"Moving beyond silos": focus groups to understand the impact of an adapted project ECHO model for a multidisciplinary statewide forum of substance use disorder care leaders manuscript authors.

BACKGROUND: Although clinical substance use disorder (SUD) care is multidisciplinary there are few opportunities to collaborate for quality improvement or systems change. In Oregon, the Project ECHO (Extension for Community Healthcare Outcomes) model was adapted to create a novel multidisciplinary SUD Leadership ECHO. The objective of this study was to understand the unique effects of the adapted ECHO model, determine if the SUD Leadership ECHO could promote systems change, and identify elements that enabled participant-leaders to make changes. METHODS: Four focus groups were conducted between August and September of 2022 with a purposive sample of participants from the second cohort of the Oregon ECHO Network's SUD Leadership ECHO that ran January to June 2022. Focus group domains addressed the benefits of the adapted ECHO model, whether and why participants were able to make systems change following participation in the ECHO, and recommendations for improvement. Thematic analysis developed emergent themes. RESULTS: 16 of the 53 ECHO participants participated in the focus groups. We found that the SUD Leadership ECHO built a multi-disciplinary community of practice among leaders and reduced isolation and burnout. Three participants reported making organizational changes following participation in the ECHO. Those who successfully made changes heard best practices and how other organizations approached problems. Barriers to initiating practice and policy changes included lack of formal leadership authority, time constraints, and higher-level systemic issues. Participants desired for future iterations of the ECHO more focused presentations on a singular topic, and asked for a greater focus on solutions, advocacy, and next steps. CONCLUSIONS: The adapted ECHO model was well received by focus group participants, with mixed reports on whether participation equipped them to initiate organizational or policy changes. Our findings suggest that the SUD Leadership ECHO model, with fine-tuning, is a promising avenue to support SUD leaders in promoting systems change and reducing isolation among SUD leaders.

Dynamic Anthropometrics in Pancreatic Cancer: Associations Between Body Composition Changes During Neoadjuvant Therapy and Survival Outcomes After Resection.

BACKGROUND: Assessment of individual tumor biology and response to systemic therapy in pancreatic ductal adenocarcinoma (PDAC) remains a clinical challenge. The significance of anthropometric (body composition) changes during chemotherapy as a surrogate for tumor biology in the setting of localized PDAC is unknown. METHODS: A retrospective, single-institution analysis of patients with PDAC who received neoadjuvant therapy (NAT) and pancreatectomy from 2017 to 2021 was performed. Radiologic anthropometric analysis used artificial intelligence-driven software to segment and compute total and sub-compartment muscle area, adipose tissue area, and attenuation values at the level of the L3 vertebra. Kaplan-Meier survival estimates, log-rank tests, and multivariable Cox regression models were used in survival analyses. RESULTS: The inclusion criteria were met by 138 patients. Although decreases in muscle and adipose tissue areas during NAT were predominant, a subset of patients experienced an increase in these compartments. Increases in muscle greater than 5% (hazard ratio [HR], 0.352; 95% confidence interval [CI] 0.135-0.918; p = 0.033) and increases in adipose tissue greater than 15% (HR, 0.375; 95% CI 0.144-0.978; p = 0.045), were significantly associated with improved survival, whereas loss of visceral fat greater than 15% was detrimental (HR 1.853; CI 1.099-3.124; p = 0.021). No significant associations with single time-point anthropometrics were observed. Gains in total muscle and adipose mass were associated with improved pathologic response to systemic therapy and less advanced pathologic tumor stage. CONCLUSIONS: Dynamic anthropometric analysis during NAT for PDAC is a stronger prognostic indicator than measurements taken at a single point in time. Repeated anthropometric analysis during preoperative chemotherapy may serve as a biomarker for individual tumor biology and response to therapy.

Enhancing agency and empowerment in agricultural development projects: A synthesis of mixed methods impact evaluations from the Gender, Agriculture, and Assets Project, Phase 2 (GAAP2).

Development interventions increasingly include women's empowerment and gender equality among their objectives, but evaluating their impact has been stymied by the lack of measures that are comparable across interventions. This paper synthesizes the findings of 11 mixed-methods impact evaluations of agricultural development projects from South Asia and sub-Saharan Africa that were part of the Gender, Agriculture, and Assets Project, Phase 2 (GAAP2). As part of GAAP2, qualitative and quantitative data were used to develop and validate the multidimensional project-level Women's Empowerment in Agriculture Index (pro-WEAI), which was used to assess the impact of GAAP2 projects on women's empowerment. This paper assesses the extent to which: (1) a two- to three-year agricultural development project can contribute to women's empowerment; and (2) a suite of methods comprising a standardized quantitative measure of women's empowerment and a set of qualitative protocols, can evaluate such impacts. Our synthesis finds that the most common positive significant impacts were on the instrumental and collective agency indicators that comprise pro-WEAI, owing to the group-based approaches used. We found few projects significantly improved intrinsic agency, even among those with explicitly stated objectives to change gender norms. Unsurprisingly, we find mixed, and mostly null impacts on aggregate pro-WEAI, with positive impacts more likely in the South Asian, rather than African, cases. Our results highlight the need for projects to design their strategies specifically for empowerment, rather than assume that projects aiming to reach and benefit women automatically empower them. Our study also shows the value of a suite of methods containing a common metric to compare empowerment impacts and qualitative protocols to understand and contextualize these impacts.

Auditory Processing of Speech and Nonspeech in People Who Stutter.

PURPOSE: We investigated speech and nonspeech auditory processing of temporal and spectral cues in people who do and do not stutter. We also asked whether self-reported stuttering severity was predicted by performance on the auditory processing measures. METHOD: People who stutter (n = 23) and people who do not stutter (n = 28) completed a series of four auditory processing tasks online. These tasks consisted of speech and nonspeech stimuli differing in spectral or temporal cues. We then used independent-samples t-tests to assess differences in phonetic categorization slopes between groups and linear mixed-effects models to test differences in nonspeech auditory processing between stuttering and nonstuttering groups, and stuttering severity as a function of performance on all auditory processing tasks. RESULTS: We found statistically significant differences between people who do and do not stutter in phonetic categorization of a continuum differing in a temporal cue and in discrimination of nonspeech stimuli differing in a spectral cue. A significant proportion of variance in self-reported stuttering severity was predicted by performance on the auditory processing measures. CONCLUSIONS: Taken together, these results suggest that people who stutter process both speech and nonspeech auditory information differently than people who do not stutter and may point to subtle differences in auditory processing that could contribute to stuttering. We also note that these patterns could be the consequence of listening to one's own speech, rather than the cause of production differences.

Measurement Properties of Backward Walking and Its Sensitivity and Feasibility in Predicting Falls in People With Multiple Sclerosis.

BACKGROUND: People with multiple sclerosis (MS) experience mobility impairments that elevate fall risk, increasing the need to identify clinical measures that accurately predict falls. Backward walking (BW) better differentiates fallers from nonfallers in MS. However, no studies have reported the measurement properties of the backward walking Timed 25-Foot Walk (B-T25-FW) and BW metrics, like BW velocity. Additionally, it is unknown whether BW can predict future falls in MS or its link to activity levels. This study assessed the reliability and responsiveness of B-T25-FW and BW metrics, including BW velocity. It also examined whether BW could predict falls at 3 and 6 months and its association with activity levels. METHODS: During 2 separate visits, 23 people with MS completed the forward walking Timed 25-Foot Walk (F-T25-FW) and B-T25-FW, as well as forward walking and BW assessments in which spatiotemporal measures were recorded. Test-retest reliability was determined with intraclass correlation coefficients, and minimum detectable changes were calculated. Correlation analyses explored the relationship between BW velocity, B-T25-FW, prospective falls, and activity levels. RESULTS: B-T25-FW and BW velocity exhibited excellent test-retest reliability. Large effect sizes to interpret clinically meaningful change in the B-T25-FW and BW velocity were also found. Both metrics demonstrated modest negative correlations with falls at 3 and 6 months and correlated strongly with very active minutes at 3- and 6-months post study. CONCLUSIONS: The B-T25-FW and BW velocity are effective and reliable in clinical use for evaluating functional mobility in people with MS, are sensitive enough to detect subtle changes, and may be a meaningful marker for tracking disease progression and treatment efficacy.

Adaptations to a patient navigation program for follow-up colonoscopy in rural primary care practices.

PURPOSE: Patient navigation is a recommended practice to improve cancer screenings among underserved populations including those residing in rural areas with care access barriers. We report on patient navigation programme adaptations to increase follow-up colonoscopy rates after abnormal fecal testing in rural primary care practices. METHODS: Participating clinics delivered a patient navigation programme to eligible patients from 28 affiliated clinics serving rural communities in Oregon clustered within 3 Medicaid health plans. Patient navigation adaptations were tracked using data sources including patient navigation training programme reflections, qualitative interviews, clinic meetings, and periodic reflections with practice facilitators. FINDINGS: Initial, planned (proactive) adaptations were made to address the rural context; later, unplanned (reactive) adaptations were implemented to address the impact of the COVID-19 global pandemic. Initial planned adaptations to the patient navigation programme were made before the main trial to address the needs of the rural context, including provider shortages and geographic dispersion limiting both patient access to care and training opportunities for providers. Later unplanned adaptations were made primarily in response to COVID-19 care suspension and staff redeployments and shortages that occurred during implementation. CONCLUSION: While unplanned adaptations were implemented to address the contextual impact of the COVID-19 pandemic on care access patterns and staffing, the changes to training content and context were beneficial to the rural setting overall and should be sustained. Our findings can guide future efforts to optimise the success of such programmes in other rural settings and highlight the important role of adaptations in implementation projects.

Effort Required and Lessons Learned From Recruiting Health Plans and Rural Primary Care Practices for a Cancer Screening Outreach Study.

INTRODUCTION: Recruiting organizations (i.e., health plans, health systems, or clinical practices) is important for implementation science, yet limited research explores effective strategies for engaging organizations in pragmatic studies. We explore the effort required to meet recruitment targets for a pragmatic implementation trial, characteristics of engaged and non-engaged clinical practices, and reasons health plans and rural clinical practices chose to participate. METHODS: We explored recruitment activities and factors associated with organizational enrollment in SMARTER CRC, a randomized pragmatic trial to increase rates of CRC screening in rural populations. We sought to recruit 30 rural primary care practices within participating Medicaid health plans. We tracked recruitment outreach contacts, meeting content, and outcomes using tracking logs. Informed by the Consolidated Framework for Implementation Research, we analyzed interviews, surveys, and publicly available clinical practice data to identify facilitators of participation. RESULTS: Overall recruitment activities spanned January 2020 to April 2021. Five of the 9 health plans approached agreed to participate (55%). Three of the health plans chose to operate centrally as 1 site based on network structure, resulting in 3 recruited health plan sites. Of the 101 identified practices, 76 met study eligibility criteria; 51% (n = 39) enrolled. Between recruitment and randomization, 1 practice was excluded, 5 withdrew, and 7 practices were collapsed into 3 sites for randomization purposes based on clinical practice structure, leaving 29 randomized sites. Successful recruitment required iterative outreach across time, with a range of 2 to 17 encounters per clinical practice. Facilitators to recruitment included multi-modal outreach, prior relationships, effective messaging, flexibility, and good timing. CONCLUSION: Recruiting health plans and rural clinical practices was complex and iterative. Leveraging existing relationships and allocating time and resources to engage clinical practices in pragmatic implementation research may facilitate more diverse representation in future trials and generalizability of research findings.

Individual differences in the use of top-down versus bottom-up cues to resolve phonetic ambiguity.

How listeners weight a wide variety of information to interpret ambiguities in the speech signal is a question of interest in speech perception, particularly when understanding how listeners process speech in the context of phrases or sentences. Dominant views of cue use for language comprehension posit that listeners integrate multiple sources of information to interpret ambiguities in the speech signal. Here, we study how semantic context, sentence rate, and vowel length all influence identification of word-final stops. We find that while at the group level all sources of information appear to influence how listeners interpret ambiguities in speech, at the level of the individual listener, we observe systematic differences in cue reliance, such that some individual listeners favor certain cues (e.g., speech rate and vowel length) to the exclusion of others (e.g., semantic context). While listeners exhibit a range of cue preferences, across participants we find a negative relationship between individuals' weighting of semantic and acoustic-phonetic (sentence rate, vowel length) cues. Additionally, we find that these weightings are stable within individuals over a period of 1 month. Taken as a whole, these findings suggest that theories of cue integration and speech processing may fail to capture the rich individual differences that exist between listeners, which could arise due to mechanistic differences between individuals in speech perception.

Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation.

BACKGROUND: Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees. OBJECTIVES: To address disparities, we used a modified community engagement approach, Boot Camp Translation (BCT). Research partners, an advisory board, and the rural community informed messaging about CRC outreach and a mailed fecal immunochemical test program. METHODS: Eligible rural patients (English-speaking and ages 50-74) and clinic staff involved in patient outreach participated in a BCT conducted virtually over two months. We applied qualitative analysis to BCT transcripts and field notes. RESULTS: Key themes included: the importance of directly communicating about the seriousness of cancer, leveraging close clinic-patient relationships, and communicating the test safety, ease, and low cost. CONCLUSIONS: Using a modified version of BCT delivered in a virtual format, we were able to successfully capture community input to adapt a CRC outreach program for use in rural settings. Program materials will be tested during a pragmatic trial to address rural CRC screening disparities.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas.

BACKGROUND: Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings. METHODS: SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up. DISCUSSION: Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. TRIAL REGISTRATION: Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT).

BACKGROUND: In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes. METHODS: Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS. RESULTS: A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission. CONCLUSIONS: In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.

Pupil Dilation Reflects Perceptual Priorities During a Receptive Speech Task.

OBJECTIVES: The listening demand incurred by speech perception fluctuates in normal conversation. At the acoustic-phonetic level, natural variation in pronunciation acts as speedbumps to accurate lexical selection. Any given utterance may be more or less phonetically ambiguous-a problem that must be resolved by the listener to choose the correct word. This becomes especially apparent when considering two common speech registers-clear and casual-that have characteristically different levels of phonetic ambiguity. Clear speech prioritizes intelligibility through hyperarticulation which results in less ambiguity at the phonetic level, while casual speech tends to have a more collapsed acoustic space. We hypothesized that listeners would invest greater cognitive resources while listening to casual speech to resolve the increased amount of phonetic ambiguity, as compared with clear speech. To this end, we used pupillometry as an online measure of listening effort during perception of clear and casual continuous speech in two background conditions: quiet and noise. DESIGN: Forty-eight participants performed a probe detection task while listening to spoken, nonsensical sentences (masked and unmasked) while recording pupil size. Pupil size was modeled using growth curve analysis to capture the dynamics of the pupil response as the sentence unfolded. RESULTS: Pupil size during listening was sensitive to the presence of noise and speech register (clear/casual). Unsurprisingly, listeners had overall larger pupil dilations during speech perception in noise, replicating earlier work. The pupil dilation pattern for clear and casual sentences was considerably more complex. Pupil dilation during clear speech trials was slightly larger than for casual speech, across quiet and noisy backgrounds. CONCLUSIONS: We suggest that listener motivation could explain the larger pupil dilations to clearly spoken speech. We propose that, bounded by the context of this task, listeners devoted more resources to perceiving the speech signal with the greatest acoustic/phonetic fidelity. Further, we unexpectedly found systematic differences in pupil dilation preceding the onset of the spoken sentences. Together, these data demonstrate that the pupillary system is not merely reactive but also adaptive-sensitive to both task structure and listener motivation to maximize accurate perception in a limited resource system.

Examination of disparities in prehospital encounters for pediatric asthma exacerbations.

Introduction: There are disparities in multiple aspects of pediatric asthma care; however, prehospital care disparities are largely undescribed. This study's objective was to examine racial and geographic disparities in emergency medical services (EMS) medication administration to pediatric patients with asthma. Methods: This is a substudy of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial, which includes data from pediatric asthma patients ages 2-18 years. We examined rates of EMS administration of systemic corticosteroids and inhaled bronchodilators by patient race. We geocoded EMS scene addresses, characterized the locations' neighborhood-based conditions and resources relevant to children using the Child Opportunity Index (COI) 2.0, and analyzed associations between EMS scene address COI with medications administered by EMS. Results: A total of 765 patients had available racial data and 825 had scene addresses that were geocoded to a COI. EMS administered at least 1 bronchodilator to 84.7% (n = 492) of non-White patients and 83.2% of White patients (n = 153), P = 0.6. EMS administered a systemic corticosteroid to 19.4% (n = 113) of non-White patients and 20.1% (n = 37) of White patients, P = 0.8. There was a significant difference in bronchodilator administration between COI categories of low/very low versus moderate/high/very high (85.0%, n = 485 vs. 75.9%, n = 192, respectively, P = 0.003). Conclusions: There were no racial differences in EMS administration of medications to pediatric asthma patients. However, there were significantly higher rates of EMS bronchodilator administration for encounters in low/very low COIs. That latter finding may reflect inequities in asthma exacerbation severity for patients living in disadvantaged areas.

Measuring Women's Empowerment in Agriculture: Innovations and evidence.

This paper addresses women's empowerment in agriculture, innovations in its measurement, and emerging evidence. We discuss the evolution of the conceptualization and measurement of women's empowerment and gender equality since 2010. Using a gender and food systems framework and a standardized measure of women's empowerment, the Women's Empowerment in Agriculture Index (WEAI), we review the evidence on "what works" to empower women based on impact evaluations of a portfolio of 11 agricultural development projects with empowerment objectives and a scoping review of livestock interventions. We then review the evidence on associations between empowering women and societal benefits--agricultural productivity, incomes, and food security and nutrition. We conclude with recommendations for measurement and policy.

EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval.

INTRODUCTION: Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS: This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS: A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION: In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.

Use of Immunization Information Systems in Ascertainment of COVID-19 Vaccinations for Claims-Based Vaccine Safety and Effectiveness Studies.

Importance: Safety and effectiveness studies of COVID-19 vaccines are being conducted using clinical data, including administrative claims. However, claims data only partially capture administered COVID-19 vaccine doses for numerous reasons, such as vaccination at sites that do not generate claims for reimbursement. Objective: To evaluate the extent to which Immunization Information Systems (IIS) data linked to claims data enhances claims-based COVID-19 vaccine capture for a commercially insured population and to estimate the magnitude of misclassification of vaccinated individuals as having unvaccinated status in the linked IIS and claims data. Design, Setting, and Participants: This cohort study used claims data from a commercial health insurance database and obtained vaccination data from IIS repositories in 11 US states. Participants were individuals younger than 65 years who resided in 1 of 11 states of interest and who were insured in health plans from December 1, 2020, through December 31, 2021. Main Outcomes and Measures: Estimated proportion of individuals with at least 1 dose of any COVID-19 vaccine and proportion of individuals with a completed vaccine series based on general population guidelines. Vaccination status estimates were calculated and compared using claims data alone and linked IIS and claims data. Remaining misclassification of vaccination status was assessed by comparing linked IIS and claims data estimates with estimates from external surveillance data sources (Centers for Disease Control and Prevention [CDC] and state Department of Health [DOH]) and capture-recapture analysis. Results: This cohort study included 5 112 722 individuals (mean [SD] age, 33.5 [17.6] years; 2 618 098 females [51.2%]) from 11 states. Characteristics of those who received at least 1 vaccine dose and those who completed a vaccine series were similar to the overall study population. The proportion with at least 1 vaccine dose increased from 32.8% using claims data alone to 48.1% when the data were supplemented with IIS vaccination records. Vaccination estimates using linked IIS and claims data varied widely by state. The percentage of individuals who completed a vaccine series increased from 24.4% to 41.9% after the addition of IIS vaccine records and varied across states. The percentages of underrecording using linked IIS and claims data were 12.1% to 47.1% lower than those using CDC data, 9.1% to 46.9% lower than the state DOH, and 9.2% to 50.9% lower than capture-recapture analysis. Conclusion and Relevance: Results of this study suggested that supplementing COVID-19 claims records with IIS vaccination records substantially increased the number of individuals who were identified as vaccinated, yet potential underrecording remained. Improvements in reporting vaccination data to IIS infrastructures could allow frequent updates of vaccination status for all individuals and all vaccines.

Right Posterior Temporal Cortex Supports Integration of Phonetic and Talker Information.

Though the right hemisphere has been implicated in talker processing, it is thought to play a minimal role in phonetic processing, at least relative to the left hemisphere. Recent evidence suggests that the right posterior temporal cortex may support learning of phonetic variation associated with a specific talker. In the current study, listeners heard a male talker and a female talker, one of whom produced an ambiguous fricative in /s/-biased lexical contexts (e.g., epi?ode) and one who produced it in /∫/-biased contexts (e.g., friend?ip). Listeners in a behavioral experiment (Experiment 1) showed evidence of lexically guided perceptual learning, categorizing ambiguous fricatives in line with their previous experience. Listeners in an fMRI experiment (Experiment 2) showed differential phonetic categorization as a function of talker, allowing for an investigation of the neural basis of talker-specific phonetic processing, though they did not exhibit perceptual learning (likely due to characteristics of our in-scanner headphones). Searchlight analyses revealed that the patterns of activation in the right superior temporal sulcus (STS) contained information about who was talking and what phoneme they produced. We take this as evidence that talker information and phonetic information are integrated in the right STS. Functional connectivity analyses suggested that the process of conditioning phonetic identity on talker information depends on the coordinated activity of a left-lateralized phonetic processing system and a right-lateralized talker processing system. Overall, these results clarify the mechanisms through which the right hemisphere supports talker-specific phonetic processing.

Using TMS to evaluate a causal role for right posterior temporal cortex in talker-specific phonetic processing.

Theories suggest that speech perception is informed by listeners' beliefs of what phonetic variation is typical of a talker. A previous fMRI study found right middle temporal gyrus (RMTG) sensitivity to whether a phonetic variant was typical of a talker, consistent with literature suggesting that the right hemisphere may play a key role in conditioning phonetic identity on talker information. The current work used transcranial magnetic stimulation (TMS) to test whether the RMTG plays a causal role in processing talker-specific phonetic variation. Listeners were exposed to talkers who differed in how they produced voiceless stop consonants while TMS was applied to RMTG, left MTG, or scalp vertex. Listeners subsequently showed near-ceiling performance in indicating which of two variants was typical of a trained talker, regardless of previous stimulation site. Thus, even though the RMTG is recruited for talker-specific phonetic processing, modulation of its function may have only modest consequences.