Lyme disease is a spatially heterogeneous tick-borne infection, with approximately 85% of US cases concentrated in the mid-Atlantic and northeastern states. Surveillance for Lyme disease and its causative agent, including public health case reporting and entomologic surveillance, is necessary to understand its endemic range, but currently used case detection methods have limitations. To evaluate an alternative approach to Lyme disease surveillance, we have performed a geospatial analysis of Lyme disease cases from the Johns Hopkins Health System in Maryland. We used two sources of cases: a) individuals with both a positive test for Lyme disease and a contemporaneous diagnostic code consistent with a Lyme disease-related syndrome; and b) individuals referred for a Lyme disease evaluation who were adjudicated to have Lyme disease. Controls were individuals from the referral cohort judged not to have Lyme disease. Residential address data were available for all cases and controls. We used a hierarchical Bayesian model with a smoothing function for a coordinate location to evaluate the probability of Lyme disease within 100 km of Johns Hopkins Hospital. We found that the probability of Lyme disease was greatest in the north and west of Baltimore, and the local probability that a subject would have Lyme disease varied by as much as 30-fold. Adjustment for demographic and ecological variables partially attenuated the spatial gradient. Our study supports the suitability of electronic medical record data for the retrospective surveillance of Lyme disease.

Historical applications of manures and fertilizers at rates exceeding crop P removal in the Mid-Atlantic region (United States) have resulted in decades of increased water quality degradation from P losses in agricultural runoff. As such, many growers in this region face restrictions on future P applications. An improved understanding of the fate, transformations, and availability of P is needed to manage P-enriched soils. We paired chemical extractions (i.e., Mehlich-3, water extractable P, and chemical fractionation) with nondestructive methods (i.e., x-ray absorption near edge structure [XANES] spectroscopy and x-ray fluorescence [XRF]) to investigate P dynamics in eight P-enriched Mid-Atlantic soils with various management histories. Chemical fractionation and XRF data were used to support XANES linear combination fits, allowing for identification of various Al, Ca, and Fe phosphates and P sorbed phases in soils amended with fertilizer, poultry litter, or dairy manure. Management history and P speciation were used to make qualitative comparisons between the eight legacy P soils; we also speculate about how P speciation may affect future management of these soils with and without additional P applications. With continued P applications, we expect an increase in semicrystalline Al and Fe-P, P sorbed to Al (hydro)oxides, and insoluble Ca-P species in these soils for all P sources. Under drawdown scenarios, we expect plant P uptake first from semicrystalline Al and Fe phosphates followed by P sorbed phases. Our results can help guide management decisions on coastal plain soils with a history of P application.

OBJECTIVE: The study aimed to characterize the experiences of primary caregivers of children with medical complexity (CMC) in engaging with other members of the child\'s caregiving network, thereby informing the design of health information technology (IT) for the caregiving network. Caregiving networks include friends, family, community members, and other trusted individuals who provide resources, information, health, or childcare.
METHODS: We performed a secondary analysis of two qualitative studies. Primary studies conducted semi-structured interviews (n = 50) with family caregivers of CMC. Interviews were held in the Midwest (n = 30) and the mid-Atlantic region (n = 20). Interviews were transcribed verbatim for thematic analysis. Emergent themes were mapped to implications for the design of future health IT.
RESULTS: Thematic analysis identified 8 themes characterizing a wide range of primary caregivers\' experiences in constructing, managing, and ensuring high-quality care delivery across the caregiving network.
CONCLUSIONS: Findings evidence a critical need to create flexible and customizable tools designed to support hiring/training processes, coordinating daily care across the caregiving network, communicating changing needs and care updates across the caregiving network, and creating contingency plans for instances where caregivers are unavailable to provide care to the CMC. Informaticists should additionally design accessible platforms that allow primary caregivers to connect with and learn from other caregivers while minimizing exposure to sensitive or emotional content as indicated by the user.
CONCLUSIONS: This article contributes to the design of health IT for CMC caregiving networks by uncovering previously underrecognized needs and experiences of CMC primary caregivers and drawing direct connections to design implications.

A bloom of Karenia papilionacea that occurred along the Delaware coast in late summer of 2007 was the first Karenia bloom reported on the Delmarva Peninsula (Delaware, Maryland, and Virginia, USA). Limited spatial and temporal monitoring conducted by state agencies and citizen science groups since 2007 have documented that several Karenia species are an annual component of the coastal phytoplankton community along the Delmarva Peninsula, often present at background to low concentrations (100 to 10,000 cells L-1). Blooms of Karenia (> 105 cells L-1) occurred in 2010, 2016, 2018, and 2019 in different areas along the Delmarva Peninsula coast. In late summer and early autumn of 2017, the lower Chesapeake Bay experienced a K. papilionacea bloom, the first recorded in Bay waters. Blooms typically occurred summer into autumn but were not monospecific; rather, they were dominated by either K. mikimotoi or K. papilionacea, with K. selliformis, K. brevis-like cells, and an undescribed Karenia species also present. Cell concentrations during these mid-Atlantic Karenia spp. blooms equalled concentrations reported for other Karenia blooms. However, the negative impacts to environmental and human health often associated with Karenia red tides were not observed. The data compiled here report on the presence of multiple Karenia species in coastal waters of the Delmarva Peninsula detected through routine monitoring and opportunistic sampling conducted between 2007 and 2022, as well as findings from research cruises undertaken in 2018 and 2019. These data should be used as a baseline for future phytoplankton community analyses supporting coastal HAB monitoring programs.

With loss of wetlands and their associated ecosystem services within landscapes, it is imperative to be able to understand the change in ecological functions underlying these services. Field-based functional assessments can produce a range of specific scores among a robust set of functions but are time and cost prohibitive as the number of wetlands assessed increases. Remote-based functional assessments are an alternative for broad scale assessments, but trade-off cost for limitations in scoring and functional assemblage. To address these concerns, we created a framework for the development of the Hydrogeomorphic Remote Assessment of Wetland Function (HGM-RAWF). Rooted in the hydrogeomorphic approach of an existing field-based functional assessment and its underlying models, this remote functional assessment substitutes field-based assessment methods with remotely assessed proxies. As potential remote proxies were determined through literature review and statistically screened for use in the remote assessment, a field-based reference wetland database of 222 freshwater wetlands in the Mid-Atlantic Region provided a baseline by which remote data could be compared and calibrated. The resulting HGM-RAWF protocol remotely assesses seven hydrology and biogeochemistry functions in the Mid-Atlantic with assessment scores similar to its field-based counterparts. With noted limitations, the HGM-RAWF framework provides the means to create desktop functional assessments across broad geographic scales with the diversity and specificity of field-based assessments at the reduced costs associated with remote assessments. Its basis in the HGM approach and use of public spatial datasets allows the framework to be adopted regionally and can be used as a model for national wetland functional assessment.

The 2015 \"Paris Agreement\" aims to limit the global average temperature rise to significantly less than 2 °C, preferably within 1.5 °C above pre-industrial levels. A multitude of studies have focused on evaluating how different sectors respond to such levels of warming. Nonetheless, most of these studies fail to provide a clear roadmap to mitigate these impacts. A case in point is the anticipated decline in corn and soybean yields and increased phosphorus (P) and nitrogen (N) discharge into water bodies, a trend linked to past agricultural practices and climate change. In this research, we employ a novel assessment of how existing management practices under 1.5 °C and 2 °C global warming (GW) scenarios can affect nutrient availability in time and space as well as crop yield in a typical agricultural watershed in the Mid-Atlantic Region, specifically the Upper Maurice River Watershed (UMRW) in New Jersey. Using the Soil and Water Assessment Tool (SWAT) with multiple Global Climate Model (GCM) projections, we found that compared to 1.5 °C, a 2 °C GW scenario would exacerbate runoff, leading to amplified nutrient leaching. These losses decrease nutrient availability during the crop growing season. Moreover, a mismatch between the timing of fertilizer application and crop nutrient absorption caused nutrient-related stress. This nutrient and anticipated temperature stress resulted in a more significant decrease in crop yields under the 2 °C GW scenario than the 1.5 °C scenario. We have designed a management scenario to reduce future nutrient losses while increasing crop yields. The strategy involves altering the timing of planting/harvesting and the fertilizer application rate in response to a warming climate. This approach is projected to increase corn and soybean yields by +39 % (+21 %) and +2 % (+17 %), respectively, under the 1.5 °C (2.0 °C) GW scenario for the RCP-4.5 pathway. Simultaneously, it is expected to decrease the N and P loads at 1.5 °C (2.0 °C) GW. Comparable projections are also observed under the RCP-8.5 pathway.

Racial disparities in school discipline may have collateral consequences on the larger non-suspended student population. The present study leveraged two longitudinal datasets with 1201 non-suspended adolescents (48% Black, 52% White; 55% females, 45% males; Mage : 12-13) enrolled in 84 classrooms in an urban mid-Atlantic city of the United States during the 2016-2017 and 2017-2018 academic years. Classmates\' minor infraction suspensions predicted greater next year\'s defiant infractions among non-suspended Black adolescents, and this longitudinal relation was worse for Black youth enrolled in predominantly Black classrooms. For White youth, classmates\' minor infraction suspensions predicted greater defiant infractions specifically when they were enrolled in predominantly non-White classrooms. Racial inequities in school discipline may have repercussions that disadvantage all adolescents regardless of race.

OBJECTIVE: To examine the microbial distribution and antimicrobial susceptibility of culture-positive microbial keratitis at a large tertiary referral center in the mid-Atlantic region of the United States.
METHODS: Retrospective review of culture-positive microbial keratitis cases at the Wilmer Eye Institute from 2016 through 2020.
RESULTS: Of the 474 culture-positive microbial keratitis cases, most were bacterial (N=450, 94.9%), followed by fungal (N=48, 10.1%) and Acanthamoeba keratitis (N=15, 3.1%). Of the 450 bacterial isolates, 284 (69.5%) were gram-positive organisms, whereas 157 (28.4%) were gram-negative organisms. The most common bacterial species isolated was coagulase-negative Staphylococcus spp (N=154, 24.8%), and the most common gram-negative isolate was Pseudomonas aeruginosa (N=76, 12.3%). Among fungi, the most common isolates were Candida (N=25, 45.4%), whereas Fusarium (N=6, 10.9%) and Aspergillus (N=3, 5.5%) were less common. Of the 217 bacterial isolates tested for erythromycin susceptibility, 121 (55.7%; ∼60% of coagulase-negative staphylococci and corynebacteria tested) showed resistance to erythromycin.
CONCLUSIONS: Microbial keratitis in the Baltimore Mid-Atlantic region of the United States is most commonly caused by bacteria, with fungi and acanthamoeba being less common. Gram-positive bacterial infections predominate. Among fungal keratitis cases, Candida species are more commonly encountered than are filamentous species. Use of erythromycin as infection prophylaxis should be reexamined. Findings from our study may guide empiric treatment in this geographic region.

The COVID-19 pandemic has disrupted traditional health care, including pediatric health care. We described the impact of the pandemic on disparities in pediatric health care engagement.
Using a population-based cross-sectional time-series design, we compared monthly ambulatory care visit volume and completion rates (completed vs no-show and cancelled visits) among pediatric patients aged 0-21 years in 4 states in the mid-Atlantic United States during the first year of the COVID-19 pandemic (March 2020-February 2021) with the same period before the pandemic (March 2019-February 2020). We used unadjusted odds ratios, stratified by visit type (telehealth or in-person) and sociodemographic characteristics (child race and ethnicity, caregiver primary language, geocoded Child Opportunity Index, and rurality).
We examined 1 556 548 scheduled ambulatory care visits for a diverse pediatric patient population. Visit volume and completion rates (mean, 70.1%) decreased during the first months of the pandemic but returned to prepandemic levels by June 2020. Disparities in in-person visit completion rates among non-Hispanic Black versus non-Hispanic White patients (64.9% vs 74.3%), patients from socioeconomically disadvantaged versus advantaged communities as measured by Child Opportunity Index (65.8% vs 76.4%), and patients in rural versus urban neighborhoods (66.0% vs 70.8%) were the same during the remainder of the first year of the pandemic as compared with the previous year. Concurrent with large increases in telehealth (0.5% prepandemic, 19.0% during the pandemic), telehealth completion rates increased.
Disparities in pediatric visit completion rates that existed before the pandemic persisted during the pandemic. These findings underscore the need for culturally tailored practices to reduce disparities in pediatric health care engagement.

Enteric bacterial pathogen levels can influence the suitability of irrigation water sources for fruits and vegetables. We hypothesize that stable spatial patterns of Salmonella enterica and Listeria monocytogenes levels may exist across surface water sources in the Mid-Atlantic U.S. Water samples were collected at four streams and two pond sites in the mid-Atlantic U.S. over 2 years, biweekly during the fruit and vegetable growing seasons, and once a month during nongrowing seasons. Two stream sites and one pond site had significantly different mean concentrations in growing and nongrowing seasons. Stable spatial patterns were determined for relative differences between the site concentrations and average concentration of both pathogens across the study area. Mean relative differences were significantly different from zero at four of the six sites for S. enterica and three of six sites for L. monocytogenes. There was a similarity between the mean relative difference distribution between sites over growing season, nongrowing season, and the entire observation period. Mean relative differences were determined for temperature, oxidation-reduction potential, specific electrical conductance, pH, dissolved oxygen, turbidity, and cumulative rainfall. A moderate-to-strong Spearman correlation (rs > 0.657) was found between spatial patterns of S. enterica and 7-day rainfall, and between relative difference patterns of L. monocytogenes and temperature (rs = 0.885) and dissolved oxygen (rs = -0.885). Persistence in ranking sampling sites by the concentrations of the two pathogens was also observed. Finding spatially stable patterns in pathogen concentrations highlights spatiotemporal dynamics of these microorganisms across the study area can facilitate the design of an effective microbial water quality monitoring program for surface irrigation water.