Search

Background: The COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017–2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic. Methods: We analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity. Results: In 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52–0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57–0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout (p = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent (p < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome. Conclusions: Employee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care. [ABSTRACT FROM AUTHOR]

Background/Objective: Optimizing patients' access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. Methods: Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans' perceived access from 2018–2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). Main measures: The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. Analytic approach: We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. Key Results: Veterans at clinics with more access management challenges (> 75th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR:.86, 95% CI:.78–.95); always receiving routine appointments (AOR:.74, 95% CI:.67–.82); and always reporting same- or next-day answers to telephone questions (AOR:.79, 95% CI:.70–.90) compared to veterans receiving care at clinics with fewer (< 25th percentile) challenges. Discussion/Conclusion: Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience. [ABSTRACT FROM AUTHOR]

Triphenyl phosphate (TPHP) is a commonly used organophosphate flame retardant and plasticizer with widespread human exposure. Data on health effects of TPHP are limited. Recent toxicological studies suggest TPHP may alter thyroid function. We used repeated measures to assess the temporal variability in urinary concentrations of the TPHP metabolite, diphenyl phosphate (DPHP), and to examine relationships between DPHP concentrations and thyroid hormones. We sampled 51 adults at months 1, 6, and 12 from 2010 to 2011. Urine samples were analyzed for DPHP. Serum samples were analyzed for free and total thyroxine (fT 4 , TT 4 ), total triiodothyronine (TT 3 ), and thyroid stimulating hormone (TSH). We assessed variability in DPHP using intraclass correlation coefficients (ICCs) and kappa statistics. We used linear mixed-effects models to examine associations between DPHP and thyroid hormones. DPHP was detected in 95% of urine samples. Mean DPHP concentrations were 43% higher in women than men. DPHP showed high within-subject variability (ICC range, 0.13–0.39; kappa range, 0.16–0.39). High versus low (≥ 2.65 vs. < 2.65 ng/mL) DPHP in all participants was associated with a 0.43 μg/dL (95% confidence interval: 0.15, 0.72) increase in mean TT 4 levels. In sex-stratified analyses, high versus low DPHP was associated with a 0.91 μg/dL (95% CI: 0.47, 1.36) increase in mean TT 4 in women. The association was attenuated in men (βeta = 0.19; 95% CI: − 0.15, 0.52). We found no significant associations between DPHP and fT 4 , TT 3 , or TSH. We found evidence that TPHP exposure may be associated with increased TT 4 levels, especially in women. [ABSTRACT FROM AUTHOR]

Background Polybrominated diphenyl ethers (PBDEs) are flame retardant chemicals that are persistent organic pollutants. Animal experiments and some human studies indicate that PBDEs may adversely affect male reproductive function. Objectives To assess the association between PBDE exposure and reproductive hormones (RHs) in a North American male adult cohort. Methods From 2010-11, we collected three serum samples from 27 healthy adult men. We assessed associations between PBDEs and RHs using mixed effect regression models. Results PBDEs were inversely associated with inhibin-B. In older men, increased concentrations of BDE-47 and BDE-100 were significantly associated with a decrease in inhibin-B, and an increase in follicular stimulating hormone (FSH). Conclusions These findings suggest PBDE exposure may affect RHs in older men. We did not measure other parameters of male reproductive function and therefore these results are preliminary. [ABSTRACT FROM AUTHOR]

BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are flame-retardant chemicals that are added to many consumer products. Multiple animal studies have shown PBDEs to be thyroid hormone (TH) disruptors. Epidemiologic evidence of PBDE exposure associated with TH disruption has been inconclusive. OBJECTIVES: We used repeated measures to estimate associations between serum PBDE concentrations and THs in a North American adult cohort. METHODS: From 2010 to 2011, we collected ≤ 3 serum samples at approximately 6-month intervals from 52 healthy adult office workers from Boston, Massachusetts, for analysis of PBDE congeners and THs. RESULTS: The geometric mean sum concentrations of the most prevalent PBDE congeners (BDE-28, BDE-47, BDE-99, BDE-100, and BDE-153) were 22 ng/g lipid in winter 2010, 23 ng/g lipid in summer 2010, and 19 ng/g lipid in winter 2011. BDE-47 was the predominant congener. Based on a multivariable mixed regression model, we estimated that on average, a 1-ng/g serum increase in BDE-47 was associated with a 2.6-µg/dL decrease in total thyroxine (T4) (95% CI: -4.7, -0.35). Total T4 was inversely associated with each PBDE congener. Serum concentrations of PBDEs were not strongly associated with total triiodothyronine (T3), free T4, or thyroid-stimulating hormone (TSH). CONCLUSION: These results are consistent with those from animal studies showing that exposure to PBDEs is associated with a decrease in serum T4. Because the other TH concentrations did not appear to be associated with BDE exposures, our findings do not indicate effects on the pituitary-thyroid axis. Taken together, our findings suggest that PBDE exposure might decrease the binding of T4 to serum T4 binding proteins. [ABSTRACT FROM AUTHOR]

Polybrominated diphenyl ethers (PBDEs) are flame retardant chemicals used in consumer products. They are common contaminants in human serum and associated with adverse health effects. Our objectives were to characterize PBDE serum concentrations in a New England cohort and assess temporal variability of this exposure biomarker over a one-year period. We collected three repeated measurements at six-month intervals from 52 office workers from the greater Boston (MA, United States) area from 2010 to 2011. The intraclass correlation coefficient for BDEs 28, 47, 99, 100, and 153 ranged from 0.87 to 0.99, indicating that a single serum measurement can reliably estimate exposure over a one-year period. This was true for both lipid adjusted and nonlipid adjusted concentrations. The kappa statistics, quantifying the level of agreement of categorical exposure classification, based on medians, tertiles, or quartiles ranged from 0.67 to 0.90. Some congeners showed nonsignificant increases from sampling round 1 (winter) to round 2 (summer) and significant decreases from round 2 to round 3 (winter). This study highlights the high reliability of a single serum PBDE measurement for use in human epidemiologic studies. [ABSTRACT FROM AUTHOR]

Abstract: Increased use of flame-retardants in office furniture may increase exposure to PBDEs in the office environment. However, partitioning of PBDEs within the office environment is not well understood. Our objectives were to examine relationships between concurrent measures of PBDEs in office air, floor dust, and surface wipes. We collected air, dust, and surface wipe samples from 31 offices in Boston, MA. Correlation and linear regression were used to evaluate associations between variables. Geometric mean (GM) concentrations of individual BDE congeners in air and congener specific octanol–air partition coefficients (Koa) were used to predict GM concentrations in dust and surface wipes and compared to the measured concentrations. GM concentrations of PentaBDEs in office air, dust, and surface wipes were 472pg/m3, 2411ng/g, and 77pg/cm2, respectively. BDE209 was detected in 100% of dust samples (GM=4202ng/g), 93% of surface wipes (GM=125pg/cm2), and 39% of air samples. PentaBDEs in dust and air were moderately correlated with each other (r=0.60, p=0.0003), as well as with PentaBDEs in surface wipes (r=0.51, p=0.003 for both dust and air). BDE209 in dust was correlated with BDE209 in surface wipes (r=0.69, p=0.007). Building (three categories) and PentaBDEs in dust were independent predictors of PentaBDEs in both air and surface wipes, together explaining 50% (p=0.0009) and 48% (p=0.001) of the variation respectively. Predicted and measured concentrations of individual BDE congeners were highly correlated in dust (r=0.98, p<0.0001) and surface wipes (r=0.94, p=002). BDE209 provided an interesting test of this equilibrium partitioning model as it is a low volatility compound. Associations between PentaBDEs in multiple sampling media suggest that collecting dust or surface wipes may be a convenient method of characterizing exposure in the indoor environment. The volatility of individual congeners, as well as physical characteristics of the indoor environment, influence relationships between PBDEs in air, dust, and surface wipes. [Copyright &y& Elsevier]

Abstract: Tris(1,3-dichloro-2-propyl) phosphate (TDCPP) is a flame retardant widely used in furniture containing polyurethane foam. It is a carcinogen, endocrine disruptor, and potentially neurotoxic. Our objectives were to characterize exposure of adult office workers (n=29) to TDCPP by measuring its primary metabolite, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), in their urine; measuring TDCPP in dust from their homes; offices and vehicles; and assessing possible predictors of exposure. We identified TDCPP in 99% of dust (GM=4.43μg/g) and BDCPP in 100% of urine samples (GM=408pg/mL). Concentrations of TDCPP were significantly higher in dust from vehicles (GM=12.5μg/g) and offices (GM=6.06μg/g) than in dust from the main living area (GM=4.21μg/g) or bedrooms (GM=1.40μg/g) of worker homes. Urinary BDCPP concentrations among participants who worked in a new office building were 26% of those who worked in older buildings (p=0.01). We found some evidence of a positive trend between urinary BDCPP and TDCPP in office dust that was not observed in the other microenvironments and may be related to the timing of urine sample collection during the afternoon of a workday. Overall our findings suggest that exposure to TDCPP in the work environment is one of the contributors to the personal exposure for office workers. Further research is needed to confirm specific exposure sources (e.g., polyurethane foam), determine the importance of exposure in other microenvironments such as homes and vehicles, and address the inhalation and dermal exposure pathways. [Copyright &y& Elsevier]

Introduction: Paving workers are exposed to polycyclic aromatic compounds (PACs) while working with hot-mix asphalt (HMA). Further characterization of the source and route of these exposures is necessary to guide exposure-reduction strategies. Methods: Personal air (n = 144), hand-wash (n = 144), and urine (n = 480) samples were collected from 12 paving workers over 3 workdays during 4 workweeks. Urine samples were collected at preshift, postshift, and bedtime and analyzed for 10 hydroxylated PACs (1-OH-pyrene; 1-, 2-, 3-, 4-OH-phenanthrene; 1-, 2-OH-naphthalene; 2-, 3-, 9-OH-fluorene) by an immunochemical quantification of PACs (I-PACs). The air and hand-wash samples were analyzed for the parent compounds corresponding to the urinary analytes. Using a crossover study design, each of the 4 weeks represented a different exposure scenario: a baseline week (normal conditions), a dermal protection week (protective clothing), a powered air-purifying respirator (PAPR) week, and a biodiesel substitution week (100% biodiesel provided to replace the diesel oil normally used by workers to clean tools and equipment). The urinary analytes were analyzed using linear mixed-effects models. Results: Postshift and bedtime concentrations were significantly higher than preshift concentrations for most urinary biomarkers. Compared with baseline, urinary analytes were reduced during the dermal protection (29% for 1-OH-pyrene, 15% for I-PACs), the PAPR (24% for 1-OH-pyrene, 15% for I-PACs), and the biodiesel substitution (15% for 1-OH-pyrene) weeks. The effect of PACs in air was different by exposure scenario (biodiesel substitution > dermal protection > PAPR and baseline) and was still a significant predictor of most urinary analytes during the week of PAPR use, suggesting that PACs in air were dermally absorbed. The application temperature of HMA was positively associated with urinary measures, such that an increase from the lowest application temperature (121°C) to the highest (154°C) was associated with a 72% increase in ΣOH-fluorene and 1-OH-pyrene and an 82% increase in ΣOH-phenanthrene. Though PACs in hand-wash samples were not predictors of urinary analytes, the effects observed during the PAPR scenario and the week of increased dermal protection provide evidence of dermal absorption. Conclusions: Our results provide evidence that PACs in air are dermally absorbed. Reducing the application temperature of asphalt mix appears to be a promising strategy for reducing PAC exposure among paving workers. Additional reductions may be achieved by requiring increased dermal coverage of workers and by substituting biodiesel for diesel oil as a cleaning agent. [ABSTRACT FROM AUTHOR]

Our objectives were to determine relative contributions of diet and dust exposure from multiple microenvironments to PentaBDE body burden, and to explore the role of handwipes as a measure of personal exposure to PentaBDE. We administered a food frequency questionnaire and collected serum, dust (office, main living area, bedroom, and vehicle), and handwipe samples from 31 participants. ΣPentaBDEs (sum of BDE 28/33, 47, 99, 100, and 153) in handwipes collected in the office environment were weakly correlated with dust collected from offices (r = 0.35, p = 0.06) and bedrooms (r = 0.39, p = 0.04), but not with dust from main living areas (r = -0.05, p = 0.77) or vehicles (r = 0.17, p = 0.47). ΣPentaBDEs in serum were correlated with dust from main living areas (r = 0.42, p = 0.02) and bedrooms (r = 0.49, p = 0.008), but not with dust from offices (r = 0.22, p = 0.25) or vehicles (r = 0.20, p = 0.41). Our final regression model included variables for main living area dust and handwipes, and predicted 55% of the variation in serum ΣPentaBDE concentrations (p = 0.0004). Diet variables were not significant predictors of ΣPentaBDEs in serum. Our research suggests that exposure to dust in the home environment may be the most important factor in predicting PentaBDE body burden in North Americans, and potential exposure pathways may involve PBDE residues on hands. [ABSTRACT FROM AUTHOR]

Background: Polybrominated diphenyl ethers (PBDEs) have been widely used as flame retardants in consumer products and are ubiquitous in residential indoor air and dust. However, little is known about exposure in the office environment. Objectives: We examined relationships between PBDE concentrations in the office environment and internal exposure using concurrent measurements of PBDEs in serum, handwipes, and office dust. Methods: We collected serum, dust, and handwipe samples from 31 participants who spent at least 20 hr/week in an office. We used a questionnaire to collect information about work and personal habits. Results: We found positive associations between PBDEs in room dust, handwipes (a measure of personal exposure), and serum. PBDE office dust concentrations were weakly correlated with measurements in handwipes: r = 0.35 (p = 0.06) for pentaBDE (sum of BDE congeners 28/33, 47, 99, 100, and 153) and 0.33 (p = 0.07) for BDE-209. Hand washing also predicted pentaBDE levels in handwipes: low handwashers had 3.3 times the pentaBDE levels in their handwipes than did high hand-washers (p = 0.02). PentaBDE in handwipes predicted pentaBDE levels in serum (p = 0.03): Serum concentrations in the highest handwipe tertile were on average 3.5 times the lowest handwipe tertile. The geometric mean concentration of pentaBDEs in serum was 27 ng/g lipid. We detected BDE-209 in 20% of serum samples, at levels ranging from < 4.8 to 9.7 ng/g lipid. Conclusion: Our research suggests that exposure to pentaBDE in the office environment contributes to pentaBDE body burden, with exposure likely linked to PBDE residues on hands. In addition, hand washing may decrease exposure to PBDEs. [ABSTRACT FROM AUTHOR]

The contribution of microRNAs (miRNAs) to carcinogenesis in many tumors, including head and neck squamous cell carcinomas (HNSCCs), is clear, but the etiology and clinical significance of their alteration remain important questions. Our previous work has identified four miRNAs as differentially expressed HNSCCs compared with non-diseased epithelia and showed that there is potential diagnostic utility in examining their expression. Here, we used quantitative real-time polymerase chain reaction to determine the relative expression of these miRNAs in a larger independent case series of HNSCC tumors (n = 169), examining associations of miRNA expression with exposures and clinical features associated with HNSCC. In multivariate analyses, expression of miR-375 was shown to increase with alcohol consumption (P = 0.002) and showed higher expression in tumors of pharyngeal and laryngeal origin compared with oral tumors (P < 0.05 and P < 0.01, respectively). Additionally, high miR-21 expression was associated with significantly decreased 5 year survival in patients (hazard ratio, 1.68; 95% CI: 1.04–2.77) in a model controlled for patient age, gender and tumor stage. Together, these data suggest that alterations in miRNA expression are related to exposures causal in head and neck cancer and may be useful biomarkers of patient outcome. [ABSTRACT FROM PUBLISHER]

When working with hot mix asphalt, road pavers are exposed to polycyclic aromatic hydrocarbons (PAHs) through the inhalation of vapors and particulate matter (PM) and through dermal contact with PM and contaminated surfaces. Several PAHs with four to six rings are potent carcinogens which reside in these particulate emissions. Since urinary biomarkers of large PAHs are rarely detectable in asphalt workers, attention has focused upon urinary levels of the more volatile and abundant two-ring and three-ring PAHs as potential biomarkers of PAH exposure. Here, we compare levels of particulate polycyclic aromatic compounds (P-PACs, a group of aromatic hydrocarbons containing PAHs and heterocyclic compounds with four or more rings) in air and dermal patch samples from 20 road pavers to the corresponding urinary levels of naphthalene (U-Nap) (two rings), phenanthrene (U-Phe) (three rings), monohydroxylated metabolites of naphthalene (OH-Nap) and phenanthrene (OH-Phe), and 1-hydroxypyrene (OH-Pyr) (four rings), the most widely used biomarker of PAH exposure. For each worker, daily breathing-zone air (n = 55) and dermal patch samples (n = 56) were collected on three consecutive workdays along with postshift, bedtime, and morning urine samples (n = 149). Measured levels of P-PACs and the urinary analytes were used to statistically model exposure–biomarker relationships while controlling for urinary creatinine, smoking status, age, body mass index, and the timing of urine sampling. Levels of OH-Phe in urine collected postshift, at bedtime, and the following morning were all significantly associated with levels of P-PACs in air and dermal patch samples. For U-Nap, U-Phe, and OH-Pyr, both air and dermal patch measurements of P-PACs were significant predictors of postshift urine levels, and dermal patch measurements were significant predictors of bedtime urine levels (all three analytes) and morning urine levels (U-Nap and OH-Pyr only). Significant effects of creatinine concentration were observed for all analytes, and modest effects of smoking status and body mass index were observed for U-Phe and OH-Pyr, respectively. Levels of OH-Nap were not associated with P-PAC measurements in air or dermal patch samples but were significantly affected by smoking status, age, day of sample collection, and urinary creatinine. We conclude that U-Nap, U-Phe, OH-Phe, and OH-Pyr can be used as biomarkers of exposure to particulate asphalt emissions, with OH-Phe being the most promising candidate. Indications that levels of U-Nap, U-Phe, and OH-Pyr were significantly associated with dermal patch measurements well into the evening after a given work shift, combined with the small ratios of within-person variance components to between-person variance components at bedtime, suggest that bedtime measurements may be useful for investigating dermal PAH exposures. [ABSTRACT FROM PUBLISHER]

Airborne emissions from hot asphalt contain mixtures of polycyclic aromatic hydrocarbons (PAHs), including several carcinogens. We investigated urinary biomarkers of three PAHs, namely naphthalene (Nap), phenanthrene (Phe), and pyrene (Pyr) in 20 road-paving workers exposed to hot asphalt and in 6 road milling workers who were not using hot asphalt (reference group). Our analysis included baseline urine samples as well as postshift, bedtime, and morning samples collected over three consecutive days. We measured unmetabolized Nap (U-Nap) and Phe (U-Phe) as well as the monohydroxylated metabolites of Nap (OH-Nap), Phe (OH-Phe), and Pyr (OH-Pyr) in each urine sample. In baseline samples, no significant differences in biomarker levels were observed between pavers and millers, suggesting similar background exposures. In postshift, bedtime, and morning urine samples, the high pairwise correlations observed between levels of all biomarkers suggest common exposure sources. Among pavers, levels of all biomarkers were significantly elevated in postshift samples, indicating rapid uptake and elimination of PAHs following exposure to hot asphalt (biomarker levels were not elevated among millers). Results from linear mixed-effects models of levels of U-Nap, U-Phe, OH-Phe, and OH-Pyr across pavers showed significant effects of work assignments with roller operators having lower biomarker levels than the other workers. However, no work-related effect was observed for levels of OH-Nap, apparently due to the influence of cigarette smoking. Biological half-lives, estimated from regression coefficients for time among pavers, were 8 h for U-Phe, 10 h for U-Nap, 13 h for OH-Phe and OH-Pyr, and 26 h for OH-Nap. These results support the use of U-Nap, U-Phe, OH-Phe, and OH-Pyr, but probably not OH-Nap, as short-term biomarkers of exposure to PAHs emanating from hot asphalt. [ABSTRACT FROM PUBLISHER]

Background: Biomonitoring studies can provide information about individual and populationwide exposure. However they must be designed in a way that protects the rights and welfare of participants. This descriptive qualitative study was conducted as a follow-up to a breastmilk biomonitoring study. The primary objectives were to assess participants' experiences in the study, including the report-back of individual body burden results, and to determine if participation in the study negatively affected breastfeeding rates or duration. Methods: Participants of the Greater Boston PBDE Breastmilk Biomonitoring Study were contacted and asked about their experiences in the study: the impact of study recruitment materials on attitudes towards breastfeeding; if participants had wanted individual biomonitoring results; if the protocol by which individual results were distributed met participants' needs; and the impact of individual results on attitudes towards breastfeeding. Results: No participants reported reducing the duration of breastfeeding because of the biomonitoring study, but some responses suggested that breastmilk biomonitoring studies have the potential to raise anxieties about breastfeeding. Almost all participants wished to obtain individual results. Although several reported some concern about individual body burden, none reported reducing the duration of breastfeeding because of biomonitoring results. The study literature and report-back method were found to mitigate potential negative impacts. Conclusion: Biomonitoring study design, including clear communication about the benefits of breastfeeding and the manner in which individual results are distributed, can prevent negative impacts of biomonitoring on breastfeeding. Adoption of more specific standards for biomonitoring studies and continued study of risk communication issues related to biomonitoring will help protect participants from harm. [ABSTRACT FROM AUTHOR]

Abstract: Assessment of indoor exposure to polybrominated diphenyl ethers (PBDEs) requires a critical examination of methods that may influence exposure estimates and comparisons between studies. We measured PBDEs in residential dust collected from 20 homes in Boston, MA, to examine 5 key questions: 1) Does the choice of dust exposure metric—e.g., concentration (ng/g) or dust loading (ng/m2)—affect analysis and results? 2) To what degree do dust concentrations change over time? 3) Do dust concentrations vary between rooms? 4) Is the home vacuum bag an acceptable surrogate for researcher-collected dust? 5) Are air and dust concentrations correlated for the same room? We used linear mixed-effects models to analyze the data while accounting for within-home and within-room correlations. We found that PBDE dust concentration and surface loading were highly correlated (r =0.86–0.95, p <0.001). Average dust concentrations did not significantly differ over an 8-month period, possibly because home furnishings changed little over this time. We observed significant differences between rooms in the same home: PBDE concentrations in the main living area were 97% higher than the bedroom for decaBDE (p =0.02) and 72% higher for pentaBDE (p =0.05). Home vacuum bag dust concentrations were significantly lower than researcher-collected dust and not strongly correlated. Air (vapor and particulate phase) and dust concentrations were correlated for pentaBDE (p =0.62, p <0.01), but not for decaBDE (p =0.25). In addition, potential markers of BDE 209 debromination (BDE 202 and the BDE197:BDE201 ratio) were also observed in household dust samples. One vacuum bag sample contained the highest concentrations of BDE 209 (527,000 ng/g) and total PBDEs (544,000 ng/g) that have been reported in house dust. [Copyright &y& Elsevier]

The indoor environment is an important source of exposure to polybrominated diphenyl ethers (PBDEs), a class of fire retardants used in many household products. Previous attempts to link PBDE concentrations in house dust to consumer products have been hampered by the inability to determine the presence of PBDEs in otherwise similar products. We used a portable X-ray fluorescence (XRF) analyzer to nondestructively quantify bromine concentrations in consumer goods. In the validation phase, XRF-measured bromine was highly correlated with GC/MS-measured bromine for furniture foam and plastic from electronics (n = 29, r = 0.93, p < 0.0001). In the field study phase, the XRF-measured bromine in room furniture was associated with pentaBDE concentrations in room dust in the bedroom (r = 0.68, p = 0.001) and main living area (r = 0.51, p = 0.02). We also found an association between XRF- measured bromine levels in electronics and decaBDE levels in dust, largely driven by the high levels in televisions (r = 0.64, p = 0.003 for bedrooms). For the main living area, predicting decaBDE in dust improved when we included an interaction effect between the bromine content of televisions and the number of persons in the house (p < 0.005), a potential surrogate for television usage. [ABSTRACT FROM AUTHOR]

We used personal air samplers to measure indoor air exposure to polybrominated diphenyl ethers (PBDEs) for 20 residents of the Greater Boston Area (Massachusetts). Area air measures were simultaneously collected from two rooms in each participant's home. Total personal air concentrations (particulate + vapor) were 469 pg/m³ for non-209 BDEs and 174 pg/m³ for BDE 209, significantly higher than bedroom and main living room concentrations (p = 0.01). The ratio of personal air to room air increased from 1 for vapor-phase congeners to 4 for fully particulate-bound congeners, indicating a personal cloud effect. Bedroom and main living area air samples were moderately correlated for non-209 BDEs (r = 0.45, p = 0.045) and BDE 209 (r = 0.58, p = 0.008). Use of personal air concentrations increased estimates of inhalation exposure over those previously reported. Inhalation may account for up to 22% of the total BDE 209 exposure in U.S. adults. [ABSTRACT FROM AUTHOR]

Abstract: Participants of stuttering treatment programs provide an opportunity to evaluate persons who stutter as they demonstrate varying levels of fluency. Identifying physiologic correlates of altered fluency levels may lead to insights about mechanisms of speech disfluency. This study examined respiratory, orofacial kinematic and acoustic measures in 35 persons who stutter prior to and as they were completing a 1-month intensive stuttering treatment program. Participants showed a marked reduction in stuttering severity as they completed the treatment program. Coincident with reduced stuttering severity, participants increased the amplitude and duration of speech breaths, reduced the rate of lung volume change during inspiration, reduced the amplitude and speed of lip movements early in the test utterance, increased lip and jaw movement durations, and reduced syllable rate. A multiple regression model that included two respiratory measures and one orofacial kinematic measure accounted for 62% of the variance in changes in stuttering severity. Finally, there was a weak but significant tendency for speech of participants with the largest reductions in stuttering severity to be rated as more unnatural as they completed the treatment program. Learning outcomes: As a result of this activity, the reader will be able to (1) outline the rationale for studying speech motor correlates of treatment-related variations in fluency levels; (2) identify those speech motor behaviors that are associated with reduced stuttering severity; and (3) recognize possible reasons for the associations between speech motor behavior and stuttering severity. [Copyright &y& Elsevier]

Stuttering is often viewed as a problem in coordinating the movements of different muscle systems involved in speech production. From this perspective, it is logical that efforts be made to quantify and compare the strength of neural coupling between muscle systems in persons who stutter (PS) and those who do not stutter (NS). This problem was addressed by correlating the speeds of different orofacial structures with vowel fundamental frequency (F0) and intensity as subjects produced fluent repetitions of a simple nonsense phrase at habitual, high, and low intensity levels. It is assumed that resulting correlations indirectly reflect the strength of neural coupling between particular orofacial structures and the respiratory-laryngeal system. An electromagnetic system was employed to record movements of the upper lip, lower lip, tongue, and jaw in 43 NS and 39 PS. The acoustic speech signal was recorded and used to obtain measures of vowel F0 and intensity. For each subject, correlation measures were obtained relating peak orofacial speeds to F0 and intensity. Correlations were significantly reduced in PS compared to NS for the lower lip and tongue, although the magnitude of these group differences covaried with the correlation levels relating F0 and intensity. It is suggested that the group difference in correlation pattern reflects a reduced strength of neural coupling of the lower lip and tongue systems to the respiratory-laryngeal system in PS. Consideration is given to how this may contribute to temporal discoordination and stuttering. [ABSTRACT FROM AUTHOR]

This study was intended to replicate and extend previous findings that (a) during fluent speech persons who stutter (PS) and those who do not (NS) differ in their vocal tract closing movements (L. Max, A. J. Caruso, & V. L. Gracco, 2003) and (b) ratios relating lip and tongue speed to jaw speed increase with stuttering severity (M. D. McClean & C. R. Runyan, 2000). An electromagnetic system was used to record movements of the upper lip, lower lip, tongue, and jaw of 43 NS and 37 PS during productions of a nonsense phrase and a sentence. Measure-ment and analysis of movement speeds, durations, and ratios of lip and tongue speed to jaw speed were performed on fluent productions of a nonsense phrase and sentence. Statistical comparisons were made between PS with low and high stuttering severity levels (LPS and HPS) and NS. Significant variations across groups in movement speed and duration were observed, but the pattern of these effects was complex and did not replicate the results of the two earlier studies. In the nonsense phrase, significant reductions in lower lip closing duration, jaw closing duration, and jaw closing speed were seen in PS. In the sentence task, HPS showed elevated tongue opening and closing durations. For tongue opening in the sentence, LPS showed elevated speeds and HPS showed reduced speeds. The elevated speeds for LPS are interpreted as a contributing factor to speech disfluency, whereas the reduced speeds and increased durations in HPS are attributed to adaptive behavior intended to facilitate fluent speech. Significant group effects were not seen for the speed ratio measures. Results are discussed in relation to multivariate analyses intended to identify subgroups of PS. [ABSTRACT FROM AUTHOR]

Studies of normal and disordered articulatory movement often rely on the use of short, simple speech tasks. However, the severity of speech disorders can be observed to vary markedly with task. Understanding task-related variations in articulatory kinematic behavior may allow for an improved understanding of normal and disordered speech motor behavior in varying communication contexts. This study evaluated how orofacial kinematic behavior varies as a function of speaking task in a group of 15 healthy male speakers. The speech tasks included a nonsense phrase with a high frequency of stop consonants, a sentence, an oral reading passage, and a spontaneous monologue. In addition, rate and intensity conditions were varied for the nonsense phrase and sentence. The articulatory positions of the upper lip, lower lip, tongue blade, and mandible were recorded, and measures reflecting (a) average features of individual movements or strokes (i.e., peak speed, distance, and duration) and (b) overall spatial variability of the articulators for each task were extracted, derived, and analyzed. Results showed a number of task- and condition-related differences in speech kinematic behavior. The most prominent result from the task comparison was that the nonsense speech task exhibited larger, faster, and longer movement strokes than the other speech tasks. For some articulators (lower lip and tongue), there were task-related differences in spatial variability. Changes in loudness and rate revealed variation in kinematic measures that were often complicated by articulator identity and task type. The results suggest that an expanded range of speech tasks and conditions may aid in the study of normal and disordered speech motor behavior. [ABSTRACT FROM AUTHOR]

Understanding how orofacial muscle activity and movement covary across changes in speech rate and intensity has implications for the neural control of speech production and the use of clinical procedures that manipulate speech prosody. The present study involved a correlation analysis relating average lower-lip and jaw-muscle activity to lip and jaw movement distance, speed, and duration. Recordings were obtained on orofacial movement, muscle activity, and the acoustic signal in 3 normal speakers as they repeated a simple test utterance with targeted speech rates varying from 60% to 160% of their habitual rate and at targeted vocal intensities of-6 dB and +6 dB relative to their habitual intensity. Surface electromyographic (EMG) recordings were obtained with electrodes positioned to sample primarily the mentalis, depressor labii inferior, anterior belly of the digastric, and masseter muscles. Two-dimensional displacements of the lower lip and jaw in the midsagittal plane were recorded with an electromagnetic system. All participants produced linear changes in percent utterance duration relative to the auditory targets for speech rate variation. Intensity variations ranged from -10 dB to +8 dB. Average EMG levels for all 4 muscles were well correlated with specific parameters of movement. Across the intensity conditions, EMG level was positively correlated with movement speed and distance in all participants. Across the rate conditions, EMG level was negatively correlated with movement duration in all participants, while greater interparticipant variability was noted for correlations relating EMG to speed and distance. For intensity control, it is suggested that converging neural input to orofacial motoneurons varies monotonically with movement distance and speed. In contrast, rate control appears to be more strongly related to... [ABSTRACT FROM AUTHOR]

Discusses a study which examined the variations in the relative speeds of orofacial structures with stuttering severity. Subjects; Stuttering severity ratings; Results.

To understand the clinical aspects of speech rate control, a clearer picture is needed of how orofacial structures are coordinated across variations in speech rate. To address this problem, patterns of orofacial tangential velocity or speed were analyzed in a group of 9 normal speakers as they produced the utterance "a bad daba" at fast, normal, and slow speech rates. An electromagnetic system was used to record the movements of the upper lip, lower lip, jaw, and tongue. Measures of the magnitude of peak tangential velocities were obtained across the four structures. Orofacial velocities consistently decreased at slow rates relative to normal rates, whereas at fast rates increased and decreased velocities were observed in an equivalent number of cases. Significant correlations frequently were obtained across speech rate between lip, tongue, and jaw velocities. Upper and lower lip velocities showed consistent positive correlations with one another, whereas marked intersubject differences were observed in the sign of jaw-related correlations. Repeated testing on 3 subjects indicated a high degree of consistency within subjects in the overall patterns of mean velocity for the different structures. Results are discussed in relation to possible motor control differences underlying fast and slow speech, neural coupling of muscle systems, and jaw-related individual differences in speech motor coordination. [ABSTRACT FROM AUTHOR]

Background: Technological burden and medical complexity are significant drivers of clinician burnout. Electronic health record(EHR)-based population health management tools can be used to identify high-risk patient populations and implement prophylactic health practices. Their impact on clinician burnout, however, is not well understood. Our objective was to assess the relationship between ratings of EHR-based population health management tools and clinician burnout. Methods: We conducted cross-sectional analyses of 2018 national Veterans Health Administration(VA) primary care personnel survey, administered as an online survey to all VA primary care personnel (n = 4257, response rate = 17.7%), using bivariate and multivariate logistic regressions. Our analytical sample included providers (medical doctors, nurse practitioners, physicians' assistants) and nurses (registered nurses, licensed practical nurses). The outcomes included two items measuring high burnout. Primary predictors included importance ratings of 10 population health management tools (eg. VA risk prediction algorithm, recent hospitalizations and emergency department visits, etc.). Results: High ratings of 9 tools were associated with lower odds of high burnout, independent of covariates including VA tenure, team role, gender, ethnicity, staffing, and training. For example, clinicians who rated the risk prediction algorithm as important were less likely to report high burnout levels than those who did not use or did not know about the tool (OR 0.73; CI 0.61-0.87), and they were less likely to report frequent burnout (once per week or more) (OR 0.71; CI 0.60-0.84). Conclusions: Burned-out clinicians may not consider the EHR-based tools important and may not be using them to perform care management. Tools that create additional technological burden may need adaptation to become more accessible, more intuitive, and less burdensome to use. Finding ways to improve the use of tools that streamline the work of population health management and/or result in less workload due to patients with poorly managed chronic conditions may alleviate burnout. More research is needed to understand the causal directional of the association between burnout and ratings of population health management tools. [ABSTRACT FROM AUTHOR]

Objective: Parkinsonism and Parkinson's disease (PD) have been described as consequences of repetitive head impacts (RHI) from boxing, since 1928. Autopsy studies have shown that RHI from other contact sports can also increase risk for neurodegenerative diseases, including chronic traumatic encephalopathy (CTE) and Lewy bodies. In vivo research on the relationship between American football play and PD is scarce, with small samples, and equivocal findings. This study leveraged the Fox Insight study to evaluate the association between American football and parkinsonism and/or PD Diagnosis and related clinical outcomes. Participants and Methods: Fox Insight is an online study of people with and without PD who are 18+ years (>50,000 enrolled). Participants complete online questionnaires on motor function, cognitive function, and general health behaviors. Participants self-reported whether they "currently have a diagnosis of Parkinson's disease, or parkinsonism, by a physician or other health care professional." In November 2020, the Boston University Head Impact Exposure Assessment was launched in Fox Insight for large-scale data collection on exposure to RHI from contact sports and other sources. Data used in this abstract were obtained from the Fox Insight database https://foxinsight-info.michaeljfox.org/insight/explore/insight.jsp on 01/06/2022. The sample includes 2018 men who endorsed playing an organized sport. Because only 1.6% of football players were women, analyses are limited to men. Responses to questions regarding history of participation in organized football were examined. Other contact and/or non-contact sports served as the referent group. Outcomes included PD status (absence/presence of parkinsonism or PD) and Penn Parkinson's Daily Activities Questionnaire-15 (PDAQ-15) for assessment of cognitive symptoms. Binary logistic regression tested associations between history and years of football play with PD status, controlling for age, education, current heart disease or diabetes, and family history of PD. Linear regressions, controlling for these variables, were used for the PDAQ-15. Results: Of the 2018 men (mean age=67.67, SD=9.84; 10, 0.5% Black), 788 (39%) played football (mean years of play=4.29, SD=2.88), including 122 (16.3%) who played youth football, 494 (66.0%) played high school, 128 (17.1%) played college football, and 5 (0.7%) played at the semi-professional or professional level. 1738 (86.1%) reported being diagnosed with parkinsonism/PD, and 707 of these were football players (40.7%). History of playing any level of football was associated with increased odds of having a reported parkinsonism or PD diagnosis (OR=1.52, 95% CI=1.14-2.03, p=0.004). The OR remained similar among those age <69 (sample median age) (OR=1.45, 95% CI=0.97-2.17, p=0.07) and 69+ (OR=1.45, 95% CI=0.95-2.22, p=0.09). Among the football players, there was not a significant association between years of play and PD status (OR=1.09, 95% CI=1.00-1.20, p=0.063). History of football play was not associated with PDAQ-15 scores (n=1980) (beta=-0.78, 95% CI=-1.59-0.03, p=0.059) among the entire sample. Conclusions: Among 2018 men from a data set enriched for PD, playing organized football was associated with increased odds of having a reported parkinsonism/PD diagnosis. Next steps include examination of the contribution of traumatic brain injury and other sources of RHI (e.g., soccer, military service). [ABSTRACT FROM AUTHOR]

The article discusses the prevalence of chronic kidney disease (CKD) among young men of working age in Central America. The authors provide a brief overview of the epidemiological, etiological and public health dimensions of the CKD epidemic, which was the result of their research studies conducted in 2009. The researchers discounted the role of established risk factors for CKD, while cited the possible multifactorial synergistic causal mechanism involved in the epidemic.

The authors discuss the epidemic of chronic kidney disease (CKD) in large areas of Central America. They state that CKD is spreading but its cause is unknown and major victims are young men of working age. They reveal that identifying the cause of this epidemic is a challenge that will require the investigation of multiple possible risk factors; they suggest four priorities for public health action and hope that the scientific community will identify the causes of this puzzling epidemic.

An investigation of 24 buildings in the Greater Boston Area revealed that one-third (8 of 24) contained caulking materials with polychlorinated biphenyl (PCB) content exceeding 50 ppm by weight, which is the U.S. Environmental Protection Agency (U.S. EPA) specified limit above which this material is considered to be PCB bulk product waste. These buildings included schools and other public buildings. In a university building where similar levels of PCB were found in caulking material, PCB levels in indoor air ranged from 111 to 393 ng/m³; and in dust taken from the building ventilation system, < 1 ppm to 81 ppm. In this building, the U.S. EPA mandated requirements for the removal and disposal of the PCB bulk product waste as well as for confirmatory sampling to ensure that the interior and exterior of the building were decontaminated. Although U.S. EPA regulations under the Toxic Substances Control Act stipulate procedures by which PCB-contaminated materials must be handled and disposed, the regulations apparently do not require that materials such as caulking be tested to determine its PCB content. This limited investigation strongly suggests that were this testing done, many buildings would be found to contain high levels of PCBs in the building materials and potentially in the building environment. The presence of PCBs in schools is of particular concern given evidence suggesting that PCBs are developmental toxins. [ABSTRACT FROM AUTHOR]

Background: The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout.Methods: Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate).Results: 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records.Conclusions: VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience. [ABSTRACT FROM AUTHOR]

Polychlorinated biphenyls (PCBs) are a class of lipophilic endocrine-disrupting chemicals with wide industrial use in the U.S. from the 1930s through 1977. Due to their environmental and biological persistence, low levels of PCBs remain detected in wildlife and humans. Although U.S. studies have shown higher serum PCB concentrations among Black women compared with White women, studies of correlates of PCB exposure among Black women are scarce. We examined predictors of plasma PCB concentrations in a cross-sectional analysis of baseline data from a prospective cohort study of 1693 premenopausal Black women aged 23-35 years from Detroit, Michigan (2010-2012). We collected demographic, behavioral, dietary, and medical data via self-administered questionnaires, telephone interviews, and in-person clinic visits, as well as non-fasting blood samples. We measured concentrations of 24 PCB congeners in baseline plasma from a subset of 762 participants. We used linear regression for log-transformed lipid-adjusted PCB concentrations to calculate percentage differences across levels of selected predictors. We did this separately for individual PCBs, sum of total PCBs, and sum of PCBs by degree of chlorination and hormonal activity. PCB concentrations were positively associated with age, duration of urban residence, cigarette smoking, heavy alcohol intake, and being breastfed in infancy, and inversely associated with body mass index (BMI) and lactation duration. The strength of some associations varied by degree of chlorination. For example, a 5-kg/m2 higher BMI corresponded to a 2.9% lower summed concentration of tri- and tetra-substituted PCBs (95% CI -4.6%, -1.2%), an 8.3% lower summed concentration of penta- and hexa-substituted PCBs (95% CI -10.0%, -6.5%), and a 12.1% lower summed concentration of hepta-, octa-, nona-, and deca-substituted PCBs (95% CI -13.7%, -10.4%). Likewise, associations for age and being breastfed in infancy were stronger for higher-chlorinated PCBs. Results agree with studies on predictors of PCB body burdens, few of which include large numbers of Black women. [ABSTRACT FROM AUTHOR]

Background: Exposure to repetitive head impacts (RHI) in American football players can lead to cognitive impairment and dementia due to neurodegenerative disease, particularly chronic traumatic encephalopathy (CTE). The pathognomonic lesion of CTE consists of perivascular aggregates of hyper-phosphorylated tau in neurons at the depths of cortical sulci. However, it is unclear whether exposure to RHI accelerates amyloid-β (Aβ) plaque formation and increases the risk for Alzheimer's disease (AD). Although the Aβ neuritic plaques characteristic of AD are observed in a minority of later-stage CTE cases, diffuse plaques are more common. This study examined whether former professional and college American football players, including those with cognitive impairment and dementia, have elevated neuritic Aβ plaque density, as measured by florbetapir PET. Regardless of cognitive and functional status, elevated levels of florbetapir uptake were not expected. Methods: We examined 237 men ages 45–74, including 119 former professional (PRO) and 60 former college (COL) football players, with and without cognitive impairment and dementia, and 58 same-age men without a history of contact sports or TBI (unexposed; UE) and who denied cognitive or behavioral symptoms at telephone screening. Former players were categorized into four diagnostic groups: normal cognition, subjective memory impairment, mild cognitive impairment, and dementia. Positive florbetapir PET was defined by cortical-cerebellar average SUVR of ≥ 1.10. Multivariable linear regression and analysis of covariance (ANCOVA) compared florbetapir average SUVR across diagnostic and exposure groups. Multivariable logistic regression compared florbetapir positivity. Race, education, age, and APOE4 were covariates. Results: There were no diagnostic group differences either in florbetapir average SUVR or the proportion of elevated florbetapir uptake. Average SUVR means also did not differ between exposure groups: PRO-COL (p = 0.94, 95% C.I. = [− 0.033, 0.025]), PRO-UE (p = 0.40, 95% C.I. = [− 0.010, 0.029]), COL-UE (p = 0.36, 95% CI = [0.0004, 0.039]). Florbetapir was not significantly associated with years of football exposure, cognition, or daily functioning. Conclusions: Cognitive impairment in former American football players is not associated with PET imaging of neuritic Aβ plaque deposition. These findings are inconsistent with a neuropathological diagnosis of AD in individuals with substantial RHI exposure and have both clinical and medico-legal implications. Trial registration: NCT02798185. [ABSTRACT FROM AUTHOR]

Objective: White matter hyperintensity (WMH) burden is greater, has a frontal-temporal distribution, and is associated with proxies of exposure to repetitive head impacts (RHI) in former American football players. These findings suggest that in the context of RHI, WMH might have unique etiologies that extend beyond those of vascular risk factors and normal aging processes. The objective of this study was to evaluate the correlates of WMH in former elite American football players. We examined markers of amyloid, tau, neurodegeneration, inflammation, axonal injury, and vascular health and their relationships to WMH. A group of age-matched asymptomatic men without a history of RHI was included to determine the specificity of the relationships observed in the former football players. Participants and Methods: 240 male participants aged 45-74 (60 unexposed asymptomatic men, 60 male former college football players, 120 male former professional football players) underwent semi-structured clinical interviews, magnetic resonance imaging (structural T1, T2 FLAIR, and diffusion tensor imaging), and lumbar puncture to collect cerebrospinal fluid (CSF) biomarkers as part of the DIAGNOSE CTE Research Project. Total WMH lesion volumes (TLV) were estimated using the Lesion Prediction Algorithm from the Lesion Segmentation Toolbox. Structural equation modeling, using Full-Information Maximum Likelihood (FIML) to account for missing values, examined the associations between log-TLV and the following variables: total cortical thickness, whole-brain average fractional anisotropy (FA), CSF amyloid ß42, CSF p-tau181, CSF sTREM2 (a marker of microglial activation), CSF neurofilament light (NfL), and the modified Framingham stroke risk profile (rFSRP). Covariates included age, race, education, APOE z4 carrier status, and evaluation site. Bootstrapped 95% confidence intervals assessed statistical significance. Models were performed separately for football players (college and professional players pooled; n=180) and the unexposed men (n=60). Due to differences in sample size, estimates were compared and were considered different if the percent change in the estimates exceeded 10%. Results: In the former football players (mean age=57.2, 34% Black, 29% APOE e4 carrier), reduced cortical thickness (B=-0.25, 95% CI [0.45, -0.08]), lower average FA (B=-0.27, 95% CI [-0.41, -.12]), higher p-tau181 (B=0.17, 95% CI [0.02, 0.43]), and higher rFSRP score (B=0.27, 95% CI [0.08, 0.42]) were associated with greater log-TLV. Compared to the unexposed men, substantial differences in estimates were observed for rFSRP (Bcontrol=0.02, Bfootball=0.27, 994% difference), average FA (Bcontrol=-0.03, Bfootball=-0.27, 802% difference), and p-tau181 (Bcontrol=-0.31, Bfootball=0.17, -155% difference). In the former football players, rFSRP showed a stronger positive association and average FA showed a stronger negative association with WMH compared to unexposed men. The effect of WMH on cortical thickness was similar between the two groups (Bcontrol=-0.27, Bfootball=-0.25, 7% difference). Conclusions: These results suggest that the risk factor and biological correlates of WMH differ between former American football players and asymptomatic individuals unexposed to RHI. In addition to vascular risk factors, white matter integrity on DTI showed a stronger relationship with WMH burden in the former football players. FLAIR WMH serves as a promising measure to further investigate the late multifactorial pathologies of RHI. [ABSTRACT FROM AUTHOR]

Background: Patterns of cognitive impairment in former American football players are uncertain because objective neuropsychological data are lacking. This study characterized the neuropsychological test performance of former college and professional football players. Methods: One hundred seventy male former football players (n=111 professional, n=59 college; 45–74 years) completed a neuropsychological test battery. Raw scores were converted to T-scores using age, sex, and education-adjusted normative data. A T-score ≤ 35 defined impairment. A domain was impaired if 2+ scores fell in the impaired range except for the language and visuospatial domains due to the limited number of tests. Results: Most football players had subjective cognitive concerns. On testing, rates of impairments were greatest for memory (21.2% two tests impaired), especially for recall of unstructured (44.7%) versus structured verbal stimuli (18.8%); 51.8% had one test impaired. 7.1% evidenced impaired executive functions; however, 20.6% had impaired Trail Making Test B. 12.1% evidenced impairments in the attention, visual scanning, and psychomotor speed domain with frequent impairments on Trail Making Test A (18.8%). Other common impairments were on measures of language (i.e., Multilingual Naming Test [21.2%], Animal Fluency [17.1%]) and working memory (Number Span Backward [14.7%]). Impairments on our tasks of visuospatial functions were infrequent. Conclusions: In this sample of former football players (most of whom had subjective cognitive concerns), there were diffuse impairments on neuropsychological testing with verbal memory being the most frequently impaired domain. [ABSTRACT FROM AUTHOR]

Background: Patterns of cognitive impairment in former American football players are uncertain because objective neuropsychological data are lacking. This study characterized the neuropsychological test performance of former college and professional football players. Methods: One hundred seventy male former football players (n=111 professional, n=59 college; 45–74 years) completed a neuropsychological test battery. Raw scores were converted to T-scores using age, sex, and education-adjusted normative data. A T-score ≤ 35 defined impairment. A domain was impaired if 2+ scores fell in the impaired range except for the language and visuospatial domains due to the limited number of tests. Results: Most football players had subjective cognitive concerns. On testing, rates of impairments were greatest for memory (21.2% two tests impaired), especially for recall of unstructured (44.7%) versus structured verbal stimuli (18.8%); 51.8% had one test impaired. 7.1% evidenced impaired executive functions; however, 20.6% had impaired Trail Making Test B. 12.1% evidenced impairments in the attention, visual scanning, and psychomotor speed domain with frequent impairments on Trail Making Test A (18.8%). Other common impairments were on measures of language (i.e., Multilingual Naming Test [21.2%], Animal Fluency [17.1%]) and working memory (Number Span Backward [14.7%]). Impairments on our tasks of visuospatial functions were infrequent. Conclusions: In this sample of former football players (most of whom had subjective cognitive concerns), there were diffuse impairments on neuropsychological testing with verbal memory being the most frequently impaired domain. [ABSTRACT FROM AUTHOR]

USEPA recommends a multiple lines of evidence approach to make informed decisions at vapor intrusion sites because the vapor intrusion pathway is notoriously difficult to characterize. Our study uses this approach by incorporating groundwater, soil gas, indoor air field measurements and numerical models to evaluate vapor intrusion exposure risks in a Metro-Boston neighborhood known to exhibit lower than anticipated indoor air concentrations based on groundwater concentrations. We collected and evaluated five rounds of field sampling data over the period of one year. Field data results show a steep gradient in soil gas concentrations near the groundwater surface; however as the depth decreases, soil gas concentration gradients also decrease. Together, the field data and the numerical model results suggest that a subsurface feature is limiting vapor transport into indoor air spaces at the study site and that groundwater concentrations are not appropriate indicators of vapor intrusion exposure risks in this neighborhood. This research also reveals the importance of including relevant physical models when evaluating vapor intrusion exposure risks using the multiple lines of evidence approach. Overall, the findings provide insight about how the multiple lines of evidence approach can be used to inform decisions by using field data collected using regulatory-relevant sampling techniques, and a well-established 3-D vapor intrusion model. [ABSTRACT FROM AUTHOR]

1. State the magnitudes of the disparities in depression management among Veterans Integrated Service Network 22 primary care patients with and without cancer or advanced cancer 2. Describe the operationalization of the three depression management quality measures applied in this study Depression is common among patients with cancer, especially advanced cancer. High-quality palliative care for patients with cancer should include appropriate management of depression. We aimed to evaluate depression management quality in patients with cancer and advanced cancer seen in Veterans Affairs (VA) primary care clinics. Data were from primary care patients within Veterans Integrated Service Network 22 (VISN 22) (Arizona, New Mexico, and southern California) during fiscal years 2016-2019. "Patients with cancer" and "patients with advanced cancer" had at least one VA inpatient or outpatient visit with any nonhematological cancer or any advanced or poor-prognosis cancer ICD-10 diagnosis code, respectively, within a fiscal year. Advanced and poor-prognosis cancer codes were selected using previously validated codes. 1,607,447 patient-year observations representing 608,042 individuals constituted the cohort. 8.2% (49,839/608,042) were patients with cancer, and 1.5% (9,278/608,042) were patients with advanced cancer during the study. 30,771 patients (5.1%) died during the study, including 8,327 (16.7%) patients with cancer and 4,117 (44.4%) patients with advanced cancer. Among 15,649 observations of patients who had new episodes of depression, appropriate follow-up rates within 84 and 180 days were 32.2% and 50.2% for the cohort but 22.3% and 38.2% for the 686 any cancer observations and 21.9% and 34.3% for the 73 advanced cancer observations, respectively. Minimally appropriate depression treatment within a year was 76.9%, 68.4%, and 64.4% for cohort, any cancer, and advanced cancer observations, respectively. When patients who died are excluded, appropriate follow-up rates for all, any cancer, and advanced cancer patients within 84 days were 32.3%, 22.6%, and 21.3%; within 180 days they were 50.3%, 38.8%, and 34.4%; and minimally appropriate treatment within a year was 76.8%, 69.2%, and 67.2%. Appropriate management of depression lags for patients with cancer. Care quality gaps for patients with comorbid mental illness and serious illness remain even in health care systems where mental health services are well integrated. [ABSTRACT FROM AUTHOR]

HPV infection is a causal agent in many epithelial cancers, yet our understanding of genetic susceptibility to HPV infection and resultant cancer risk is limited. Epidermodysplasia Verruciformis is a rare condition of extreme susceptibility to cutaneous HPV infection primarily attributable to mutations in TMC6 and TMC8. Genetic variation in the TMC6/TMC8 region has been linked to beta-type HPV infection and squamous cell carcinoma of the skin, cervical cancer, HPV persistence and progression to cervical cancer. Here, we have tested the hypothesis that the common TMC8 SNP rs7208422 is associated with high-risk HPV infection and risk of head and neck squamous cell carcinoma (HNSCC). Seropositivity to the HPV L1 protein (HPV16, 18, 11, 31, 33, 35, 45, 52, 58) was measured in 514 cases and 452 population-based controls. Genotype was significantly associated with seropositivity to HPV18 L1 (OR TT vs AA = 0.48, 95% CI = 0.22–0.99) and borderline significantly associated with HPV16 L1 (OR TT vs AA = 0.58, 95% CI = 0.22–1.17). There was a consistent inverse association between TMC8 genotype and infection with other HPV types, including statistically significant associations for HPV31 and HPV52. Consistent with these results, the variant T genotype was associated with a reduced risk of HNSCC (ORAT: 0.63, 95% CI 0.45–0.89, ORTT: 0.54, 95% CI 0.36–0.81), even among subjects seronegative for all HPV types (ORAT: 0.71, 95% CI 0.45–1.11, ORTT: 0.54, 95% CI 0.31–0.93). Our data indicate that common genetic variation in TMC8 is associated with high-risk HPV infection and HNSCC etiology. [ABSTRACT FROM AUTHOR]

Polybrominated diphenyl ethers (PBDEs) are fire retardants used in consumer products such as foam-containing furniture and electronics. This paper reviews human exposure to PBDEs in North America, applying the source to exposure paradigm, and arrives to the following five conclusions. (1) PentaBDE concentrations in residential house dust are associated with the amount of bromine contained in furniture as measured by X-ray fluorescence; similarly, DecaBDE in dust is associated with bromine in electronics. (2) Microscopic analysis of dust suggests that physical breakdown of products may be an important source of DecaBDE in dust. (3) Concentrations of PentaBDE in people were associated with PentaBDE levels in dust from their homes. (4) Inhalation appears to be a minor route of exposure for most of the population. PentaBDEs on handwipes are associated with both dust concentrations and body burdens, suggesting hand-to-mouth activity (or dermal absorption) as important routes of exposure. (5) Diet appears to be another, independent source of exposure. Fire fighters may be exposed via dust, ash or air, particularly in the aftermath of a fire. The existing literature suggests that human health effects may be associated with PentaBDE exposures in the general population. Manufacture of PentaBDE has been banned; replacement fire retardants can be measured in products and dust. The use of PBDEs and related flame retardants poses a potential risk-risk trade-off that requires the joint efforts of environmental scientists and the fire science community. [ABSTRACT FROM AUTHOR]

Gymnastics training facilities contain large volumes of polyurethane foam, a material that often contains additive flame retardants such as PentaBDE. While investigations of human exposure to flame retardants have focused on the general population, potentially higher than background exposures may occur in gymnasts and certain occupational groups. Our objectives were to compare PentaBDE body burden among gymnasts to the general United States population and characterize flame retardants levels in gym equipment, air, and dust. We recruited 11 collegiate female gymnasts (ages 18-22) from one gym in the eastern United States. The geometric mean (GM) concentration of BDE-153 in gymnast sera (32.5 ng/g lipid) was 4-6.5 times higher than in the general United States population groups. Median concentrations of PentaBDE, TBB, and TBPH in paired handwipe samples were 2-3 times higher after practice compared to before, indicating the gymnasts contacted these flame retardants during practice. GM concentrations of PentaBDE, TBB, and TBPH were 1-3 orders of magnitude higher in gym air and dust than in residences. Our findings suggest that these collegiate gymnasts experienced higher exposures to PentaBDE flame retardants compared to the general United States population and that gymnasts may also have increased exposure to other additive flame retardants used in polyurethane foam such as TBB and TBPH. [ABSTRACT FROM AUTHOR]

Objective: To examine the association of urinary concentrations of phenols, parabens, and triclocarban with incidence and growth of uterine leiomyomata (UL; fibroids).Design: Case-cohort study, nested within the Study of Environment, Lifestyle, and Fibroids, a prospective cohort study.Setting: Clinic visits at baseline and every 20 months for 60 months.Patient(s): 754 Black women aged 23-35 years residing in the Detroit, Michigan area (enrolled during 2010-2012).Intervention: None.Main Outcome Measure(s): At each study visit, women underwent transvaginal ultrasound for measurement of UL incidence and growth and provided urine specimens in which we quantified concentrations of seven phenols, four parabens, and triclocarban. We used Cox proportional hazards regression to estimate hazard ratios and 95% confidence intervals (CIs) characterizing the relation of urinary biomarker concentrations with UL incidence during the 60 months of follow-up. In a subset of UL detected and measured at multiple time points, we used linear regression to assess the associations between biomarker concentrations and UL growth.Result(s): Urinary biomarker concentrations were generally inversely associated with UL incidence, but the associations were weak and nonmonotonic. For example, hazard ratios comparing concentrations ≥90th with <50th percentile were 0.77 (95% CI: 0.46, 1.27) for bisphenol A, 0.72 (95% CI: 0.40, 1.28) for bisphenol S, and 0.76 (95% CI: 0.43, 1.33) for methylparaben. Biomarker concentrations were not strongly associated with UL growth.Conclusion(s): In this study of reproductive-aged Black women, urinary phenols, parabens, and triclocarban biomarkers were neither strongly nor consistently associated with UL incidence and growth. [ABSTRACT FROM AUTHOR]

Abstract: Exposure to polycyclic aromatic hydrocarbons has often been quantified via DNA or human serum albumin (HSA) adducts of the carcinogenic metabolite benzo[a]pyrene diol epoxide (BPDE). We previously reported a sandwich ELISA, using 8E11 as capture antibody and anti-HSA as detection antibody, that detected intact BPDE adducts in HSA isolated from plasma. After confirming that BPDE binds to HSA at His146 and Lys195, we modified the ELISA to measure intact BPDE–HSA directly in human plasma. To adjust for interference due to nonspecifically bound HSA on well surfaces and to cross-reactivity of the antibodies, the ELISA employs paired wells with and without addition of BPDE tetrols to deactivate 8E11. By performing assays in quadruplicate, a series of sample-specific adjustments and screening steps are used to reduce measurement errors that are a consequence of detecting low BPDE–HSA concentrations in the general population. ELISA measurements of BPDE–HSA in plasma from smoking and nonsmoking subjects (range 0.280–2.88 ng BPDE–HSA/mg HSA) and from highway workers with and without exposure to asphalt emissions (range 0.346–13.9 ng BPDE–HSA/mg HSA) detected differences in BPDE–HSA levels in the a priori expected directions. [Copyright &y& Elsevier]

Human papillomavirus (HPV) is an accepted cause of head and neck squamous cell carcinoma (HNSCC), and patients with HPV-associated HNSCC have a favorable prognosis. Currently, there is no general guidance on the most appropriate biomarkers for clinical assessment of HPV in these malignancies. We compared PCR-based and serologic HPV assays, as well as p16 immunohistochemistry, individually and in combination in a single population-based study to assess their associations with overall survival among patients with HNSCC, and thus their potential value as biomarkers. HPV16 serology was determined for 488 patients; immunohistochemical detection of p16 expression in tumors was conducted in a subset of 233 cases, and PCR-based methods to assess the presence of HPV16 DNA in a subset of 179 cases of tumors. Considering each biomarker individually in the subset of patients studied for all endpoints, seropositivity for the E6 and E7 proteins was significantly associated with enhanced all-cause survival in oropharyngeal disease [HRE6/E7+ = 0.1, 95% confidence interval (CI) = 0.02-0.3]. Neither the presence of HPV16 DNA nor p16 immunostaining was associated with significant enhanced overall survival in oropharyngeal disease (HRDNA=0.9, 95% CI=0.3-2.9; HRp16=0.3, 95% CI=0.1-1.1). However, the combination of HPV-positive DNA and E6 or E7 serology was associated with enhanced overall survival in oropharyngeal disease (HRDNA+/E6/E7+ = 0.1, 95% CI = 0.02-1.0), whereas E6/E7 seronegative patients with evidence of HPV in tumor DNA did not show any evidence of favorable survival (HRDNA+/E6-/E7- = 3.4, 95% CI = 0.6-18.1). Furthermore, patients with p16 staining and E6 or E7 seropositivity had favorable survival from oropharyngeal disease (HRp16+/E6/E7+ = 0.1, 95% CI = 0.02-0.4), whereas patients who were p16 positive and E6/ E7 seronegative had significantly increased hazard of all causes of death (HRp16+/E6-/E7- = 3.1, 95% CI=1.2-7.7). A stronger association of HPV presence with prognosis (assessed by all-cause survival) is observed when "HPV-associated" HNSCC is defined using tumor status (HPV DNA status or P16) and HPV E6/E7 serology in combination rather using tumor HPV status alone. [ABSTRACT FROM AUTHOR]

Abstract: Biomarkers are useful exposure surrogates given their ability to integrate exposures through all routes and to reflect interindividual differences in toxicokinetic processes. Also, biomarker concentrations tend to vary less than corresponding environmental measurements, making them less-biasing surrogates for exposure. In this article, urinary PAH biomarkers (namely, urinary naphthalene [U-Nap]; urinary phenanthrene [U-Phe]; 1-hydroxypyrene [1-OH-Pyr]; and 1-, (2+3)-, 4-, and 9-hydroxyphenanthrene [1-, (2+3)-, 4-, and 9-OH-Phe]) were evaluated as surrogates for exposure to hot asphalt emissions using data from 20 road-paving workers. Linear mixed-effects models were used to estimate the within- and between-person components of variance for each urinary biomarker. The ratio of within- to between-person variance was then used to estimate the biasing effects of each biomarker on a theoretical exposure–response relationship. Mixed models were also used to estimate the amounts of variation in Phe metabolism to individual OH-Phe isomers that could be attributed to Phe exposure (as represented by U-Phe concentrations) and covariates representing time, hydration level, smoking status, age, and body mass index. Results showed that 1-OH-Phe, (2+3)-OH-Phe, and 1-OH-Pyr were the least-biasing surrogates for exposure to hot asphalt emissions, and that effects of hydration level and sample collection time substantially inflated bias estimates for the urinary biomarkers. Mixed-model results for the individual OH-Phe isomers showed that between 63% and 82% of the observed biomarker variance was collectively explained by Phe exposure, the time and day of sample collection, and the hydration level, smoking status, body mass index, and age of each worker. By difference, the model results also showed that, depending on the OH-Phe isomer, a maximum of 6–23% of the total biomarker variance was attributable to differences in unobserved toxicokinetic processes between the workers. Therefore, toxicokinetic processes are probably less influential on urinary biomarker variance than are exposures and observable covariate effects. The methods described in this analysis should be considered for the selection and interpretation of biomarkers as exposure surrogates in future exposure investigations. [Copyright &y& Elsevier]

Background: Exposure of the U.S. population to polybrominated diphenyl ethers (PBDEs) is thought to be via exposure to dust and diet. However, little work has been done to empirically link body burdens of these compounds to either route of exposure. Objectives: The primary goal of this research was to evaluate the dietary contribution to PBDE body burdens in the United States by linking serum levels to food intake. Method s: We used two dietary instruments - a 24-hr food recall (24FR) and a 1-year food frequency questionnaire (FFQ) - to examine food intake among participants of the 2003-2004 National Health and Nutrition Examination Survey. We regressed serum concentrations of five PBDEs (BDE congeners 28, 47, 99, 100, and 153) and their sum (SPBDE) against diet variables while adjusting for age, sex, race/ethnicity, income, and body mass index. Results: SPBDE serum concentrations among vegetarians were 23% (p = 0.006) and 27% (p = 0.009) lower than among omnivores for 24FR and 1-year FFQ, respectively. Serum levels of five PBDE congeners were associated with consumption of poultry fat: Low, medium, and high intake corresponded to geometric mean SPBDE concentrations of 40.6, 41.9, and 48.3 ng/g lipid, respectively (p = 0.0005). We observed similar trends for red meat fat, which were statistically significant for BDE-100 and BDE-153. No association was observed between serum PBDEs and consumption of dairy or fish. Results were similar for both dietary instruments but were more robust using 24FR. Conclusions: Intake of contaminated poultry and red meat contributes significantly to PBDE body burdens in the United States. [ABSTRACT FROM AUTHOR]

Speech-related motions of small markers attached to the tongue, lower lip, and lower jaw of 44 normal young adult talkers of American English were analyzed to estimate the relative accuracy of selected methods for decoupling tongue and lip motions from ongoing jaw motion when all movements are originally measured relative to a common reference frame (such as the head). In general, results of the analysis show that a common "simple subtraction" method that ignores pitching rotation of the jaw yields larger errors in positions and speeds of decoupled tongue and lip markers than methods that do not ignore rotation. When the jaw is widely opened, is moving quickly, and/or when any decoupled marker is relatively far from the origin of a local coordinate system fixed to the jaw, positional and speed errors associated with the subtraction method can exceed 5 mm and 25 mm/s, respectively. We propose a simple procedure for estimating the pitching rotation of the jaw that can be applied when pitch cannot be measured. We then show that decoupled motions of tongue and lower lip markers based on estimated jaw rotation involve less error than those derived from any other decoupling method considered. Careful attention to processing methods should yield more accurate inferences about the nature and degree of coordination between speech-related movements of the tongue and lower lip that are decoupled from, and hence independent of, concurrent movements of the lower jaw. [ABSTRACT FROM AUTHOR]

The Cardiff Atomic Weapons Establishment (AWE) plant, located in Cardiff, Wales, United Kingdom, used metallic beryllium in their beryllium facility during the years of operation 1961-1997. The beryllium production processes included melting and casting, powder production, pressing, machining, and heat and surface treatments. As part of Cardiff's industrial hygiene program, extensive area measurements and personal lapel measurements of airborne beryllium concentrations were collected for Cardiff workers over the 36-year period of operation. In addition to extensive air monitoring, the beryllium control program also utilized surface contamination controls, building design, engineering controls, worker controls, material controls, and medical surveillance. The electronic database includes 367,757 area sampling records at 101 locations and 217,681 personal lapel sampling records collected from 194 employees over the period 1981-1997. Similar workplace samples were collected from 1961 to 1980, but they were not analyzed because they were not available electronically.Annual personal mean sampling concentrations for all workers ranged from 0.11 to 0.72 micrograms per cubic meter (μg/m[sup 3]) with 95th percentiles ranging from 0.22 to 1.89 μg/m[sup 3]; foundry workers worked in the highest concentration areas with a mean of 0.87 μg/m[sup 3] and a 95th percentile of 2.9 μg/m[sup 3]. Area sampling concentrations, as expected, were lower than personal sampling concentrations. Mean annual area sample concentrations for all locations ranged from 0.02 to 0.32 μg/m[sup 3]. The area sample 95th percentile concentrations for all years were below 0.5 μg/m[sup 3]. For the overwhelming majority of samples, airborne beryllium concentrations were below the 2.0 μg/m[sup 3] standard. Although blood lymphocyte testing for beryllium sensitization has not been routinely conducted among these workers, this metal beryllium processing facility is the only large scale beryllium facility of its kind to have experienced only one unique a case of clinical chronic beryllium disease (CBD) ascertained by traditional medical monitoring procedures. The treating physician determined that this lung disease was likely caused by a systems reaction resulting from a mound contaminated with beryllium. However,he could not rule out the potential for inhalation exposure. Over the 17 years of measurement data analyzed, on occasion, airborne beryllium concentrations have exceeded 2.0 μg/m[sup 3]; however, the Cardiff experience demonstrates that strict and consistent adherence to exposure control measures that emphasized airborne and surface levels and appropriate engineering controls, work practices, and use of personal protective equipment appears to have successfully prevented the incidence of clinical CBD with the exception of one unique case. [ABSTRACT FROM AUTHOR]

Background: The patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model. Objective: We analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)—a central component of burnout—and intent to remain in VA primary care. Design: Logistic regression analysis of a cross-sectional survey. Subjects: 116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region. Main Measures: Outcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics. Key Results: Forty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58–19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93–24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01–28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care. Conclusions: To reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model. [ABSTRACT FROM AUTHOR]