Arsenic Trioxide and Venetoclax Synergize against AML Progenitors by ROS Induction and Inhibition of Nrf2 Activation.

Venetoclax (VEN) in combination with hypomethylating agents induces disease remission in patients with de novo AML, however, most patients eventually relapse. AML relapse is attributed to the persistence of drug-resistant leukemia stem cells (LSCs). LSCs need to maintain low intracellular levels of reactive oxygen species (ROS). Arsenic trioxide (ATO) induces apoptosis via upregulation of ROS-induced stress to DNA-repair mechanisms. Elevated ROS levels can trigger the Nrf2 antioxidant pathway to counteract the effects of high ROS levels. We hypothesized that ATO and VEN synergize in targeting LSCs through ROS induction by ATO and the known inhibitory effect of VEN on the Nrf2 antioxidant pathway. Using cell fractionation, immunoprecipitation, RNA-knockdown, and fluorescence assays we found that ATO activated nuclear translocation of Nrf2 and increased transcription of antioxidant enzymes, thereby attenuating the induction of ROS by ATO. VEN disrupted ATO-induced Nrf2 translocation and augmented ATO-induced ROS, thus enhancing apoptosis in LSCs. Using metabolic assays and electron microscopy, we found that the ATO+VEN combination decreased mitochondrial membrane potential, mitochondria size, fatty acid oxidation and oxidative phosphorylation, all of which enhanced apoptosis of LSCs derived from both VEN-sensitive and VEN-resistant AML primary cells. Our results indicate that ATO and VEN cooperate in inducing apoptosis of LSCs through potentiation of ROS induction, suggesting ATO+VEN is a promising regimen for treatment of VEN-sensitive and -resistant AML.

Synergy of Venetoclax and 8-Chloro-Adenosine in AML: The Interplay of rRNA Inhibition and Fatty Acid Metabolism.

It is known that 8-chloro-adenosine (8-Cl-Ado) is a novel RNA-directed nucleoside analog that targets leukemic stem cells (LSCs). In a phase I clinical trial with 8-Cl-Ado in patients with refractory or relapsed (R/R) AML, we observed encouraging but short-lived clinical responses, likely due to intrinsic mechanisms of LSC resistance. LSC homeostasis depends on amino acid-driven and/or fatty acid oxidation (FAO)-driven oxidative phosphorylation (OXPHOS) for survival. We recently reported that 8-Cl-Ado and the BCL-2-selective inhibitor venetoclax (VEN) synergistically inhibit FAO and OXPHOS in LSCs, thereby suppressing acute myeloid leukemia (AML) growth in vitro and in vivo. Herein, we report that 8-Cl-Ado inhibits ribosomal RNA (rRNA) synthesis through the downregulation of transcription initiation factor TIF-IA that is associated with increasing levels of p53. Paradoxically, 8-Cl-Ado-induced p53 increased FAO and OXPHOS, thereby self-limiting the activity of 8-Cl-Ado on LSCs. Since VEN inhibits amino acid-driven OXPHOS, the addition of VEN significantly enhanced the activity of 8-Cl-Ado by counteracting the self-limiting effect of p53 on FAO and OXPHOS. Overall, our results indicate that VEN and 8-Cl-Ado can cooperate in targeting rRNA synthesis and OXPHOS and in decreasing the survival of the LSC-enriched cell population, suggesting the VEN/8-Cl-Ado regimen as a promising therapeutic approach for patients with R/R AML.

A CBPR-Enhanced Delphi Method: The Measurement Approaches to Partnership Success Case Study.

As part of a 5-year study to develop and validate an instrument for measuring success in long-standing community-based participatory research (CBPR) partnerships, we utilized the Delphi method with a panel of 16 community and academic CBPR experts to assess face and content validity of the instrument's broad concepts of success and measurement items. In addition to incorporating quantitative and qualitative feedback from two online surveys, we included a 2-day face-to-face meeting with the Expert Panel to invite open discussion and diversity of opinion in line with the CBPR principles framing and guiding the study. The face-to-face meeting allowed experts to review the survey data (with maintained anonymity), convey their perspectives, and offer interpretations that were untapped in the online surveys. Using a CBPR approach facilitated a synergistic process that moved above and beyond the consensus achieved in the initial Delphi rounds, to enhance the Delphi technique and the development of items in the instrument.

Educational Outcomes of a 4-Year MD-MPH Dual-Degree Program: High Completion Rates and Higher Likelihood of Primary Care Residency.

PURPOSE: In 2007, University of Texas Health Science Center Houston School of Public Health at San Antonio (UTHealth SPH) and UT Health San Antonio Long School of Medicine (LSOM) designed and implemented a 4-year dual MD and Master of Public Health (MPH) program. Dual MD-MPH programs wherein students can receive both degrees within 4 years are unique, and programmatic evaluation may have generalizable implications for accredited MD-MPH programs. METHOD: Demographic information was collected from UTHealth SPH and LSOM student data. The primary outcome variable was MD-MPH program completion in 4 years. Comprehensive Basic Science Examination (CBSE) scores, United States Medical Licensing Examination Step 1 and Step 2 scores, and successful primary care residency match data were compared between MD-MPH and MD-only students. Family medicine, internal medicine, obstetrics-gynecology, and pediatrics were considered primary care residencies, and an analysis excluding obstetrics-gynecology was also conducted. RESULTS: Of 241 MD-MPH students enrolled 2007-2017, 66% were women, 22% Hispanic, and 10% African American. Four-year MD-MPH program completion occurred for 202 (93% of eligible) students; 9 (4.1%) received MD only, 3 (1.4%) received MPH only; and 4 (1.8%) received neither. MD-MPH students' median CBSE score was 2 points lower than for MD-only students (P = .035), but Step 1 and 2 scores did not differ. Primary care residency match was more likely compared with MD-only students, both including and excluding obstetrics-gynecology (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.31, 2.33; and OR: 1.36; 95% CI: 1.02, 1.82, respectively). CONCLUSIONS: The 4-year MD-MPH program retains and graduates a socioeconomically and racial/ethnically diverse group of students with a 93% success rate. MD-MPH graduates were more likely to pursue primary care residency than non-dual-degree students, which may have implications for addressing population health disparities.

Development of an E-Cigarettes Education and Cessation Program: A South Texas Oral Health Network Study.

Electronic cigarette (e-cigarette) use, or vaping, among youth and young adults has become a major public health concern. The prevalence of vaping has grown an astounding 900% among high school students from 2011 to 2015, and e-cigarette use among high school students has increased by 78% from 2017 to 2018, largely due to the rise in popularity of the high-dose nicotine product, JUUL. To date, there are few evidence-based e-cigarette cessation programs. To address this need, the South Texas Oral Health Network collaborated with dental practitioners and community members to conduct focus groups assessing knowledge and awareness of e-cigarette use. Based on this feedback, we developed a dental practitioner-based e-cigarette cessation program. The next step will be to utilize this program in a practice-based research network, a "real-world" practice setting that has the potential to increase the number of dental practitioners who counsel their patients about ecigarettes.

A Participatory, State-Community-Academic Model to Improve Pregnancy Outcomes in Texas: The Healthy Families Initiative.

BACKGROUND: While the Texas infant mortality rate (IMR) is below the Healthy People 2020 objective (5.7 per 1,000 live births), stark differences in IMR are seen across Texas communities. Health indicators for the state suggest important missed opportunities for improving maternal and infant outcomes. The Healthy Families initiative was a collaboration between a Texas state agency, community partners, and academic institutions to understand how evidence-based interventions could be identified, adapted, and implemented to address community priorities and reduce disparities in pregnancy outcomes. METHOD: The Healthy Families initiative included two Texas counties, one with low utilization of prenatal care and one with persistent disparities in infant mortality. The model served to (1) identify community factors influencing IMR and maternal morbidity through stakeholder engagement and secondary data, (2) build community capacity to link pregnant women with existing and newly developed services, and (3) develop partnerships within the community and clinics to improve access to and sustainability of services. RESULTS: A community-based participatory approach focused on stakeholder engagement was used to identify, design, and adapt strategies to address community-identified priorities. CONCLUSIONS: The Healthy Families initiative is a unique state-community-academic partnership aimed at improving pregnancy outcomes in vulnerable communities, with a focus on promotion of capacity building, maintenance, and sustainability of maternal and infant health programs.

Low Adherence to Post Emergency Department Follow-Up Among Hypertensive Patients With Medical Insurance.

BACKGROUND: Improvement in hypertension control in the insured, adult population could improve morbidity and mortality associated with hypertension in the United States. The emergency department (ED) is a potential site of intervention, where individuals are diagnosed with asymptomatic hypertension and referred to primary care. OBJECTIVE: To inform intervention strategies, we identified risk factors of nonadherence to primary care follow-up among individuals aged 18-60 years with a primary discharge diagnosis of asymptomatic hypertension in the ED. METHODS: Data were obtained from a commercial claims database for January 2012-September 2015. A total of 84,929 individuals were included. Rate of nonadherence to primary care follow-up was determined for individuals billed for a primary discharge diagnosis of essential hypertension. Multivariate logistic regression was used to calculate adjusted odds ratios. The relationships between demographic and clinical variables with nonadherence to follow-up were assessed. RESULTS: Two-thirds of the study population did not adhere to follow-up within 30 days of ED discharge. Risk factors for nonadherence included no history of recent visit with primary care (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.81-1.93) and multiple prior ED visits (OR 1.65; 95% CI 1.57-1.73). Protective characteristics included history of filling antihypertensive prescriptions in the last year (OR 0.42; 95% CI 0.40-0.43); or history of filling a 30-day antihypertensive prescription on day of diagnosis (OR 0.83; 95% CI 0.80-0.87). CONCLUSIONS: Individuals without a recent primary care visit or who visit the ED frequently are at higher risk of nonadherence to follow-up for hypertension, despite medical insurance. Insurance status may not overcome individual level barriers to follow-up.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents.

PURPOSE: Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake. METHODS: A convenience sample of 58 participants, aged 35-65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening. FINDINGS: Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening. CONCLUSIONS: Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

Development of an Implementation Intervention Using Intervention Mapping to Increase Mammography Among Low Income Women.

Background: Although much work has begun to elucidate contextual factors influencing implementation, the specific processes that facilitate and hinder adoption, implementation, and maintenance of evidence-based interventions (EBIs) in clinical settings remains poorly understood. Intervention Mapping (IM) is a systematic process that facilitates planning and design for dissemination, implementation and maintenance of EBIs in practice. IM has been used to guide the design of many health interventions, focusing on program implementation. Less studied is its use to adapt and scale screening interventions within the healthcare clinic setting. This paper describes the development of an implementation intervention using IM to facilitate the adoption, implementation, and maintenance of an EBI designed to increase mammography adherence in healthcare clinics, the adapted Peace of Mind Program (PMP). Methods: IM framework, Step 5, was used to guide the implementation intervention planning. IM guided identification of specific adoption, implementation, and maintenance performance objectives. We formed an implementation intervention planning group consisting of members of the academic team, our community partner and community health workers (CHWs) with substantial experience working on mammography screening programs in federally qualified health centers (FQHCs) and charity clinics. Results: Results are presented by Intervention Mapping task for Step 5 (Program Implementation Plan). We describe how the consolidated framework for implementation research (CFIR) informed the selection of performance objectives, determinants, methods, and practical applications in the final implementation intervention. Conclusions: This paper provides an example of the use of Intervention Mapping Step 5 and CFIR to create an implementation intervention to support EBI scale up of an evidence-based mammography intervention within a specific setting. Clinical trials registration number: NCT02296177.

Exploring the links between groundwater quality and bacterial communities near oil and gas extraction activities.

Bacterial communities in groundwater are very important as they maintain a balanced biogeochemical environment. When subjected to stressful environments, for example, due to anthropogenic contamination, bacterial communities and their dynamics change. Studying the responses of the groundwater microbiome in the face of environmental changes can add to our growing knowledge of microbial ecology, which can be utilized for the development of novel bioremediation strategies. High-throughput and simpler techniques that allow the real-time study of different microbiomes and their dynamics are necessary, especially when examining larger data sets. Matrix-assisted laser desorption-ionization (MALDI) time-of-flight mass spectrometry (TOF-MS) is a workhorse for the high-throughput identification of bacteria. In this work, groundwater samples were collected from a rural area in southern Texas, where agricultural activities and unconventional oil and gas development are the most prevalent anthropogenic activities. Bacterial communities were assessed using MALDI-TOF MS, with bacterial diversity and abundance being analyzed with the contexts of numerous organic and inorganic groundwater constituents. Mainly denitrifying and heterotrophic bacteria from the Phylum Proteobacteria were isolated. These microorganisms are able to either transform nitrate into gaseous forms of nitrogen or degrade organic compounds such as hydrocarbons. Overall, the bacterial communities varied significantly with respect to the compositional differences that were observed from the collected groundwater samples. Collectively, these data provide a baseline measurement of bacterial diversity in groundwater located near anthropogenic surface and subsurface activities.

Ethnic differences in patients' perceptions towards isolated orthopedic injuries: a pilot study.

BACKGROUND: Patients' perceptions of their healthcare have been reported to influence clinical outcomes following orthopedic trauma. Findings across clinical outcomes have demonstrated significant differences in perceptions towards healthcare between Hispanics and non-Hispanic whites. However, ethnic disparities in perceptions towards orthopedic injuries have not been examined in the literature. AIM OF STUDY: The aim of this pilot study is to explore whether Hispanic patients with isolated orthopedic injuries will demonstrate different perceptions towards their injury as compared to non-Hispanic white patients. The pilot data will be used to inform a subsequent larger clinical investigation and interventional study. METHODS: A total of 43 patients (31 Hispanics and 12 non-Hispanic whites) with isolated orthopedic injuries requiring surgical treatment were enrolled in this cross-sectional observational pilot study. Outcome measures included the Questionnaire of Perceived Injustice (QPI), Short-Form 36 Health Survey (SF-36v2), Pain Catastrophizing Scale, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence (CC) item set. RESULTS: The CAHPS was completed by 34 patients, and the remaining scoring systems were completed by all 43 subjects enrolled in this study. Hispanic patients trended towards higher QPI scores indicating poorer outcomes than non-Hispanic whites (mean difference [MD] 5.4, 95%; confidence interval [CI] - 4.4, 15.2). The mental component summary score of the SF-36 trended lower in Hispanics as compared to non-Hispanic white (MD - 6.8, 95%; CI - 15.0, 1.4). Hispanic patients also expressed less trust in their doctor on a scale from 0 to 10 (MD - 1.0, 95%; CI - 1.9, - 0.1). CONCLUSIONS: Our study suggests ethnic differences in patients' perceptions towards isolated orthopedic injuries. These results must be interpreted cautiously given the limited number of subjects in this pilot examination. We collected sufficient data to allow a sample size calculation for a subsequent larger clinical investigation. Future clinical investigations may determine the influence of ethnic differences in patients' perceptions towards orthopedic injuries, identify their impact on the functional outcomes, and establish intervention strategies.

Less Exercise and More Drugs: How a Low-Income Population Manages Chronic Pain.

OBJECTIVES: To evaluate chronic pain management in a multistate, low-income Hispanic population, and to examine predictors of exercising and prescription pain medication (PPM) use. DESIGN: Online survey administered to a representative sample of Hispanic adults in June 2015. SETTING: Five southwestern states. PARTICIPANTS: Among all online panel members who were Hispanic (N=1007), aged 35 to 75 years from 5 states, representing 11,016,135 persons, the survey was completed by 516 members (51%). Among these, 102 participants were identified with chronic noncancer pain representing 1,140,170 persons. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Exercising or using PPM for chronic pain in past year. RESULTS: Most participants reported using PPM (58%) and exercise (54%) to manage pain. Compared with annual household incomes >$75,000, adjusted odds ratios [AORs] for exercising were .20 for <$10,000 (P=.12); .40 for $10,000 to $34,999 (P=.22); and .15 for $35,000 to $74,999 (P=.015). Conversely, AORs for PPM were over 4-fold higher for lower-income groups as follows: 14.2, 4.79, and 4.85, respectively (all P<.065). PPM users rated the importance of accessing a gym to manage pain lower (P=.01), while exercisers rated the feasibility of gym access to manage pain higher (P=.001). CONCLUSIONS: In a Hispanic population-based sample with chronic pain, lower-income groups tended to exercise less but use PPM more. Barriers to gym access and use may play a role in these disparities.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States.

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain. PERSPECTIVE: In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.

Comparing two sampling methods to engage hard-to-reach communities in research priority setting.

BACKGROUND: Effective community-partnered and patient-centered outcomes research needs to address community priorities. However, optimal sampling methods to engage stakeholders from hard-to-reach, vulnerable communities to generate research priorities have not been identified. METHODS: In two similar rural, largely Hispanic communities, a community advisory board guided recruitment of stakeholders affected by chronic pain using a different method in each community: 1) snowball sampling, a chain- referral method or 2) purposive sampling to recruit diverse stakeholders. In both communities, three groups of stakeholders attended a series of three facilitated meetings to orient, brainstorm, and prioritize ideas (9 meetings/community). Using mixed methods analysis, we compared stakeholder recruitment and retention as well as priorities from both communities' stakeholders on mean ratings of their ideas based on importance and feasibility for implementation in their community. RESULTS: Of 65 eligible stakeholders in one community recruited by snowball sampling, 55 (85 %) consented, 52 (95 %) attended the first meeting, and 36 (65 %) attended all 3 meetings. In the second community, the purposive sampling method was supplemented by convenience sampling to increase recruitment. Of 69 stakeholders recruited by this combined strategy, 62 (90 %) consented, 36 (58 %) attended the first meeting, and 26 (42 %) attended all 3 meetings. Snowball sampling recruited more Hispanics and disabled persons (all P < 0.05). Despite differing recruitment strategies, stakeholders from the two communities identified largely similar ideas for research, focusing on non-pharmacologic interventions for management of chronic pain. Ratings on importance and feasibility for community implementation differed only on the importance of massage services (P = 0.045) which was higher for the purposive/convenience sampling group and for city improvements/transportation services (P = 0.004) which was higher for the snowball sampling group. CONCLUSIONS: In each of the two similar hard-to-reach communities, a community advisory board partnered with researchers to implement a different sampling method to recruit stakeholders. The snowball sampling method achieved greater participation with more Hispanics but also more individuals with disabilities than a purposive-convenience sampling method. However, priorities for research on chronic pain from both stakeholder groups were similar. Although utilizing a snowball sampling method appears to be superior, further research is needed on implementation costs and resources.

Examining health literacy among urban African-American adolescents with asthma.

OBJECTIVE: This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma. METHODS: We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006-2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization. RESULTS: Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44-0.84), not on Medicaid (OR 0.36; 95% CI 0.17-0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07-1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59-0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25-0.94), have one or more emergency visits (OR 1.21 95% CI 1.02-1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01-1.41), respectively. CONCLUSIONS: The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.

Do pre-existing diabetes social support or depressive symptoms influence the effectiveness of a diabetes management intervention?

OBJECTIVE: Examine influences of diabetes-specific social support (D-SS) and depressive symptoms on glycemic control over time, among adults randomized to a diabetes self-management education and support (DSME/S) intervention or usual care. METHODS: Data were from 108 African-American and Latino participants in a 6-month intervention trial. Multivariable linear regression models assessed associations between baseline D-SS from family and friends and depressive symptoms with changes in HbA1c. We then examined whether baseline D-SS or depression moderated intervention-associated effects on HbA1c. RESULTS: Higher baseline D-SS was associated with larger improvements in HbA1c (adjusted ΔHbA1c -0.39% for each +1-point D-SS, p=0.02), independent of intervention-associated HbA1c decreases. Baseline depressive symptoms had no significant association with subsequent HbA1c change. Neither D-SS nor depression moderated intervention-associated effects on HbA1c. CONCLUSIONS AND PRACTICE IMPLICATIONS: Diabetes self-management education and support programs have potential to improve glycemic control for participants starting with varying levels of social support and depressive symptoms. Participants starting with more support for diabetes management from family and friends improved HbA1c significantly more over 6 months than those with less support, independent of additional significant DSME/S intervention-associated HbA1c improvements. Social support from family and friends may improve glycemic control in ways additive to DSME/S.

National Survey of Medical Spanish Curriculum in U.S. Medical Schools.

BACKGROUND: Patients with limited English proficiency (LEP) may be at risk for medical errors and worse health outcomes. Language concordance between patient and provider has been shown to improve health outcomes for Spanish-speaking patients. Nearly 40 % of Hispanics, a growing population in the United States, are categorized as having limited English proficiency. Many medical schools have incorporated a medical Spanish curriculum to prepare students for clinical encounters with LEP patients. OBJECTIVE: To describe the current state of medical Spanish curricula at United States medical schools. METHODS: The Latino Medical Student Association distributed an e-mail survey comprising 39 items to deans from each U.S. medical school from July 2012 through July 2014. This study was IRB-exempt. RESULTS: Eighty-three percent (110/132) of the U.S. medical schools completed the survey. Sixty-six percent (73/110) of these schools reported offering a medical Spanish curriculum. In addition, of schools with no curriculum, 32 % (12/37) planned to incorporate the curriculum within the next two years. Most existing curricula were elective, not eligible for course credit, and taught by faculty or students. Teaching modalities included didactic instruction, role play, and immersion activities. Schools with the curriculum reported that the diverse patient populations in their respective service areas and/or student interest drove course development. Barriers to implementing the curriculum included lack of time in students' schedules, overly heterogeneous student language skill levels, and a lack of financial resources. Few schools reported the use of validated instruments to measure language proficiency after completion of the curriculum. CONCLUSIONS: Growing LEP patient populations and medical student interest have driven the implementation of medical Spanish curricula at U.S. medical schools, and more schools have plans to incorporate this curriculum in the near future. Studies are needed to reveal best practices for developing and evaluating the curriculum.

Community based research network: opportunities for coordination of care, public health surveillance, and farmworker research.

INTRODUCTION: The lack of aggregated longitudinal health data on farmworkers has severely limited opportunities to conduct research to improve their health status. To correct this problem, we have created the infrastructure necessary to develop and maintain a national Research Data Repository of migrant and seasonal farmworker patients and other community members receiving medical care from Community and Migrant Health Centers (C/MHCs). Project specific research databases can be easily extracted from this repository. METHODS: The Community Based Research Network (CBRN) has securely imported and merged electronic health records (EHRs) data from five geographically dispersed C/MHCs. To demonstrate the effectiveness of our data aggregation methodologies, we also conducted a small pilot study using clinical, laboratory and demographic data from the CBRN Data Repository from two initial C/MHCs to evaluate HbA1c management. RESULTS: Overall, there were 67,878 total patients (2,858 farmworkers) that were seen by two C/MHCs from January to August 2013. A total of 94,189 encounters were captured and all could be linked to a unique patient. HbA1c values decreased as the number of tests or intensity of testing increased. CONCLUSION: This project will inform the foundation for an expanding collection of C/MHC data for use by clinicians for medical care coordination, by clinics to assess quality of care, by public health agencies for surveillance, and by researchers under Institutional Review Board (IRB) oversight to advance understanding of the needs and capacity of the migrant and seasonal farmworker population and the health centers that serve them. Approved researchers can request data that constitute a Limited Data Set from the CBRN Data Repository to establish a specific research database for their project.