Western Massachusetts Research Articles

Exposure assessment of acetaminophen use in pregnancy: a study comparing self-reported intake with maternal and newborn biomarker measures

Background: Acetaminophen (APAP) is the most commonly used medication during pregnancy. Increasingly, studies have reported potential adverse associations between maternal prenatal use of APAP and offspring asthma, adverse reproductive outcomes, and neurodevelopmental disorders. However, most studies have relied on self-reported maternal exposure which has the potential for exposure misclassifications. We conducted this study to compare maternal self-reported APAP intake and three acetaminophen metabolites measured in urine collected during pregnancy and umbilical cord serum samples. Methods We used maternal interview data and biospecimens from the Nutrition in Pregnancy cohort of 2291 pregnant women recruited from Connecticut and Western Massachusetts during 1996-2000. We selected three exposure groups including 10 mothers who reported frequent intake (14 days+) of APAP in the first 3 months of pregnancy, 10 who reported frequent intake in the last 3 months of pregnancy, and 10 who reported never using APAP in these two periods from the cohort. We analyzed three APAP metabolites (parent compound, acetaminophen glucuronide, and 3-(N-acetyl-l-cystein-S-yl)-acetaminophen) levels in the maternal urine (avg. 24 gestational weeks) and the umbilical cord serum samples. Results The parent APAP compound and 3-(N-acetyl-l-cystein-S-yl)-acetaminophen) were detected in all urine and serum samples analyzed (100%), while acetaminophen glucuronide was less detectable in the cord serum (40% vs. 100% in urine). APAP metabolites in maternal urine and cord serum were correlated (r=0.43-0.70) within mother-child pairs. All three urinary and cord serum APAP metabolite levels were more strongly correlated with the reported number of days of APAP intake in late pregnancy (r=0.57-0.73; p-values <0.03, rank tests), and less with early pregnancy intake (r=0.18-0.34; p-values 0.21-0.60, rank tests). Conclusions Our findings suggest detailed intake data collected in maternal interviews is an efficient and valid measure to indicate exposure to APAP in pregnancy, while biomarker measures can be used to represent a specific exposure period of interest.

Clinician perspectives on pediatric COVID-19 vaccination: A qualitative study in central and western, Massachusetts

We explored perspectives of clinicians in central and western Massachusetts about efforts to vaccinate pediatric patients against COVID-19 as well as best practices and challenges for vaccine delivery. We conducted semi-structured qualitative interviews (n = 16) with family practice and pediatric clinicians between late October and early December 2021. Our interviews addressed: process for vaccination and vaccine promotion, parental receptivity to COVID-19 vaccination, receptivity to other pediatric vaccines, resources needed to support vaccine promotion, and best practices developed to encourage hesitant parents. Using a multi-prong recruitment strategy we invited clinicians to participate in telephone interviews, which were audio-recorded and transcribed. We used rapid qualitative analysis to produce summary templates for each interview which were ultimately combined into a matrix summary. The majority of participants (n = 10) were offering the vaccine in their own clinics, while the remainder cited challenges related to staffing, logistics, and space that prevented them from offering the vaccine. Clinicians reported parents fall into three groups: vaccine-accepting, hesitant but potentially accepting, and refusers. Strategies they identified that worked to encourage hesitant parents were sharing personal vaccine stories, acknowledging parents’ fears about the vaccine, and being persistent with the most hesitant parents. Yet resources are needed including educational materials and training in how to have these conversations. While challenges related to staffing and space will be difficult to overcome for clinics to be able to offer vaccination on-site, our results highlight the importance of developing effective messaging strategies and training clinicians in how to integrate them into routine practice.

Spatial and Nonspatial Factors Associated with Access to Medication for Opioid Use Disorder among Pregnant Women in Massachusetts

Introduction In Massachusetts, one-third of pregnant women with opioid use disorder (OUD) do not receive medications for OUD (MOUD), such as buprenorphine and methadone. Research has demonstrated that broadly, access to medications differs by location and by socioeconomic and geographic characteristics of communities, but a comprehensive understanding at the micro-level is lacking. This study aims to identify and characterize access to MOUD treatment among pregnant women in Massachusetts. Methods We used enhanced two-step floating catchment area analyses, which incorporated supply and demand measures, as well as local drive-time, to determine spatial accessibility to MOUD. We used four publicly available data sources to calculate geographic accessibility to MOUD. We then merged the resulting accessibility indices with data from the American Community Survey to statistically analyze ZIP Code Tabulation Area (ZCTA) characteristics that were associated with geographic accessibility to MOUD among the study population. Results We calculated access to 258 opioid (methadone and/or buprenorphine) treatment programs and 2,585 buprenorphine-waivered prescribers among 74,969 pregnant women during the period 2016–2020 in 448 ZCTAs (N = 537 ZCTAs). ZCTAs with lower accessibility to both types of MOUD were concentrated in Western Massachusetts. Central Massachusetts had poor accessibility to buprenorphine providers. Accessibility was greater in ZCTAs that were nonmetropolitan, that had higher minority status and langauge vulnerability, and that had less extreme concentration of privilege. Conclusions There is a need to improve MOUD access overall, and to enhance access to both types of medications, so pregnant women can choose the one that works best for them.

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Previous article FreeBack CoverPDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreThe Price of FalsehoodsJames Fisk, Jr., was still more original in character. He was not yet forty years of age, and had the instincts of fourteen. He came originally from Vermont, probably the most respectable and correct State in the Union, and his father had been a pedler who sold goods from town to town in his native valley of the Connecticut. The son followed his father’s calling with boldness and success. He drove his huge wagon, made resplendent with paint and varnish, with four or six horses, through the towns of Vermont and Western Massachusetts; and when his father remonstrated at his reckless management, the young man, with his usual bravado, took his father into his service at a fixed salary, with the warning that he was not to put on airs on the strength of his new dignity…..Personally Fisk was coarse, noisy, boastful, ignorant, the type of a young butcher in appearance and mind…. A story not without a stroke of satirical wit was told by him to illustrate his estimate of abstract truth. An old woman who had bought of the elder Fisk a handkerchief which cost ninepence in the New England currency, where six shillings are reckoned to the dollar, complained to Mr. Fisk, Jr., that his father had cheated her. Mr. Fisk considered the case maturely, and gave a decision based on a priori principles. “No!” said he, “the old man would n’t have told a lie for ninepence;” and then, as if this assertion needed some reasonable qualification, he added, “though he would have told eight of them for a dollar!” The distinction as regarded the father may have been just, since the father held oldfashioned ideas as to wholesale and retail trade; but in regard to the son this relative degree of truth cannot be predicated with confidence, since, if the investigating committee of Congress and its evidence are to be believed, Mr. Fisk seldom or never speaks truth at all.[Henry Adams, Historical Essays (London: T. Fisher Unwin, 1891), 323–25]Originally featured on the December 1989 (vol. 97, no. 6) back cover Previous article DetailsFiguresReferencesCited by Journal of Political Economy Volume 130, Number 8August 2022 Article DOIhttps://doi.org/10.1086/721829 Views: 208Total views on this site © 2022 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.

Women-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use Disorder.

Opioid-related fatalities increased exponentially during the COVID-19 pandemic and show little sign of abating. Despite decades of scientific evidence that sustained engagement with medications for opioid use disorders (MOUD) yields positive psychosocial outcomes, less than 30% of people with OUD engage in MOUD. Treatment rates are lowest for women. The aim of this project was to identify women-specific barriers and facilitators to treatment engagement, drawing from the lived experience of women in treatment. Data are provided from a parent study that used a community-partnered participatory research approach to adapt an evidence-based digital storytelling intervention for supporting continued MOUD treatment engagement. The parent study collected qualitative data between August and December 2018 from 20 women in Western Massachusetts who had received MOUD for at least 90 days. Using constructivist grounded theory, we identified major themes and selected illustrative quotations. Key barriers identified in this project include: (1) MOUD-specific discrimination encountered via social media, and in workplace and treatment/recovery settings; and (2) fear, perceptions, and experiences with MOUD, including mental health medication synergies, internalization of MOUD-related stigma, expectations of treatment duration, and opioid-specific mistrust of providers. Women identified two key facilitators to MOUD engagement: (1) feeling “safe” within treatment settings and (2) online communities as a source of positive reinforcement. We conclude with women-specific recommendations for research and interventions to improve MOUD engagement and provide human-centered care for this historically marginalized population.

Application of an Existing Syndromic Surveillance System to Quantify Possible Cases of Opioid-associated Amnestic Syndrome in Massachusetts.

In recent years, an opioid-associated amnestic syndrome (OAS) was identified in Massachusetts through elicited reporting by health care providers (traditional surveillance, TS). Whether OAS occurs more frequently and with a wider spatiotemporal distribution in Massachusetts remains unclear. We compared the frequency and spatiotemporal characteristics of emergency department (ED) visits for possible OAS (pOAS) using a pre-existing syndromic surveillance system (SyS) with OAS cases captured through TS. SyS was queried for Massachusetts ED visits in 15- to 55- year-olds with a chief complaint text and discharge codes for memory loss in association with codes for opioid use (pOAS). SyS data were extracted for 2016-2020, whereas TS was conducted for 2012-2018. Cases identified by SyS and TS were stratified by demographic and spatiotemporal variables. TS ascertained 22 reported cases of OAS (18 males) between 2012 and 2018, ranging from 0 to 5 annually. No identified OAS patients presented between January and March or in western Massachusetts. Between 2016 and 2020, SyS identified 82 ED visits (49 males) with pOAS, ranging from 13 to 22 per year. Over the 5-year period, at least 2 ED visits for pOAS occurred during each month of the year (24 total during January, February, or March) and at least 1 visit occurred in each county except 2, with the second largest number (11) in Berkshire County (at the western border of Massachusetts), where no cases were ascertained through TS. Although OAS is a relatively rare condition, use of SyS in Massachusetts suggests a broader and more frequent spatiotemporal distribution than previously indicated from TS.

Factors Associated with Risk of Perinatal Depressive Symptoms Among Puerto Rican Women with Hyperglycemia.

Rates of perinatal depression and pregnancy hyperglycemia are higher in Hispanic women as compared to non-Hispanic white women. In turn, depressive symptoms may reduce a woman's ability to engage in lifestyle changes that could reduce their subsequent diabetes risk. We conducted a secondary analysis using data from Estudio Parto to evaluate sociodemographic, behavioral, psychosocial, and medical factors associated with perinatal depressive symptoms. Estudio Parto was a randomized controlled trial conducted in Western Massachusetts from 2013 to 17. Eligible participants had pregnancy hyperglycemia. The Edinburgh Postnatal Depression Scale (EPDS) was administered at 24-28weeks gestation and at 6weeks, 6months, and 12months postpartum. An EPDS cutpoint of 10 or greater defined the presence of depressive symptoms. In this sample of Puerto Rican women with pregnancy hyperglycemia, 32% and 27% showed prenatal and postpartum depressive symptoms, respectively. Among participants, 35.5% were diagnosed with GDM, 44.3% with isolated hyperglycemia, and 20.2% with impaired glucose tolerance. In multivariable models, being unmarried (OR 3.87; 95% CI 1.51-9.94), prenatal substance use (smoking or alcohol consumption; OR 2.96; 95% CI 1.41-6.18), and maternal age (1.11 for each year; 95% CI 1.04-1.18) were associated with higher odds of prenatal depressive symptoms. None of the risk factors were associated with subsequent postpartum depression in adjusted analyses. Identifying factors associated with prenatal and postpartum depression in Puerto Rican women with pregnancy hyperglycemia can inform targeted lifestyle interventions in this at-risk group, increase the likely adoption of healthy lifestyle behaviors, and thereby work to address health disparities. gov NCT01679210; date of registration 08/07/2012.

Gaining wisdom from enduring inequities.

When it comes to discussing gender and racial inequities, I cringe and pray that my 10-year-old daughter doesn’t go through the biases and microaggressions I endured since I moved to the United States for college. I was born in New Jersey to a doctor and nurse who emigrated to the United States in the mid-1960s for work, and then moved back to their birth country (the Philippines) in 1971 to start their own medical clinic when I was barely a year old. As a second child and only daughter of four children growing up in a patriarchal society, I can say I wasn’t very assertive by nature. Although I grew up with a fervent disposition as a hardworking, ambitious A-student, I found myself in unexpected circumstances that led me to joyfully accept motherhood to my one and only son at the young age of 19. With the help of a generous financial aid package, I persevered to finish my BA in Biology, with a minor in Chemistry, on the pre-medicine track at Mount Holyoke College, an all-women's college in Western Massachusetts as a nontraditional student in their Frances Perkins Program. As a college graduate yearning to spend missed time with her 4-year-old son, I answered a newspaper ad looking for a Research Assistant and landed my first job in the biopharmaceutical industry in hopes of gaining research experience and a decent salary enough to sustain a family of two. Little did I know that I would love the culture of scientific research and the thrill of the chase in drug discovery for neurological and inflammatory diseases. I would stay in the industry for 15 years, honing my research skills between three Connecticut biotech and pharmaceutical companies. This career path enabled me to be the best parent I could be and to support my son through grade school and all the way through college.

A Preliminary Study of Foraging Habitat Use by Nesting Barn Swallows in Massachusetts

Hirundo rustica (Barn Swallow) belongs to a suite of aerial insectivores that are showing serious population declines in northeastern North America. Various causes of these declines have been postulated, especially including agricultural intensification, declining insect populations, and/or increased mortality associated with climate changes. In this study, we examined foraging behavior of Barn Swallows nesting in a large breeding colony located in western Massachusetts. Swallows foraged primarily within 1 km of their nesting site. Most of the nearby agricultural areas used by foraging swallows were broadly characterized as pasture/hay or cultivated land uses; we found no significant difference in foraging activity levels between these habitat categories. In addition to the availability of suitable nesting structures, successful conservation of Barn Swallows likely requires that breeding colonies have access to nearby fields which provide foraging opportunities. Further study is needed to clarify specific habitat management that will enhance populations of flying insects preyed upon by swallows and other aerial insectivores.

Subjects for Ignatian Meditation on Matthew 17

Subjects for Ignatian Meditation on Matthew 17 Megan McDermott (bio) what the high mountain looks likeagainst the sky and what they all saidon their way up to it, what they thoughtthey were going to do there what transfiguration really looks likeor feels like on the eyes, whetherthe light triggered migraines for oneor caused another to hold a hand,like a visor, to his brow what Moses, Jesus, and Elijah even talked about how God's voice sounds,loud, unavoidable, or its morefamiliar form, tiny and tremulous when when, finally, Jesus will touch me [End Page 129] Megan McDermott Megan McDermott is a poet and Episcopal priest living in Western Massachusetts. She is the author of chapbooks Prayer Book for Contemporary Dating and Woman as Communion as well as the forthcoming full-length collection Jesus Merch: A Catalog in Poems. Megan discovered passions for both poetry and preaching at Susquehanna University, in her home state of Pennsylvania, and continued her studies of religion and the arts at the Yale Institute of Sacred Music. megan.mcdermott1@comcast.net. Copyright © 2022 Johns Hopkins University Press

Successes and Lessons Learned From Age-Friendly Community Collaborations: Baystate Health GWEP

Baystate is the largest health system in Western Massachusetts with 4 hospitals, 3 Community Health Centers (CHCs) and a large primary care network. Baystate Medical Center (BMC) is in Springfield, Massachusetts. BMC and the CHCs were the first health care sites nationally to be recognized by the Institute for Healthcare Improvement as “Committed to Care Excellence” in the age friendly movement. Collaboration with a city-wide coalition of community-based organizations led to simultaneous recognition of Baystate as “age friendly” and recognition of the city as both dementia and age friendly. The 3 awards were presented at a Springfield senior center with media coverage and the participation of the mayor and other political leaders. This collaboration persists and the GWEP and coalition partners continue to participate in multiple joint educational and community outreach projects. As a result, the city coalition has added health care to its initial focus on housing and transportation.

The importance of oxbow lakes in the floodplain storage of pollutants

Abstract Oxbow lakes are important stores for fine-grained sediment, which potentially makes them critical sinks for sediment-associated pollutants. We leverage an exhaustive public archive of coring data, supplemented by our data collection, to provide a quantitative assessment of the role of oxbows as off-channel sinks. We investigated loading trends of sediment-sorbed polychlorinated biphenyls (PCBs) within oxbows of the Housatonic River, an actively meandering river in western Massachusetts, USA. Our results reveal the efficiency of oxbows as sinks, with average PCB concentrations (14.8 ppm) that are nearly twice that of the surrounding floodplain (7.56 ppm). Even though the 5.83 km2 floodplain is the largest sink of PCB-laden material, storing as much as 14.1 t of PCBs or 2.42 g m−2, oxbows store more than 20% of all PCBs (3.63 t of PCBs or 11.2 g m−2) while making up just over 5% of the floodplain surface area. Nearly 85% of the oxbow storage of PCBs occurs within the first 50 m of floodplain, making clear the significance of regular oxbow production to the off-channel storage of sediment-associated pollutants.

471. Descriptive Analysis of Multiinflammatory Syndrome in Children (MIS-C) Secondary to COVID 19 Infection in a Predominantly Latino Population in Western Massachusetts

BackgroundCOVID-19 infection is usually mild in children. Progression to severe disease with multiple organ systems compromise described as Multi Inflammatory Syndrome in Children (MIS-C) is a rare occurrence believed to be immunologically mediated. Previous reports describe a possible link between children of Latino origin and high incidence of MIS-C in the US. 40% of the total population in Western Massachusetts is of Latino origin. MethodsRetrospective chart review of 30 children admitted to Baystate Medical Center in Springfield, Massachusetts from April 2020-June 2021 meeting Centers for Disease Control and Prevention (CDC) criteria for MIS-C. Demographics, laboratory data, and clinical outcomes including progression to Macrophage Activation Syndrome (MAS) were analyzed.Results60% of children were Hispanic. Mean age (9.1 yrs). Range (3m-20 yrs). COVID PCR positive (78%) and COVID Antibody positive (68%). The most common symptom was fever (96.8%) followed by gastrointestinal symptoms (84%). Respiratory symptoms (29%), dermatological manifestations (39%). Most common comorbidity, asthma (19%) followed by obesity (17%). Leukocytosis (47%), lymphopenia (45%), Anemia (55%), thrombocytopenia (20%), high CRP (90%), ferritinemia (57%), acute kidney injury (20%), elevated liver enzymes (53%), 52% children had electrocardiogram (EKG) abnormalities, 34% had abnormal echocardiograms, none displayed coronary artery dilation. Progression to MAS (20%). All patients were treated with intravenous immunoglobulin G, steroids, aspirin, and anakinra (IL1 receptor antagonist) if progression to MAS. All patients survived.ConclusionIn our population, gastrointestinal symptoms were predominant despite a high prevalence of asthma and obesity, previous reports of children with MIS-C describe predominance of respiratory manifestations. We did not encounter any coronary aneurysms during admission. Most children had positive PCR or Antibodies for COVID 19 and showed important abnormalities in multiple cell lines and inflammatory markers. More research is needed to fully understand ethnical risk factors associated with disease severity especially the risk of progression to MAS from MIS-C in children of Latino origin diagnosed with COVID 19 infection.Disclosures All Authors: No reported disclosures

674. Evaluation of the Access Bio CareStart™ Rapid SARS-CoV-2 Antigen Test in Asymptomatic Individuals Tested at a Community Mass-testing Program in Western Massachusetts

Abstract Background Point-of-care antigen-detecting rapid diagnostic tests (RDTs) to detect Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) represent a scalable tool for surveillance of active SARS-CoV-2 infections in the population. Data on the performance of these tests in real-world community settings will be paramount for their implementation to combat the COVID-19 pandemic. Methods We evaluated the performance characteristics of the CareStartTM COVID-19 Antigen Test (CareStart) in a community testing site in Holyoke, Massachusetts. We compared CareStart to a SARS-CoV-2 reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) reference, both using anterior nasal swab samples. We calculated the sensitivity, specificity, and the expected positive and negative predictive values at different SARS-CoV-2 prevalence estimates. Results We performed 666 total tests on 591 unique individuals. 573 (86%) were asymptomatic. There were 52 positive tests by RT-qPCR. The sensitivity of CareStart was 49.0% (95% Confidence Interval (CI): 34.8 – 63.4) and specificity was 99.5% (95% CI: 98.5 – 99.9). Among positive RT-qPCR tests, the median cycle threshold (Ct) was significantly lower in samples that tested positive on CareStart. Using a Ct less than or equal to 30 as a benchmark for positivity increased the sensitivity of the test to 64.9% (95% CI: 47.5 – 79.8). Performance characteristics of CareStart test results benchmarked against the RT-qPCR gold standard (excluding undetermined results). Examples of images of CareStart rapid test showing variable band intensities. N2 gene RT-qPCR Cycle threshold (Ct) values corresponding to positive and negative CareStart rapid antigen test results for all RT-qPCR positive samples (n=52). Conclusion Our study shows that CareStart has a high specificity and moderate sensitivity. The utility of RDTs, such as CareStart, in mass implementation should prioritize use cases in which a higher specificity is more important, such as triage tests to rule-in active infections in community surveillance programs. Disclosures All Authors: No reported disclosures

Covid Conversations 4: Stacy Klein

The ecology of the rural setting in which Double Edge Theatre lives and works is as integral to its artistic work as to its principles of social justice, and these qualities mark the ensemble’s singular profile not only in the United States but also increasingly on the world theatre map. Stacy Klein co-founded the company in Boston in 1982 as a women’s theatre with a defined feminist programme. In 1997, Double Edge moved its work space to a farm that Klein had bought in Ashfield, Massachusetts, commuting from there back to Boston to show its productions. Within a few years, Klein and her collaborators were acutely aware of their separation from the local community, which necessitated a change of perspective to encompass personal and creative engagement with local people and to develop audiences within the area, while not losing sight of their international links. Carlos Uriona, formerly a popular-theatre activist from Argentina, had joined Double Edge and facilitated the local immersion that ultimately became its lifeline, most visibly during the Covid-19 pandemic, as Klein here observes. Klein, who had been a student of Rena Mirecka in Poland (starting in 1976), has maintained her friendship and professional relations with this founding member of the Teatr Laboratorium led by Jerzy Grotowski, inviting Mirecka to run wokshops at the Double Edge Farm. Collaboration with Gardzienice (also from the Grotowski crucible) through the Consortium of Theatre Practices (1999–2001) extended Klein’s Polish connections. She expanded her research on community cultures in Eastern and Central Europe and developed these experiences in her probing, distinctly imaginative explorations of theatre-making, while taking a new approach to participatory theatre-making in Ashfield. Her highly visual and sensual compositions are driven by her sense of the fantastic, no more strikingly so than in Klein’s Summers Spectacles, which are performed outdoors, in concert with the Farm’s natural environment – fields, trees, water, birds, animals, and heaven’s firmament. Double Edge’s profound commitment in the past decade to what it now terms ‘living culture’ and ‘art justice’ has taken root in multiracial collaborations, primarily with the indigenous peoples of Western Massachusetts. This Conversation took place on the winter solstice, 21 December 2020, a date that Maria Shevtsova, Editor of NTQ, had chosen symbolically. It was transcribed by Kunsang Kelden and edited by Shevtsova. Many thanks are extended to Travis Coe of Double Edge for assembling with such loving care the photographs requested.

First Records of Perdita bequaerti (Hymenoptera: Andrenidae) from New England

We document the first New England records of the bee Perdita bequaerti Viereck. Perdita bequaerti is a specialist on Asteraceae flowers, especially Helianthus, and is native to much of eastern North America, where it is often associated with predominantly sandy habitats. Previous records indicated P. bequaerti reached the northeastern extent of its range in the state of New York, but in August 2019, during a survey of bees on Helianthus, we collected five specimens of P. bequaerti at two sites in western Massachusetts. Both sites were located on small-scale farms with abundant non-native Helianthus, on soils characteristic of sandy outwash plains and silty floodplains. These records constitute an extension of P. bequaerti's known range into New England.

Structure, Chronology, and Local Social Meaning of a Supra-Local Vowel Shift: Emergence of the Low-Back-Merger Shift in New England

AbstractThe Low-Back-Merger Shift (LBMS) is a major North American vowel chain shift spreading across many disparate dialect regions. In this field-based study, we examine the speech of fifty-nine White Western Massachusetts speakers, aged 18–89. Using diagnostics in Becker (2019) and Boberg (2019b), we find the LBMS emerging at the expense of the Northern Cities Shift (Labov, Yaeger, & Steiner, 1972) and traditional New England features (Boberg, 2001; Kurath, 1939; Nagy & Roberts, 2004). In Becker's LBMS model (2019:9), the low-back merger (lot-thought) triggers front-vowel shifts. Our results suggest that local social meaning can sometimes override this chronology such that the front-vowel shifts occur before the low-back merger, even as the overall configuration comes to match Becker's predictions. Sociosymbolic meaning associated with the older New England system has led to a different temporal ordering of LBMS components, thus providing new theoretical and empirical insights into the mechanisms by which supralocal patterns are adopted.

System Integration: Managing Complexity to Advance Health Care Value

Summary Most American hospitals are now part of multihospital systems, and most physicians are now employed by hospitals or large group practices. Payment for care is slowly shifting from fee-for-service to value-based contracts that encourage a holistic approach to care. These fundamental changes have created complex integrated health care systems that operate under new financial imperatives and have introduced corresponding complexities in all areas: clinical, operational, and financial. Baystate Health is the dominant health delivery system in western Massachusetts and also covers a significant percentage of the population as a payer. Baystate’s CEO discusses how it has created an effective continuum of care through ownership, partnership, and innovative relationships with physicians and how it has addressed the management challenges inherent in integrating an organization that is not just greater than, but also fundamentally different from, the sum of its parts.

Effect of RAP and virgin binder source on low-temperature PG reliability

ABSTRACT MassDOT is evaluating the potential of increasing the RAP content in their asphalt surface layers from 15% RAP to 20–25% RAP while keeping the virgin binder PG fixed at PG64-28. However, each RAP can have different properties such as binder PG and binder content and can include highly aged binders. Thus, using some RAPs without changing the virgin binder PG could lead to blended binders with unacceptable low-temperature PGs even at low RAP contents. In this study, RAP binders and virgin binders were sampled from around Massachusetts. The low-temperature continuous PGs of both binders were measured. An AASHTO blending equation was used to determine the low-temperature continuous PGs of blended binders based on using 15% and 25% RAP binder contents. An LTPPbind equation was then used to calculate the standard normal distribution Z, which provides the reliability that a blended binder will meet the low temperature PG required at a specific geographic location. The results showed the high impact of RAP source, RAP binder content, virgin binder source, and geographic location on low-temperature PG reliability, and that keeping the virgin binder PG fixed at PG64-28 may not always provide binders suitable for western and northern Massachusetts.

Clinician Wellness—Self-Care for Staying Healthy: Implementation of a Wellness Calendar and Programming for Health Care Workers in Response to COVID-19

Clinician Wellness—Self-Care for Staying Healthy: Implementation of a Wellness Calendar and Programming for Health Care Workers in Response to COVID-19