Water sources for street trees in mesic urban environments.

Street trees support climate resiliency through a variety of pathways, such as offsetting urban heat and attenuating storm water runoff. While urban trees in arid and semiarid ecosystems have been shown to take up water from irrigation, it is unknown where street trees in mesic cities obtain their water. In this study, we use natural abundance stable isotopes to estimate the proportional sources of water taken up by Acer platanoides street trees in Boston, Massachusetts, United States, including precipitation, irrigation, groundwater, and wastewater. We use Bayesian multisource mixing models to estimate water sources by comparing the natural abundance isotopic ratios of hydrogen and oxygen across potential water sources with water extracted from tree stem samples. We find that during the summer of 2021, characterized by anomalously high rainfall, street trees predominantly utilized water from precipitation. Precipitation accounted for 72.3 % of water extracted from trees sampled in August and 65.6 % from trees sampled in September. Of the precipitation taken up by street trees, most water was traced back to large storm events in July, with July rainfall alone accounting for up to 84.0 % of water found within street trees. We find strong relationships between canopy cover fractions and the proportion of precipitation lost to evapotranspiration across the study domain, supporting the conclusion that tree planting initiatives result in storm water mitigation benefits due to utilization of water from precipitation by urban vegetation. However, while the mature trees studied here currently support their water demand from precipitation, the dependency of street trees on precipitation in mesic cities may lead to increased water stress in a changing climate characterized by a higher frequency and severity of drought.

Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits.

Importance: Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality. Objectives: To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors. Design, Setting, and Participants: In a retrospective cohort study, all patient visits from March 1, 2020, to December 31, 2021, at 1 large urban hospital-based primary care practice and 1 affiliated community health center in Boston, Massachusetts, were evaluated. Main Measures: Prevalence of diagnostic loop closure for (1) colonoscopy referrals (screening and diagnostic), (2) dermatology referrals for suspicious skin lesions, and (3) cardiac stress tests. Results: The study included test and referral orders for 4133 patients (mean [SD] age, 59.3 [11.7] years; 2163 [52.3%] women; 203 [4.9%] Asian, 1146 [27.7%] Black, 2362 [57.1%] White, and 422 [10.2%] unknown or other race). A total of 1151 of the 4133 orders (27.8%) were placed during a telehealth visit. Of the telehealth orders, 42.6% were completed within the designated time frame vs 58.4% of those ordered during in-person visits and 57.4% of those ordered without a visit. In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types compared with those with in-person visits (odds ratio, 0.55; 95% CI, 0.47-0.64). Conclusions: The findings of this study suggest that rates of loop closure were low for all test types across all visit modalities but worse for telehealth. Failure to close diagnostic loops presents a patient safety challenge in primary care that may be of particular concern during telehealth encounters.

Predicting profiles of post-trauma adaptation in first responders and civilians after the 2013 Boston Marathon bombings: The role of distress, growth, and emotion regulation.

INTRODUCTION: Responses to trauma are often characterized either by the presence or absence of psychological distress; however, the process of adapting after trauma also includes potential positive change. While some studies document that the majority of individuals exposed to single event terrorism report low levels of psychological distress, more research is needed to understand different adaptation profiles following this type of trauma, and the factors that might predict responses. METHODS: We examined post-trauma responses in 257 first responders/medical professionals (66.8 percent) and civilians (33.2 percent) exposed to the 2013 Boston Marathon Bombings. Data for post-trauma profiles-post-traumatic growth (PTG), post-traumatic stress, and emotion regulation-and profile predictors-trauma proximity, trauma history, and coping flexibility-were collected approximately 2.5 years after the bombings. Latent profile analysis identified response profiles, and multinomial logistic regression identified demographic, event-specific, and psychological predictors of profile membership. RESULTS: Four profiles emerged: (1) symptomatic, (2) resistant, (3) resilient, and (4) struggling growth. First responder role decreased the odds of belonging to the struggling growth profile, as compared to the symptomatic profile. Greater coping flexibility and adaptive emotion regulation increased the odds of membership in the struggling growth, rather than symptomatic profile. CONCLUSION: A subset of individuals experiencing post-traumatic stress symptoms years after trauma exposure may also be utilizing flexible, adaptive coping strategies and experiencing PTG. First responders may have difficulty experiencing simultaneous -distress and growth, and interventions designed to promote healthy post-trauma adaptation for this population could be tailored accordingly.

Cognitive decrements in 1991 Gulf War veterans: associations with Gulf War illness and neurotoxicant exposures in the Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) cohorts.

BACKGROUND: During deployment, veterans of the 1991 Gulf War (GW) were exposed to multiple war-related toxicants. Roughly a third of these veterans continue to exhibit neurotoxicant induced symptoms of Gulf War Illness (GWI), a multi-faceted condition that includes fatigue, pain and cognitive decrements. When studied empirically, both deployed veterans with exposures and those who meet the criteria for GWI are more likely to show deficits in the area of neuropsychological functioning. Although studies have shown cognitive impairments in small sample sizes, it is necessary to revisit these findings with larger samples and newer cohorts to see if other areas of deficit emerge with more power to detect such differences. A group of researchers and clinicians with expertise in the area of GWI have identified common data elements (CDE) for use in research samples to compare data sets. At the same time, a subgroup of researchers created a new repository to share these cognitive data and biospecimens within the GWI research community. METHODS: The present study aimed to compare cognitive measures of attention, executive functioning, and verbal memory in a large sample of GWI cases and healthy GW veteran controls using neuropsychological tests recommended in the CDEs. We additionally subdivided samples based on the specific neurotoxicant exposures related to cognitive deficits and compared exposed versus non-exposed veterans regardless of case criteria status. The total sample utilized cognitive testing outcomes from the newly collated Boston, Biorepository, Recruitment, and Integrative Network (BBRAIN) for GWI. RESULTS: Participants included 411 GW veterans, 312 GWI (cases) and 99 healthy veterans (controls). Veterans with GWI showed significantly poorer attention, executive functioning, learning, and short-and-long term verbal memory than those without GWI. Further, GW veterans with exposures to acetylcholinesterase inhibiting pesticides and nerve gas agents, had worse performance on executive function tasks. Veterans with exposure to oil well fires had worse performance on verbal memory and those with pyridostigmine bromide anti-nerve gas pill exposures had better verbal memory and worse performance on an attention task compared to unexposed veterans. CONCLUSIONS: This study replicates prior results regarding the utility of the currently recommended CDEs in determining impairments in cognitive functioning in veterans with GWI in a new widely-available repository cohort and provides further evidence of cognitive decrements in GW veterans related to war-related neurotoxicant exposures.

Mortality in randomised controlled trials using paclitaxel-coated devices for femoropopliteal interventional procedures: an updated patient-level meta-analysis.

BACKGROUND: Numerous randomised clinical trials and real-world studies have supported the safety of paclitaxel-coated devices for the treatment of femoropopliteal occlusive disease. However, a 2018 summary-level meta-analysis suggested an increased mortality risk for paclitaxel-coated devices compared with uncoated control devices. This study presents an updated analysis of deaths using the most complete and current data available from pivotal trials of paclitaxel-coated versus control devices. METHODS: Ten trials comparing paclitaxel-coated versus control devices were included in a patient-level pooled analysis. Cox regression models were used to evaluate the effect of paclitaxel exposure on risk of death in both intention-to-treat (ITT; primary analysis) and three as-treated analysis sets accounting for treatment group crossover at the index procedure and over time. The effect of paclitaxel dose and baseline covariates were also evaluated. FINDINGS: A total of 2666 participants were included with a median follow-up of 4·9 years. No significant increase in deaths was observed for patients treated with paclitaxel-coated devices. This was true in the ITT analysis (hazard ratio [HR] 1·14, 95% CI 0·93-1·40), the as-treated analysis (HR 1·13, 95% CI 0·92-1·39), and in two crossover analyses: 1·07 (0·87-1·31) when late crossovers were censored and 1·04 (0·84-1·28) when crossovers were analysed from the date of paclitaxel exposure. There was no significant effect of paclitaxel dose on mortality risk. INTERPRETATION: This meta-analysis found no association between paclitaxel-coated device exposure and risk of death, providing reassurance to patients, physicians, and regulators on the safety of paclitaxel-coated devices. FUNDING: Becton Dickinson, Boston Scientific, Cook, Medtronic, Philips, Surmodics, and TriReme Medical.

Evaluating Neighborhood-Level Differences in Hair Product Safety by Environmental Working Group Ratings among Retailers in Boston, Massachusetts.

BACKGROUND: Personal care products are a notable source of exposure to endocrine-disrupting chemicals (EDCs). Racial/ethnic differences in the use of hair products containing EDCs are reported, with women and children of color more commonly using hair products that are hormonally active and contain EDCs than other racial/ethnic groups. There is limited research examining the neighborhood-level social and economic factors that may contribute to these reported disparities. OBJECTIVES: We aimed to examine the safety of hair products across sociodemographically diverse neighborhoods in Boston, Massachusetts. METHODS: Eight neighborhoods were identified based on indicators of race/ethnicity and socioeconomic status (SES). We randomly selected 50 stores and collected data on the hair products for sale and their corresponding Environmental Working Group (EWG) Skin Deep hazard score. The association between neighborhood and EWG hazard category (low, moderate, high) was examined using a multinomial logistic regression. RESULTS: A total of 14,019 hair products were identified in the eight neighborhoods. When considering products with EWG hazard scores, Roxbury, a lower income community of color, and Mission Hill, a lower income community, were reported to have a higher percentage of high-hazard hair products in comparison with Beacon Hill [12.2% (163/1,332), 11.4% (65/571) vs. 7.9% (30/382), respectively]. Differences between the safety of hair products were observed, with Roxbury and Mission Hill reporting more than a 2-fold higher risk ratio (RR) of finding hair products with high vs. low EWG scores in comparison with that of Beacon Hill [RR for Roxbury: 2.3, 95% confidence interval (CI): 1.1, 4.6; RR for Mission Hill: 2.3, 95% CI: 1.0, 5.4]. Other neighborhoods were also observed to have an increased RR in comparison with Beacon Hill, however, with 95% CIs that extended beyond the null. DISCUSSION: Retail stores in neighborhoods with a higher percentage of residents of color and lower SES were found to be more likely to sell products with high hazard scores than stores in a higher SES and predominately non-Hispanic White neighborhood. https://doi.org/10.1289/EHP10653.

Risk of Mortality Related to Recurrent Limb Events After Endovascular Revascularization of the Superficial Femoral Artery for Peripheral Artery Disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) Study.

Endovascular revascularization of the superficial femoral artery (SFA) may lead to recurrent ischemic syndromes, revascularization, or amputation. The impact of these events on mortality is unknown. We followed all patients having SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in 2 cardiovascular (CV) divisions in Boston, Massachusetts. Any recurrent limb event after the initial SFA revascularization included recurrent claudication (67%), limb ulceration or gangrene (13%), repeat endovascular revascularization (61%), surgical revascularization (15%), or major (9%) or minor amputation (8%). We linked data to the National Death Index to ascertain cause of death grouped into CV mortality, or non-CV mortality. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) from Cox proportional hazards and sub-HRs from Fine-Gray competing risks analyses were clustered by patient. Overall, there were 202 patients with 253 index limb endovascular procedures. A recurrent limb event occurred in 123 limbs (49%) and 93 patients (46%). Patients with and without recurrent limb events had similar numbers of deaths over follow-up (76 [62%] vs 71 [55%], respectively). In multivariable models, recurrent limb event was not related to all-cause death (HR 0.92, 95% CI 0.64 to 1.33), CV death (HR 1.29, 95% CI 0.72 to 1.30), or non-CV death (HR 0.65, CI 0.39 to 1.07). Competing risk analyses suggested male gender and chronic limb-threatening ischemia were more strongly related to CV death, and chronic kidney more strongly related to disease to non-CV death. In conclusion, recurrent limb events, which contribute to patient morbidity, do not increase the risk of all-cause or cause-specific mortality, and should not discourage repeat revascularization to relieve symptoms or ischemia.

Bridging Health Disparities and Improving Reproductive Outcomes With Health Center-Affiliated Doula Programs.

Doulas are community perinatal professionals trained in pregnancy health, childbirth preparation, labor support, lactation counseling, and postnatal care. Doulas serve as patient advocates and provide laboring patients with continuous one-to-one support including informational, physical, and emotional support. Research shows that access to continuous labor support contributes to positive health outcomes such as increasing rates of spontaneous vaginal delivery, shorter labor, less need for analgesics, and increased satisfaction with the birthing process. However, despite their benefits, socioeconomic, structural, and systemic factors limit doula accessibility and manifest in low utilization among patients who could benefit from doulas the most. Given the positive health implications of doula support and the need for these services in underserved populations, there is an urgency to increase the accessibility of doulas. Several health centers in the United States have created successful doula programs to meet the needs of their patient populations. To better understand these programs, we interviewed and collaborated on this paper with program representatives from Boston Medical Center's Birth Sisters and DREAM: Delivery Resources, Education, and Advocacy for Moms; UNC Health's Birth Partners; and Michigan Medicine's Dial-A-Doula. Because many health centers serve as large public safety-net hospitals, having more health center-affiliated doula programs nationwide could be a positive step in bridging disparities and improving maternal and child health.

HEAR US: a qualitative study of racial discrimination in Boston's Chinatown and empowering change from within the community.

Objective: To qualitatively explore the impact of anti-Asian racism in a Chinese community in the greater Boston area. Methods: Individual semi-structured interviews (n = 27) were conducted between June and September 2021. Eligible participants were ethnic Chinese immigrants living in the Boston area, who were recruited through a community-based organization and by word-of-mouth. Interviews were conducted in Mandarin and Cantonese and translated into English. Data were coded and analyzed using a directed approach to content analysis. Results: The majority of participants reported personal experiences of anti-Asian racism, ranging from microaggressions to violent attacks. Although lockdown and isolation during COVID-19 affected all communities, the Chinese community suffered unique and prolonged trauma stemming from the fear of violent attacks against Asians. The older person/people, in particular, were severely isolated due to fear of exposure to anti-Asian hate crimes. Participants reported a variety of emotional, mental, and physical health effects associated with feelings of fear, anxiety, isolation, and powerlessness. Many preferred to engage in self-protective behavior changes rather than relying on external resources. Conclusion: Participants advocated for more education, community, and governmental support, and increased allyship between communities of color. These findings provide cultural context on the trauma this population faces and can inform further actions to address the wide range of reported health effects.

Disparities in joint exposure to environmental and social stressors in urban households in Greater Boston.

OBJECTIVES: Understanding how environmental and social stressors cluster is critical to explaining and addressing health disparities. It remains unclear how these stressors cluster at fine spatial resolution in low to medium-income, urban households. We explored patterns of environmental and social exposures at the household-level and potential predictors of these joint exposures in two environmental justice communities in the Greater Boston area. METHODS: We recruited 150 households in Chelsea, MA and the Dorchester neighborhood of Boston, MA, between 2016 and 2019 and collected data on two domains: environmental and social stressor. For each domain, we fit Latent Class Analysis (LCA) models to exposure data to assess intra-domain variability, and cross-classified the resultant classes to identify joint exposure profiles. We compared differences in the distribution of these profiles by participants' demographic and household characteristics using χ2, Fisher's exact, Analysis of Variance, and Kruskal-Wallis tests. RESULTS: We identified two latent classes in each domain: High environmental (n = 90; 60.4%), Low environmental (n = 59; 39.6%), High Social (n = 31; 20.8%), and Low Social (n = 118; 79.2%). Cross-classification yielded four joint exposure profiles: Both Low (n = 46, 30.9%); Both High (n = 18, 12.1%); High environmental-Low Social (n = 72, 48.3%); and Low environmental-High Social (n = 13, 8.7%). Significant group differences were found by housing type (e.g., single-family vs. multi-family) (Fisher's exact p = 0.0016), housing tenure (p = 0.0007), and study site (p < 0.0001). We also observed differences by race/ethnicity, income, and education: households that were Hispanic/Latinx, below the poverty level, and with lower education were more likely to be in the Both High group. CONCLUSIONS: Our analyses confirmed that environmental and social stressors cluster in socially disadvantaged households. Housing type, housing tenure, and location of the residence were also strong predictors of cluster membership, with renter and multi-family residents at risk of high exposures to environmental and social stressors.

Impact of age, race, and family history on COVID-19-related changes in breast cancer screening among the Boston mammography cohort study.

PURPOSE: We studied women enrolled in the Boston Mammography Cohort Study to investigate whether subgroups defined by age, race, or family history of breast cancer experienced differences in the incidence of screening or diagnostic imaging rates during the COVID-19 lockdown and had slower rebound in the incidence of these rates during reopening. METHODS: We compared the incidence of monthly breast cancer screening and diagnostic imaging rates over during the pre-COVID-19 (January 2019-February 2020), lockdown (March-May 2020), and reopening periods (June-December 2020), and tested for differences in the monthly incidence within the same period by age (< 50 vs ≥ 50), race (White vs non-White), and first-degree family history of breast cancer (yes vs no). RESULTS: Overall, we observed a decline in breast cancer screening and diagnostic imaging rates over the three time periods (pre-COVID-19, lockdown, and reopening). The monthly incidence of breast cancer screening rates for women age ≥ 50 was 5% higher (p = 0.005) in the pre-COVID-19 period (January 2019-February 2020) but was 19% lower in the reopening phase (June-December 2020) than that of women aged < 50 (p < 0.001). White participants had 36% higher monthly incidence of breast cancer diagnostic imaging rates than non-White participants (p = 0.018). CONCLUSION: The rebound in screening was lower in women age ≥ 50 and lower in non-White women for diagnostic imaging. Careful attention must be paid as the COVID-19 recovery continues to ensure equitable resumption of care.

Change of Seasons: Boston Marathon Wet Bulb Globe Temperature Index in October.

INTRODUCTION: The importance of providing wet bulb globe temperature (WBGT) heat stress flag category measurements in real time is well recognized by road race directors, and it is bound to become even more important with the rise of extreme weather and pandemic outbreaks. The purpose of this paper is to describe the WBGT index and its components measured during the 125th running of the Boston Marathon on October 11, 2021, for qualitative comparison to measurements made similarly on its traditional April date, 2014 to 2019. METHODS: Monitoring occurred at the 7 km, 18 km, and 32 km marks of the race in the towns of Ashland, Natick-Wellesley, and Newton. The outdoor WBGT index was calculated from direct hourly measurements of the dry bulb, black globe, and natural wet bulb temperatures from 0900 to 1500 h. RESULTS: The WBGT index was not different among towns; thus, the average hourly values for the 3 towns were compared to historical data averaged identically. Although the black globe temperature fluctuated considerably in response to changing cloud cover, on average, partly cloudy skies kept the solar load comparable to what has been observed in April. Dry bulb and wet bulb temperatures were higher than those on most April dates shown, which resulted in a yellow (or amber) flag day for most of the race. CONCLUSIONS: The historic October Boston Marathon was among the warmest in recent history. Like the impact of COVID-19 on the 2021 Boston Marathon, future climate challenges around outdoor activities could necessitate rescheduling; they underscore the importance of real-time WBGT index measures.

Pediatric Provider and Staff Burnout in Federally Qualified Community Health Centers.

This study examined changes in provider and staff burnout in 4 Boston-area federally qualified community health centers (FQHCs) participating in a pediatric behavioral health integration project. Utilizing the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSSMP), the study found that emotional exhaustion among primary care providers ( M = 20.5; confidence interval [CI], 17.8-23.2) was higher ( P = .001) than that among behavioral health clinicians ( M = 13.6; CI, 10.4-16.8) and ( P = .00005) community health workers ( M = 10.8; CI, 7.3-14.2). Emotional exhaustion among staff increased ( P = .04) from baseline ( M = 16.8; CI, 15.0-18.6) to follow-up ( M = 20.8; CI, 17.5-24.2), but burnout at follow-up was lower than national averages. FQHCs are integral in caring for marginalized patients; therefore, supporting a stable workforce by minimizing burnout is essential.

A tale of two cities: Policing and firearm homicides in Boston and Philadelphia.

BACKGROUND: Recent political movements have raised questions about the effectiveness of police funding, but the impact of law enforcement budgets on firearm violence is unknown. We hypothesized that department funding and measures of police activity would be associated with decreased shootings and firearm homicides (FHs) in two major cities with different police funding patterns. METHODS: We collected data from the following sources: district attorney's offices, police departments, Federal Bureau of Investigation Uniform Crime Reporting program, the Centers for Disease Control, the Annual Survey of Public Employment and Payroll, and the American Community Survey. Data included demographics, police department budgets, number of officers, homicide clearance rates, firearms recovered, shootings, and FHs, 2015 to 2020. Totals were normalized to population and number of shootings. We used panel linear regression to measure associations between policing variables, shootings, and FHs while adjusting for covariates. RESULTS: Firearm homicides significantly increased in Philadelphia. In Boston, the trend was less clear, although there was an increase in 2020. Police budget normalized to shootings trended toward a decrease in Philadelphia and an increase in Boston. The number of firearms recovered annually appeared to increase in Boston but peaked midstudy in Philadelphia. In multivariable analyses, police budget was associated with neither shootings nor FHs. However, increased firearm recovery was associated with lower shooting ( ß = -0.0004, p = 0.022) and FH ( ß = -0.00005, p = 0.004) rates. CONCLUSION: Philadelphia and Boston demonstrated differences in police funding, 2015 to 2020. While budget is not associated with shootings or FHs, firearm recovery is suggesting that removal of firearms from circulation remains key. The impact this has on vulnerable populations requires further investigation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Temporal trends in urinary concentrations of phenols, phthalate metabolites and phthalate replacements between 2000 and 2017 in Boston, MA.

Endocrine disrupting chemicals (EDCs) can adversely affect human health and are ubiquitously found in everyday products. We examined temporal trends in urinary concentrations of EDCs and their replacements. Urinary concentrations of 11 environmental phenols, 15 phthalate metabolites, phthalate replacements such as two di(isononyl)cyclohexane-1,2-dicarboxylate (DINCH) metabolites, and triclocarban were quantified using isotope-dilution tandem mass spectrometry. This ecological study included 996 male and 819 female patients who were predominantly White/Caucasian (83 %) with an average age of 35 years and a BMI of 25.5 kg/m2 seeking fertility treatment in Boston, MA, USA. Patients provided a total of 6483 urine samples (median = 2, range = 1-30 samples per patient) between 2000 and 2017. Over the study period, we observed significant decreases (% per year) in urinary concentrations of traditional phenols, parabens, and phthalates such as bisphenol A (ß: -6.3, 95 % CI: -7.2, -5.4), benzophenone-3 (ß: -6.5, 95 % CI: -1.1, -18.9), parabens ((ß range:-5.4 to -14.2), triclosan (ß: -18.8, 95 % CI: -24, -13.6), dichlorophenols (2.4-dichlorophenol ß: -6.6, 95 % CI: -8.8, -4.3); 2,5-dichlorophenol ß: -13.6, 95 % CI: -17, -10.3), di(2-ethylhexyl) phthalate metabolites (ß range: -11.9 to -22.0), and other phthalate metabolites including mono-ethyl, mono-n-butyl, and mono-methyl phthalate (ß range: -0.3 to -11.5). In contrast, we found significant increases in urinary concentrations of environmental phenol replacements including bisphenol S (ß: 3.9, 95 % CI: 2.7, 7.6) and bisphenol F (ß: 6, 95 % CI: 1.8, 10.3), DINCH metabolites (cyclohexane-1,2-dicarboxylic acid monohydroxy isononyl ester [MHiNCH] ß: 20, 95 % CI: 17.8, 22.2; monocarboxyisooctyl phthalate [MCOCH] ß: 16.2, 95 % CI: 14, 18.4), and newer phthalate replacements such as mono-3-carboxypropyl phthalate, monobenzyl phthalate, mono-2-ethyl-5-carboxypentyl phthalate and di-isobutyl phthalate metabolites (ß range = 5.3 to 45.1), over time. Urinary MHBP concentrations remained stable over the study period. While the majority of biomarkers measured declined over time, concentrations of several increased, particularly replacement chemicals that are studied.