Janet M. Townsend

The Residency Program in Social Medicine of Montefiore Medical Center: 37 Years of mission-driven, interdisciplinary training in primary care, population health, and social medicine

Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center, Bronx, New York, has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission. The RPSM was a model for federal funding for primary care residency programs and has received Title VII grants during most of its history. The RPSM has tailored its mission and structured its curriculum to promote a community and population orientation and to provide the requisite knowledge and skills for integrating social medicine into clinical practice. Six unique hallmarks of RPSM training are (1) mission-oriented resident recruitment/selection and self-management, (2) interdisciplinary collaborative training among primary care professionals, (3) community-health-center-based and community-oriented primary care education, (4) biopsychosocial and ecological family systems curriculum, (5) the social medicine core curriculum and projects, and (6) grant support through Title VII. These hallmark curricular, training, and funding elements, in which population health is deeply embedded, have been carefully evaluated, regularly revised, and empirically validated since the programs inception. Practice outcomes for RPSM graduates as leaders in and advocates for population health and the care of underserved communities are described and discussed in this case study.

A Randomised Trial to Evaluate the Effects of Low‐dose Aspirin in Gestation and Reproduction: Design and Baseline Characteristics

BACKGROUND Low-dose aspirin (LDA) has been proposed to improve pregnancy outcomes in couples experiencing recurrent pregnancy loss. However, results from studies of LDA on pregnancy outcomes have been inconsistent, perhaps because most studies evaluated LDA-initiated post-conception. The purpose of the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial was to determine whether preconception-initiated LDA improves livebirth rates in women with one to two prior losses. METHODS We performed a multicentre, block randomised, double-blind, placebo-controlled trial. Study participants were recruited using community-based advertisements and physician referral to four university medical centres in the US (2006-12). Eligible women were aged 18-40 years actively trying to conceive, with one to two prior losses. Participants were randomised to receive daily LDA (81 mg/day) or a matching placebo, and all were provided with daily 400-mcg folic acid. Follow-up continued for ≤6 menstrual cycles while attempting to conceive. For those who conceived, treatment was continued until 36 weeks gestation. The primary outcome was the cumulative livebirth rate over the trial period. RESULTS There were 1228 women randomised (615 LDA, 613 placebo). Participants had a mean age of 28.7, were mostly white (95%), well educated (86% more than high school education), and employed (75%) with a household income >

The effect of a very short interpregnancy interval and pregnancy outcomes following a previous pregnancy loss.

100 000 annually (40%). The characteristics of those in the treatment and placebo arms were well balanced. CONCLUSIONS We describe the study design, recruitment, data collection, and baseline characteristics of participants enrolled in EAGeR, which aimed to determine the effect of LDA on livebirth and other pregnancy outcomes in these women.

Sex ratio following preconception low-dose aspirin in women with prior pregnancy loss

OBJECTIVE We sought to assess the relationship between a short interpregnancy interval (IPI) following a pregnancy loss and subsequent live birth and pregnancy outcomes. STUDY DESIGN A secondary analysis of women enrolled in the Effects of Aspirin in Gestation and Reproduction trial with a human chorionic gonadotropin-positive pregnancy test and whose last reproductive outcome was a loss were included in this analysis (n = 677). IPI was defined as the time between last pregnancy loss and last menstrual period of the current pregnancy and categorized by 3-month intervals. Pregnancy outcomes include live birth, pregnancy loss, and any pregnancy complications. These were compared between IPI groups using multivariate relative risk estimation by Poisson regression. RESULTS Demographic characteristics were similar between IPI groups. The mean gestational age of prior pregnancy loss was 8.6 ± 2.8 weeks. The overall live birth rate was 76.5%, with similar live birth rates between those with IPI ≤3 months as compared to IPI >3 months (adjusted relative risk [aRR], 1.07; 95% confidence interval [CI], 0.98-1.16). Rates were also similar for periimplantation loss (aRR, 0.95; 95% CI, 0.51-1.80), clinically confirmed loss (aRR, 0.75; 95% CI, 0.51-1.10), and any pregnancy complication (aRR, 0.88; 95% CI, 0.71-1.09) for those with IPI ≤3 months as compared to IPI >3 months. CONCLUSION Live birth rates and adverse pregnancy outcomes, including pregnancy loss, were not associated with a very short IPI after a prior pregnancy loss. The traditional recommendation to wait at least 3 months after a pregnancy loss before attempting a new pregnancy may not be warranted.

One Last Question: Opening Pandora's Box?

BACKGROUND Several lines of evidence suggest that male embryos may have greater vulnerability than female embryos to disordered inflammation; therefore, antiinflammatory drugs, such as low-dose aspirin (LDA), may alter the sex ratio. Here, we assessed the effect of LDA on male live birth and male offspring, incorporating pregnancy losses (n = 56) via genetic assessment, as part of a parallel-design, block-randomized, placebo-controlled trial of preconception LDA. METHODS Participants (615 treated with LDA, 613 treated with placebo) ranged in age from 18 to 40 years of age, with 1 to 2 prior pregnancy losses. We estimated the intention-to-treat (ITT) risk ratio (RR) and 95% CI and assessed interaction with baseline high-sensitivity C-reactive protein (hsCRP) serum concentration - a marker of systemic inflammation. RESULTS Among the 1,078 women who completed follow-up (535 treated with LDA, 543 treated with placebo), the male live birth ITT RR equaled 1.31 (95% CI: 1.07-1.59). With increasing tertile of hsCRP, the proportion of males at birth decreased in the placebo group, and the effect of LDA on male live birth increased (first tertile: 48% male in LDA vs. 52% in placebo, ITT RR = 0.97, 95% CI: 0.70-1.35; second tertile: 57% male in LDA vs. 43% in placebo, ITT RR = 1.36, 95% CI: 0.98-1.90; third tertile: 53% male in LDA vs. 35% in placebo, ITT RR = 1.70, 95% CI: 1.13-2.57; P interaction = 0.03). Analysis of pregnancy with male offspring yielded similar results. CONCLUSION Initiation of LDA prior to conception restored numbers of male live births and pregnancy with male offspring among women with 1 to 2 prior pregnancy losses. Moreover, our data suggest that LDA modulates inflammation that would otherwise reduce the conception or survival of male embryos. TRIAL REGISTRATION ClinicalTrials.gov NCT00467363. FUNDING Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health.

Recruitment for longitudinal, randomised pregnancy trials initiated preconception: lessons from the effects of aspirin in gestation and reproduction trial.

Family physicians are oriented and trained to inquire about the meaning of patients’ symptoms and to recognize when major concerns or worry are present. Yet, in the context of busy practices and the many interruptions of our workday, we may concentrate too much on efficiency in conducting visits and completing tasks for patients, with a resulting narrow focus on the medical or biological aspects of the patient’s complaint. This essay tells the story of 2 patient encounters in which I, an experienced family physician, almost missed noticing deep fears experienced by each patient. These experiences led me to reflect on the contextual, patient, and personal factors that can get in the way of recognizing and reaching a deeper understanding of patients’ worries, and on the power we have to assuage fears when we address them directly instead of hesitating to open Pandora’s box.

Preconception low-dose aspirin and pregnancy outcomes: Results from the EAGeR randomised trial

BACKGROUND Recruitment into large, preconception randomised clinical trials (RCT) is challenging. We describe clinic and community-based preconception recruitment strategies for the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial and highlight approaches that were and were not successful. This longitudinal RCT was conducted at four major sites in the US. Eligible women had one to two prior pregnancy losses and were actively trying to become pregnant. METHODS Provider/clinic and community-based outreach strategies were utilised, and the recruitment rate and costs of methods were assessed. RESULTS A screening questionnaire was completed by 5485 women; 42.4% (n = 2323) screened were initially eligible, of whom 50.7% (n = 1228) were randomised. Provider/clinic-based recruitment yielded the highest number eligible of those screened (30.1%) and also the most randomised participants overall (40.3%). The next highest yield came from direct mail and brochures/flyers at 13.1% and 12.5% of women randomised, respectively. However, direct mailings cost

Preconception low-dose aspirin and pregnancy outcomes: results from the EAGeR randomised trial.

720 per participant randomised. Other than word of mouth, provider/clinic-based recruitment was the most cost effective method, costing an average of

Public Health and Medical Education A Natural Alliance for a New Regional Medical School

60 per randomised participant. Web-based recruitment yielded 4.7% of participants at a cost of

Graduate Primary Care Training: A Collaborative Alternative for Family Practice, Internal Medicine, and Pediatrics

278 per randomised participant. CONCLUSIONS Provider and clinic-based recruitment was the most effective and cost-efficient method of recruitment in a preconception intervention study of reproduction among women.