acid-labile conjugates of carcinogenic aromatic amines.

Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England.

For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.

Highly Pathogenic Avian Influenza A(H5N1) Virus Outbreak in New England Seals, United States.

We report the spillover of highly pathogenic avian influenza A(H5N1) into marine mammals in the northeastern United States, coincident with H5N1 in sympatric wild birds. Our data indicate monitoring both wild coastal birds and marine mammals will be critical to determine pandemic potential of influenza A viruses.

The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes.

AIMS: While several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. METHODS: We used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. RESULTS: Our calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. CONCLUSIONS: There is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.

RETROSPECTIVE REVIEW OF NEUROLOGIC DISEASE IN STRANDED ATLANTIC HARBOR SEALS (PHOCA VITULINA CONCOLOR) ALONG THE NEW ENGLAND COAST.

Harbor seals (Phoca vitulina) are a common species admitted to marine mammal rehabilitation facilities. As important indicators of marine ecosystem health, monitoring trends of disease in harbor seal populations is critical. However, few studies have evaluated neurologic disease in this species. The general objective of this study was to retrospectively review and delineate neurologic disease in free-ranging Atlantic harbor seals (P. vitulina concolor) that stranded along the New England (United States) coast and entered a rehabilitation facility between 2006 and 2019. Any Atlantic harbor seal that stranded live along the New England coast during the study period and was diagnosed with neurologic disease on either antemortem or postmortem evaluation was included; medical records and pathologic reports were reviewed. From 211 records, 24 animals met the inclusion criteria. Prevalence of neurologic disease was 11% in the study population and six major categories of neurologic disease were identified including: inflammatory (54%), idiopathic (33%), trauma (4%), congenital (4%), and degenerative (4%). Of the seals diagnosed with neurologic disease, 13 (54%) seals died during rehabilitation, 10 (42%) seals were euthanized, and 1 (4%) seal survived to release. Unique cases seen included a seal with Dandy-Walker-like malformation and another seal with histopathologic findings compatible with neuroaxonal dystrophy, a degenerative process that has not been previously reported in marine mammals. This study contributes to the overall knowledge of the health of free-ranging Atlantic harbor seals and may aid clinicians in characterizing neurologic conditions that may be present in seals undergoing rehabilitation.

Racial/ethnic discrimination and suicide-related risk in a treatment-seeking group of ethnoracially minoritized adolescents.

INTRODUCTION AND AIMS: Despite growing evidence demonstrating the negative mental health effects of racism-related experiences, racial/ethnic discrimination is seldom examined in youth suicide risk. The present study tested the association between racial/ethnic discrimination and well-supported correlates of suicide-related risk including emotion reactivity and dysregulation, and severity of psychiatric symptoms in a sample of ethnoracially minoritized adolescents receiving outpatient psychiatric services. METHODS: Participants were adolescents (N = 46; 80.4% female; 65.2% Latinx) who ranged in age from 13-20 years old (M=15.42; SD=1.83) recruited from a child outpatient psychiatry clinic in a low-resourced community in Northeast US. Youth completed a clinical interview and a battery of surveys. RESULTS: Findings from separate linear regression models show that increases in frequency of racial/ethnic discrimination were associated with increases in severity of suicidal ideation (SI), independent of emotion reactivity and dysregulation, and symptoms of PTSD and depression. Discriminatory experiences involving personal insults, witnessing family being discriminated, and school-based contexts were uniquely associated with SI. DISCUSSION AND CONCLUSION: Preliminary findings support the association between racial/ethnic discrimination and increased severity of suicide-related risk in ethnoracially minoritized adolescents. Accounting for racial/ethnic discrimination may improve the cultural responsiveness of youth suicide prevention strategies within outpatient psychiatric care.

"I've been to more of my friends' funerals than I've been to my friends' weddings": Witnessing and responding to overdose in rural Northern New England.

PURPOSE: Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. METHODS: We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22). FINDINGS: Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. CONCLUSIONS: PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.

Estimates of SARS-CoV-2 Omicron BA.2 Subvariant Severity in New England.

Importance: The SARS-CoV-2 Omicron subvariant, BA.2, may be less severe than previous variants; however, confounding factors make interpreting the intrinsic severity challenging. Objective: To compare the adjusted risks of mortality, hospitalization, intensive care unit admission, and invasive ventilation between the BA.2 subvariant and the Omicron and Delta variants, after accounting for multiple confounders. Design, Setting, and Participants: This was a retrospective cohort study that applied an entropy balancing approach. Patients in a multicenter inpatient and outpatient system in New England with COVID-19 between March 3, 2020, and June 20, 2022, were identified. Exposures: Cases were assigned as being exposed to the Delta (B.1.617.2) variant, the Omicron (B.1.1.529) variant, or the Omicron BA.2 lineage subvariants. Main Outcomes and Measures: The primary study outcome planned before analysis was risk of 30-day mortality. Secondary outcomes included the risks of hospitalization, invasive ventilation, and intensive care unit admissions. Results: Of 102 315 confirmed COVID-19 cases (mean [SD] age, 44.2 [21.6] years; 63 482 women [62.0%]), 20 770 were labeled as Delta variants, 52 605 were labeled as the Omicron B.1.1.529 variant, and 28 940 were labeled as Omicron BA.2 subvariants. Patient cases were excluded if they occurred outside the prespecified temporal windows associated with the variants or had minimal longitudinal data in the Mass General Brigham system before COVID-19. Mortality rates were 0.7% for Delta (B.1.617.2), 0.4% for Omicron (B.1.1.529), and 0.3% for Omicron (BA.2). The adjusted odds ratio of mortality from the Delta variant compared with the Omicron BA.2 subvariants was 2.07 (95% CI, 1.04-4.10) and that of the original Omicron variant compared with the Omicron BA.2 subvariant was 2.20 (95% CI, 1.56-3.11). For all outcomes, the Omicron BA.2 subvariants were significantly less severe than that of the Omicron and Delta variants. Conclusions and Relevance: In this cohort study, after having accounted for a variety of confounding factors associated with SARS-CoV-2 outcomes, the Omicron BA.2 subvariant was found to be intrinsically less severe than both the Delta and Omicron variants. With respect to these variants, the severity profile of SARS-CoV-2 appears to be diminishing after taking into account various factors including therapeutics, vaccinations, and prior infections.

The Impact of the COVID-19 Pandemic on Food Insecurity in Northern New England Primary and Prenatal Care Settings.

INTRODUCTION AND OBJECTIVE: Food insecurity (FI) is associated with adverse health outcomes across the lifespan. Primary care and prenatal practices can identify and address FI among patients through screening and interventions. It is unclear how practices and communities responded to FI during the COVID-19 pandemic, and how the pandemic may have impacted practices' FI strategies. We aimed to understand how practices providing primary care or prenatal care in northern New England experienced changes in FI during the COVID-19 pandemic. METHODS: We conducted a web-based survey of clinicians and staff from 43 unique practices providing primary care or prenatal care in northern New England. RESULTS: Most practices (59.5%) reported at least 1 new food program in the practice or community since the pandemic began. Practices reporting new practice- or community-based food programs were more likely to be rural, federally qualified health centers, and have greater confidence in practice and community capacity to address FI (chi-square tests, P < .05). CONCLUSION: Results suggest that practices and surrounding communities in northern New England responded to FI during the pandemic by increasing food support programs. Future work is needed to examine the impact of food programs initiated during the pandemic and determine optimal strategies for practices to address FI among patients.

Cat Ownership and Rural Residence Are Associated with Lyme Disease Prevalence in the Northeastern United States.

Lyme disease (LD) is the most common vector-borne disease in the USA. Beyond its tick-borne nature, however, risk factors for LD are poorly understood. We used an online questionnaire to compare LD patients and non-LD counterparts and elucidate factors associated with LD. We investigated demographic, lifestyle, and household characteristics and use of prevention measures. Associations with LD were modeled using logistic regression, and average marginal effects were estimated. In total, 185 active or past LD patients and 139 non-patients participated. The majority of respondents were white (95%) and female (65%). Controlling for age, sex, and type of residential area, pet ownership was associated with an 11.1% (p = 0.038) increase in the probability of LD. This effect was limited to cat owners (OR: 2.143, p = 0.007; dog owners, OR: 1.398, p = 0.221). Living in rural areas was associated with a 36% (p = 0.001) increase in the probability of LD compared to living in an urban area. Participants who reported knowing someone with Lyme Disease were more likely to wear insect repellant and perform tick checks. This study suggests opportunities for improved LD prevention, including advising cat owners of their increased risk. Although patterns in adoption of LD prevention methods remain poorly understood, concern about LD risk does motivate their use.

COVID-19's Perceived Impact on Primary Care in New England: A Qualitative Study.

BACKGROUND: COVID-19 impacted primary care delivery, as clinicians and practices implemented changes to respond to the pandemic while safely caring for patients. This study aimed to understand clinicians' perceptions of the positive and negative impacts of COVID-19 on primary care in New England. METHODS: This qualitative interview study was conducted from October through December 2020. Participants included 22 physicians and 2 nurse practitioners practicing primary care in New England. Data were thematically coded and analyzed deductively and inductively using content analysis. RESULTS: Through qualitative content analysis, 4 areas were identified in which clinicians perceived that COVID-19 impacted primary care: 1) bureaucracy, 2) leadership, 3) telemedicine and patient care, and 4) clinician work-life. Our findings suggest that the positive impacts of COVID-19 included changes in primary care delivery, new leadership opportunities for clinicians, flexible access to care for patients via telemedicine, and a better work-life balance for clinicians. Respondents identified negative impacts related to sustaining pandemic-inspired changes, the inability for some populations to access care via telemedicine, and the rapid implementation of telemedicine causing frustration for clinicians. CONCLUSIONS: Understanding clinician perspectives on how primary care transformed to respond to COVID-19 helps to identify beneficial pandemic-related changes that should be sustained and ideas for improvement that will support patient care and clinician engagement.