Waco COVID Survey: A Community-Based SARS-CoV-2 Serological Surveillance Study in Central Texas.

In early-2020, the epidemiology of the SARS-CoV-2 virus was still in discovery and initial reports about the role of asymptomatic individuals were developing. The Waco COVID Survey was implemented in mid-2020 with targeted serological surveillance to assess relationships among risk factors and asymptomatic transmission in McLennan County, Texas, USA. Because large-scale random sampling of the population was not feasible, a targeted and repeated sampling of specific clustered groups of asymptomatic individuals was employed. This included four waves (initial intake [n = 495], two follow-ups separated by a month [n = 348; n = 287], and a final follow-up one year later [n = 313]) of sampling participants in different risk categories: (a) healthcare workers (e.g., physicians, nurses, etc.) and first responders, (b) essential service employees (e.g., convenience and grocery stores, restaurants focused on delivery and carry-out), (c) employees whose businesses began reopening on May 1 (e.g., dine-in restaurants, churches, etc.) including church attendees, and (d) individuals that practiced intensive isolation. The survey collected information on demographics, compliance with public health recommendations, satisfaction with government responses, health history, attitudes regarding the SARS-CoV-2 virus and COVID-19 disease, health behaviors, personality, stress, and general affect. Results illustrate pandemic fatigue over time, the influence of political leniency on opinions and behaviors, the importance of face coverings in preventing infection, and the positive impact of vaccination in the community. This project remains one of the largest longitudinal SARS-CoV-2 antibody seroprevalence surveys in the US, and details for successful implementation and community involvement are discussed.

Exploring links between pathogen avoidance motivation, COVID-19 case counts, and immune function.

OBJECTIVES: The selection pressures exerted by pathogens have played important roles in shaping the biology and behavior of animals, including humans. Immune systems recognize and respond to cues of infection or damage by coordinating cellular, humoral, and metabolic shifts that promote recovery. Moreover, animals also possess a repertoire of behavioral tools to help combat the threat of pathogens, often referred to as the behavioral immune system. Recently, researchers have begun to examine how cognitive, affective, and behavioral disease avoidance mechanisms interact with the biological immune system. METHODS: The present study explored relationships among individual differences in behavioral immune system activity (e.g., pathogen disgust), shifts in SARS-CoV-2 infection risk (i.e., 7-day case averages), and immune function in a community cohort from McLennan County, Texas, USA (n = 387). RESULTS: Levels of disease concern were not consistently associated with immune markers. However, serum levels of IFN-γ, TNF-α, IL-2, and IL-8, as well as serum killing ability of Escherichia coli, each varied with case counts. Additional analyses found that case counts also predicted changes in stress physiology, but not subjective measures of distress. However, follow-up mediation models did not provide evidence that relationships between case counts and immunological outcomes were mediated through levels of stress. CONCLUSIONS: The present project provides initial evidence that markers of immune function may be sensitive to changes in infection risk during the COVID-19 pandemic. This adds to the growing body of research finding relationships among behavioral and biological pathogen management mechanisms.

Longitudinal changes in COVID-19 concern and stress: Pandemic fatigue overrides individual differences in caution.

Background: Pandemic fatigue describes a phenomenon whereby individuals experience a decrease in COVID-19 concern over time, despite their risk for infection remaining stable, or even increasing. Individual differences in the experience of pandemic fatigue may have important implications for people's adherence to public health recommendations. Design and methods: Using data collected from a large community cohort in McLennan County, TX, longitudinal changes in COVID-19-related concern, stress, and affect across three appointments separated by approximately 4 weeks (July-November 2020) were examined. About 495, 349, and 286 participants completed one, two, and three appointments, respectively. Changes to stress physiology and local travel over time were also analyzed. Results: Results of a latent class growth analysis revealed four distinct classes of individuals: (a) low concern, low stress, (b) moderate concern, moderate stress, (c) moderate concern, low stress, and (d) high concern, high stress. Despite differences between latent classes in initial levels of concern, stress, and negative affect, levels of each variable decreased over time for all groups. While this reduction of concern did not coincide with changes in local travel, it was reflected in heart rate and blood pressure. Conclusions: Together, these results suggest a general trend of pandemic fatigue in the sample, even for those with moderate-to-high levels of initial COVID-19 stress and concern. Such findings may provide insights into the expected challenges of promoting compliance with public health recommendations as the pandemic continues.

Unrealistic Optimism and Risk for COVID-19 Disease.

Risk perception and consequently engagement in behaviors to avoid illness often do not match actual risk of infection, morbidity, and mortality. Unrealistic optimism occurs when individuals falsely believe that their personal outcomes will be more favorable than others' in the same risk category. Natural selection could favor overconfidence if its benefits, such as psychological resilience, outweigh its costs. However, just because optimism biases may have offered fitness advantages in our evolutionary past does not mean that they are always optimal. The current project examined relationships among personal risk for severe COVID-19, risk perceptions, and preventative behaviors. We predicted that those with higher risk of severe COVID-19 would exhibit unrealistic optimism and behave in ways inconsistent with their elevated risk of morbidity and mortality. Clinical risk scores for severe COVID-19 were calculated and compared with COVID-19 threat appraisal, compliance with shelter-in-place orders (March 13-May 22, 2020) and travel restrictions, compliance with public health recommendations, and potential covariates like self-rated knowledge about COVID-19 in a robust dataset including 492 participants from McLennan County, TX, USA. While those with high clinical risk acknowledged their greater likelihood of experiencing severe illness if infected, they actually reported lower perceived likelihood of becoming infected in the first place. While it is possible that those with higher clinical risk scores truly are less likely to become infected, the pattern and significance of these results held after controlling for possible occupational exposure, household size, and other factors related to infection probability. Higher clinical risk also predicted more recent travel within Texas and lower distress during the pandemic (i.e., feeling less stressed, depressed, and helpless). Additional behavioral data suggested that those with higher clinical risk scores did not generally behave differently than those with lower scores during the shelter-in-place order. While unrealistic optimism may provide some short-term psychological benefits, it could be dangerous due to improper assessment of hazardous situations; inferring that optimism bias has evolutionary origins does not mean that unrealistic optimism is "optimal" in every situation. This may be especially true when individuals face novel sources (or scales) of risk, such as a global pandemic.

Metabolic Phenotypes and Chronic Kidney Disease: A Cross-Sectional Assessment of Patients from a Large Federally Qualified Health Center.

The purpose of this study is to determine if renal function varies by metabolic phenotype. A total of 9599 patients from a large Federally Qualified Health Center (FQHC) were included in the analysis. Metabolic health was classified as the absence of metabolic abnormalities defined by the National Cholesterol Education Program Adult Treatment Panel III criteria, excluding waist circumference. Obesity was defined as body mass index >30 kg/m2 and renal health as an estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2. Linear and logistic regressions were used to analyze the data. The metabolically healthy overweight (MHO) phenotype had the highest eGFR (104.86 ± 28.76 mL/min/1.72 m2) and lowest unadjusted odds of chronic kidney disease (CKD) (OR = 0.46, 95%CI = 0.168, 1.267, p = 0.133), while the metabolically unhealthy normal weight (MUN) phenotype demonstrated the lowest eGFR (91.34 ± 33.28 mL/min/1.72 m2) and the highest unadjusted odds of CKD (OR = 3.63, p < 0.0001). After controlling for age, sex, and smoking status, the metabolically unhealthy obese (MUO) (OR = 1.80, 95%CI = 1.08, 3.00, p = 0.024) was the only phenotype with significantly higher odds of CKD as compared to the reference. We demonstrate that the metabolically unhealthy phenotypes have the highest odds of CKD compared to metabolically healthy individuals.

Group Medical Visit Training in Family Medicine Residency: A 2015 CERA Program Directors Survey.

BACKGROUND AND OBJECTIVES: Group medical visits (GMV) have been shown to improve clinical outcomes and patient satisfaction and are included as a new tool in the patient-centered medical home (PCMH). The capacity for and interest in developing GMV skills in family medicine residency have not been assessed. This study aims to describe the extent of existing training in GMV as well as attitudes toward and barriers to this training. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) sent a survey in the fall of 2015 to all US family medicine residency program directors (PDs) containing questions about the status of GMV training for their residents. RESULTS: The survey response rate was 53%. Fifty-nine percent of program director respondents report access to GMV and 61% note some form of training in this model of care. Seventy-nine percent of respondents indicate that GMV training is important for residents. Multiple barriers exist to optimizing GMV as part of current family medicine training. CONCLUSIONS: A majority of family medicine PD respondents report both access to and curriculum for GMV. While program directors endorse this practice model as an important element in resident training, they acknowledge challenges that may limit its availability. Opportunities to better understand and overcome barriers may increase programs' capacity to deliver GMV skills.

Increasing Residency Research Output While Cultivating Community Research Collaborations.

BACKGROUND AND OBJECTIVES: Having a research curriculum in addition to hosting a resident research day stimulates research activity in residency programs. Research collaborations outside an individual residency program may also promote research in residency. This paper describes a community-wide health research forum that engages faculty and residents in research while bringing together potential research collaborators from the community. METHODS: A yearly research forum has been held at a large community-based family medicine residency program for the past 10 years. This forum invites both residency faculty and residents to present scholarly works, and also invites researchers from the community to present health-related research. Presenters outside the residency come from hospital systems, the local university, other residency programs, and community private physicians. RESULTS: Peer-reviewed research publications have increased greatly since the advent of the research forum in 2006, with six publications from 1997-2006 and 26 from 2007-2016. Greater increases in numbers of peer reviewed presentations were also seen. Collaborative research has occurred between residency faculty and multiple departments at the local university including the business school, social work, public health, physiology, and statistics. There are now 28 collaborative projects completed or in progress. CONCLUSIONS: Development and implementation of a regional health research event has been a success in increasing faculty and resident research productivity. The even greater success however, is the progress made in advancing research collaborations between the local university and the residency program.

Academician Attitudes and Beliefs Regarding the Use of Hospitalists: A CERA Study.

BACKGROUND AND OBJECTIVES: The hospitalist model of inpatient care has spread into many hospitals in the United States with over 34,000 physicians, mostly general internists. Less than 4% of hospitalists trained as family doctors. Around 60% of family medicine residency programs (FMRPs) use hospitalists in their teaching model. Despite the swift growth of hospitalists, there are no reports as to medical educators' beliefs regarding hospitalists. The objective of this project was to survey FMRP directors regarding their attitudes and beliefs concerning the hospitalist model. This paper also reports on numbers of recent FMRP graduates entering hospitalist positions. METHODS: All US allopathic FMRP directors were surveyed in October 2013. The survey questions were part of a larger CERA omnibus survey. RESULTS: The response rate was 56.4%. Of 2012/2013 family medicine graduates, 9.2% entered hospitalist positions. FMRPs in the Southern United States, or of the community-based non-affiliated program type, as well as programs with higher percentages of current residents who are international medical graduates produce the most hospitalists. Most program directors did not feel their residents needed different hospital skills training than they are currently being taught. Use of hospitalists was not felt to improve patient care nor interfere with FMRPs influence at their teaching hospital. CONCLUSIONS: Program directors generally felt neutral or positive about hospitalists and did not think this care model had positively or adversely affected their programs. Many family medicine residents are entering hospitalist positions upon graduating. Family medicine as a discipline should continue to study the hospitalist care model and its impact on family medicine training.

Family medicine academic workforce: a national study of faculty numbers and types.

BACKGROUND AND OBJECTIVES: Little is known about the numbers of faculty in the family medicine academic workforce. As family medicine continues to advance in the current patient-centered medical home environment, baseline data on family medicine faculty may become important for policy makers and those who try to influence them. This nationwide study describes the types, numbers, and regional location of family medicine academic faculty. METHODS: All US allopathic family medicine residency program and US medical school family medicine department websites were gleaned for information regarding academic faculty. Additionally, programs were contacted via telephone and asked whether any of their faculty were considered part-time. RESULTS: Data were collected from 99% of programs/departments. There are 8,987 people in academic family medicine faculty positions. More than 80% of these are physicians. Over 50% of programs/departments have at least one physician with a doctor of osteopathy degree; 21.9% of faculty are considered part-time. Pharmacists accounted for the highest percentage of part-time faculty. CONCLUSIONS: This study provides the most complete census available to date of family medicine faculty in the United States. Such data may be useful in predicting future family medicine faculty workforce needs as the state of primary care medicine continues to evolve.

Increasing family medicine scholarly presentations and the incidence of duplicate research abstracts.

BACKGROUND AND OBJECTIVES: Scholarly activity in the form of original research presentations is valuable to the discipline of family medicine. Two major venues for family medicine researchers to present their work are the Society of Teachers of Family Medicine (STFM) Annual Spring Conference and the North American Primary Care Research Group (NAPCRG) Annual Meeting. Both of these organizations have seen increasing numbers of submissions and subsequent presentations in recent years. The purpose of this project was to analyze the trend in increasing presentations and document the incidence of duplicate research presentations across these two meetings. METHODS: Numbers of primary authors and coauthors were assessed and compared across meetings from 2009 to 2012. Abstracts from the same author(s) presenting at consecutive meetings were compared for originality. RESULTS: STFM has had a nearly 50% increase in numbers of presentations from 2009 to 2012, and NAPCRG has seen a 17.6% increase. There has been an 88.2% increase in the number of presentation authors and coauthors who present at consecutive meetings during the same time frame. Four duplicate research presentations were found from 2009 through spring of 2012. CONCLUSIONS: Numbers of author and coauthor presenters at STFM and NAPCRG annual meetings have increased greatly since 2009. Very little duplication of research presentations was found. It appears that, for the most part, presenters at both STFM and NAPCRG are not presenting duplicate research projects. This is even more important now with limited space at meetings due to record numbers of presentations.

Fit and healthy family cAMP for engaging families in a child obesity intervention: a community health center pilot project.

Childhood obesity has become a significant problem in the United States, especially in poor communities, and we know that children who have at least 1 obese parent have a much higher risk of being obese. Combined behavioral lifestyle interventions and family-based intervention programs to address pediatric obesity have the strongest evidence of effectiveness. In this pilot study, we delineate our collaborative model of family group medical visits at a community health center combined with healthy living workshops involving families with at least 1 child and 1 parent or guardian who are obese as a unique approach to address obesity in children.

Painful toe ulcers.

The patient didn't have diabetes, and wound and blood cultures were negative for infection. So what was causing these recurrent ulcers?

Vitamin D, sunlight exposure, and bone density in elderly African American females of low socioeconomic status.

BACKGROUND AND OBJECTIVES: Darker skin pigmentation and aging are known factors influencing the body's ability to synthesize adequate amounts of vitamin D (25OHD). The objective of this study is to determine the 25OHD insufficiency in elderly African American females of low socioeconomic status (SES) in a southern latitude during springtime sun exposure. METHODS: Patients >or= 70 years old who did not have disorders that might affect vitamin D and calcium absorption/metabolism were enrolled at a community health center. Serum calcium, 25OHD, and intact parathyroid hormone were measured and repeated 6--8 weeks later. Bone mineral density (BMD) scan results were obtained from clinic records. RESULTS: Most subjects (86.4%) had inadequate 25OHD levels < 32ng/mL, and no clinically significant rise in levels was seen after 6--8 weeks of sun exposure. A quarter of subjects had truly deficient 25OHD levels

Resident research in family medicine: where are we now?

Increasing the amount and quality of family medicine research has long been a goal of the specialty. The Future of Family Medicine project endorses the generation of new knowledge and promotes scholarship during residency training. Formal training in the principles of research needs to be initiated early to create the cadre of highly trained researchers that will be required to accomplish this goal. Every family medicine residency graduate should have a working understanding of study design, study conduct, presentation of results, and critical analysis of the medical literature. Teaching these research skills in residency is challenging due to time constraints, funding limitations, varying resident interest, and a relative lack of experienced faculty mentors. This paper reviews the existing literature on teaching research to family medicine residents. Program features consistently associated with successfully promoting resident research include faculty mentors, a formal research curriculum, a forum to present projects, technical assistance, dedicated research time, and funding support.

Cefdinir-associated "bloody stools" in an infant.

Cefdinir, a third-generation oral cephalosporin frequently used in pediatric populations, may cause red stools when administered with iron or products that contain iron, such as infant formula. This benign side effect is not well documented in the medical literature. We describe a 7-month-old girl who was evaluated for red stools while taking cefdinir along with an oral iron supplement.