Mapping Patient Distributions Informs Community-Oriented Primary Care in Four Community Health Centers in Central Massachusetts

Background Based on the philosophy that family medicine training should occur in community-based practices and hospitals, the Worcester Family Medicine Residency (WFMR) training program was structured to combine learning opportunities in an academic medical center with outpatient care training in three unique community-based practices: the Barre Family Health Center, a rural site thirty miles west of Worcester, the Family Health Center of Worcester, a federally funded community health center serving a poor and culturally diverse urban population, and the Hahnemann Family Health Center, a hospital-owned health center serving a socioeconomically diverse population in the northeast part of Worcester. The WFMR received an AAMC “Regional Medicine-Public Health Education Centers-Graduate Medical Education (RMPHEC-GME)” grant to further integrate public health training into the clinical training experience. As part of the effort, collaboration was begun between the department of Family Medicine and Community Health at UMASS Medical School, the academic home of the WFMR, and geographers at Clark University, a local resource providing expertise in mapping of data using Geographic Information Systems (GIS). Mapping Patient Distribution A series of thematic maps were generated from actual practice data on the patients being served by each residency site and also by Fitchburg Community Health Center. Faculty champions from each site attended two training sessions to learn more about the capabilities of mapping. They were then asked to lead faculty at their site in discussion to define five maps they would like to see made from their own patient data. Most sites chose a map showing the distribution of the entire patient population, some requested a map of their pediatric patients, and then the rest were designed to depict the spread of certain chronic diseases, including asthma, hypertension, coronary disease, and diabetes. Maps were generated using geocoding and point density tools in ArcGIS Desktop software. The main goal of this mapping activity was to educate physicians in training about where their patients live and facilitate discussion about environmental factors that impact health. These maps can also be used by practitioners to communicate important information to their patients about available community resources such as gyms, parks, health clinics, and supermarkets (as shown on some maps). Making Maps Available Online One element of the grant initiative was to build an online resource to aid faculty in teaching about population health concepts. This portal, the Community Health Toolkit (http://www.umassmed.edu/fmch/toolkit.aspx), provides three types of information to aid clinicians in both their teaching and their practice. The “Data on Communities” section was developed as part of the UMMS/Clark University collaboration. In total, 24 thematic maps were generated by the GIS team at Clark University and uploaded to the “Data on Communities” web section of the Community Health Toolkit. Other sections of the Community Health Toolkit include “Learning about Populations” which provides links to a variety of local, regional and national health indicators, and a “Community Resources” section which provides links to community resources for patients. The Toolkit is presented to learners along the continuum of medical education, including second year students in the Population Health Clerkship, first year residents in the Family Medicine and Community Health rotation, then used as a resource by residents as they complete presentations and research projects

Multi-Disciplinary Experts Supporting Graduate Medical Education through Participation in COMPLETE Chart Rounds

Learning Objective: As a result of this presentation, attendees will learn skills that they can use to implement collaborative graduate medical education learning experiences using a community of multi-disciplinary professionals within their own institutions. Background: Inter-professional Chart Rounds were implemented to provide residents an opportunity to review and present patient cases utilizing “COMPLETE” guidelines developed by residency leadership as the result of a “Regional Medicine – Public Health Education Centers” grant. COMPLETE guidelines explicitly direct residents to include consideration of: - Context – Culture of context – who is the patient? - Outside Visitors/Resources – incorporate visitors/experts such as librarians, pharmacists and psychologists and utilize their resources - Mental Health – assess behavioral health aspects of the case - Population Perspective – address prevalence of the condition in the community - Learn From Others – consider specialists, home care, and complementary therapies - Expectations – clear goals set between physician and patient - Time – Start on time, end on time. Respect everyone’s time. - End with “Culture of Continuity” – what are the key lessons? Is there a follow-up plan? Through the attendance of librarians, psychologists, pharmacologists, medical students and other faculty, discussion ensues which leads to continued resident education and support. Methods: Chart Rounds are held daily at each residency practice site. Residents are required to attend along with medical and pharmacy students rotating at the centers. The preceptor leads Chart Rounds and other faculty physicians join as they are able. Residents present cases while maintaining patient confidentiality. The preceptor leads the group discussion of the case. Faculty members discuss clinical and administrative implications, the psychologist addresses potential behavioral aspects of the case, the librarian searches for Evidence-Based information to support decisions and the pharmacologist advises on medication management. The group also discusses how individual patient care reflects the public health needs and profile of the community. Residents (n=32) were invited to complete a survey asking them to evaluate their experience with multi-disciplinary COMPLETE Chart Rounds. Results: Survey results as well as observational analysis will be used to improve the resident’s experience at Chart Rounds with the goal of making this experience an even more rewarding collaborative educational experience. Some sample findings include: - 66% of residents report satisfaction of Chart Rounds challenging the academic aspects of their work - 100% of residents in the early portion of their program report that Chart Rounds assists them in building collaborative relationships with faculty and other providers/experts - Residents report the greatest satisfaction (92% overall) with pharmacist participation in Chart Rounds across all Post Graduate Years - Satisfaction with librarian participation increases through each year (from only 10% in PGY1 to over 60% in PGY3) , possibly due to limited exposure early in the program Although these guidelines were developed for use in a Family Medicine Graduate Medical Education program and fit well into this practice model, the findings can be utilized in other resident training programs. Presented at the Patients and Populations: Public Health in Medical Education conference sponsored by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention (CDC), held September 14-15, 2010, in Cleveland, OH

Weaving public health education into the fabric of a family medicine residency

Policymakers and accrediting bodies have recognized the importance of integrating public health, population health, and prevention into graduate medical education programs. The high prevalence of chronic illness, coupled with the impact of behavioral and societal determinants of health, necessitate an urgent call for family medicine residencies to prepare future leaders to meet these challenges. The University of Massachusetts Worcester Family Medicine Residency recently developed an integrated curriculum that strives to develop a culture of incorporating fundamental public health principles into everyday practice. This public health curriculum was designed to integrate new topics within the current residency structure through longitudinal and concentrated experiences. This strategy has substantially improved public health and prevention education without substantial impact on the already strained residency curricular structure. This paper describes the integration of public health and prevention education into a family medicine residency to help residents acquire the fundamental skills necessary to improve a population\u27s health. Inc. All rights reserved

Environmental distribution of Cryptococcus neoformans and C. gattii around the Mediterranean basin

In order to elucidate the distribution of Cryptococcus neoformans and C. gattii in the Mediterranean basin, an extensive environmental survey was carried out during 2012-2015. A total of 302 sites located in 12 countries were sampled, 6436 samples from 3765 trees were collected and 5% of trees were found to be colonized by cryptococcal yeasts. Cryptococcus neoformans was isolated from 177 trees and C. gattii from 13. Cryptococcus neoformans colonized 27% of Ceratonia, 10% of Olea, Platanus and Prunus trees and a lower percentage of other tree genera. The 13 C. gattii isolates were collected from five Eucalyptus, four Ceratonia, two Pinus and two Olea trees. Cryptococcus neoformans was distributed all around the Mediterranean basin, whereas C. gattii was isolated in Greece, Southern Italy and Spain, in agreement with previous findings from both clinical and environmental sources. Among C. neoformans isolates, VNI was the prevalent molecular type but VNII, VNIV and VNIII hybrid strains were also isolated. With the exception of a single VGIV isolate, all C. gattii isolates were VGI. The results confirmed the presence of both Cryptococcus species in the Mediterranean environment, and showed that both carob and olive trees represent an important niche for these yeasts

Environmental distribution of Cryptococcus Neoformans and Cryptococcus Gattii around the Mediterranean basin.

In order to elucidate the distribution of Cryptococcus neoformans and C. gattii in the Mediterranean basin, an extensive environmental survey was carried out during 2012-2015. A total of 302 sites located in 12 countries were sampled, 6436 samples from 3765 trees were collected and 5% of trees were found to be colonized by cryptococcal yeasts. Cryptococcus neoformans was isolated from 177 trees and C. gattii from 13. Cryptococcus neoformans colonized 27% of Ceratonia, 10% of Olea, Platanus and Prunus trees and a lower percentage of other tree genera. The 13 C. gattii isolates were collected from five Eucalyptus, four Ceratonia, two Pinus and two Olea trees. Cryptococcus neoformans was distributed all around the Mediterranean basin, whereas C. gattii was isolated in Greece, Southern Italy and Spain, in agreement with previous findings from both clinical and environmental sources. Among C. neoformans isolates, VNI was the prevalent molecular type but VNII, VNIV and VNIII hybrid strains were also isolated. With the exception of a single VGIV isolate, all C. gattii isolates were VGI. The results confirmed the presence of both Cryptococcus species in the Mediterranean environment, and showed that both carob and olive trees represent an important niche for these yeasts

Assessment of multi-contaminant exposure in a cancer treatment center: a 2-year monitoring of molds, mycotoxins, endotoxins, and glucans in bioaerosols

International audienc

Enhanced Activation of Motor Execution Networks Using Action Observation Combined with Imagination of Lower Limb Movements

The combination of first-person observation and motor imagery, i.e. first-person observation of limbs with online motor imagination, is commonly used in interactive 3D computer gaming and in some movie scenes. These scenarios are designed to induce a cognitive process in which a subject imagines himself/herself acting as the agent in the displayed movement situation. Despite the ubiquity of this type of interaction and its therapeutic potential, its relationship to passive observation and imitation during observation has not been directly studied using an interactive paradigm. In the present study we show activation resulting from observation, coupled with online imagination and with online imitation of a goal-directed lower limb movement using functional MRI (fMRI) in a mixed block/event-related design. Healthy volunteers viewed a video (first-person perspective) of a foot kicking a ball. They were instructed to observe-only the action (O), observe and simultaneously imagine performing the action (O-MI), or imitate the action (O-IMIT). We found that when O-MI was compared to O, activation was enhanced in the ventralpremotor cortex bilaterally, left inferior parietal lobule and left insula. The O-MI and O-IMIT conditions shared many activation foci in motor relevant areas as confirmed by conjunction analysis. These results show that (i) combining observation with motor imagery (O-MI) enhances activation compared to observation-only (O) in the relevant foot motor network and in regions responsible for attention, for control of goal-directed movements and for the awareness of causing an action, and (ii) it is possible to extensively activate the motor execution network using O-MI, even in the absence of overt movement. Our results may have implications for the development of novel virtual reality interactions for neurorehabilitation interventions and other applications involving training of motor tasks