Boston Medical Center

Escalating political turmoil and violence in Haiti since 2021, coupled with United States (US) immigration policy changes in early 2023, have led to an influx of Haitian immigrants to the US. Scattered reports suggest that recent immigrants from Haiti have a high burden of medical and social needs. To better understand their health risks and social needs, we analyzed survey data from 35 Haitian-born, US-based postpartum individuals on topics related to pre-pregnancy, pregnancy, and postpartum health. We calculated frequencies and odds ratios, and compared responses stratified by immigration year (before versus during/after 2021). Among the more recent immigrants, we identified a higher prevalence of hypertension in pregnancy (9/15, 60% versus 4/17, 24%; odds ratio 3.3 (95% confidence interval, 1.0–18.9)) and postpartum financial concerns (7/15, 47% versus 2/17, 12%; odds ratio 5.1 (1.3–46.3)). Our findings suggest that recent immigrants from Haiti may be at increased risk for adverse pregnancy and postpartum outcomes.

Background The use of balloon guide catheter (BGC) has been associated with better reperfusion and clinical outcomes in mechanical thrombectomy (MT) for large vessel occlusion stroke. However, the impact of BGC on angiographic and clinical outcomes in patients with distal medium vessel occlusion (DMVO) strokes undergoing MT has not been extensively investigated. Methods This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients with anterior circulation DMVO due to middle cerebral artery (MCA) M3/M4 or anterior cerebral artery (ACA) A1/A2-3 were included. The cohort was divided into BGC and non-BGC groups. Multivariable logistic regression and inverse probability of treatment weighting (IPTW) were used for comparison. The primary outcome was first pass effect (FPE) defined as modified treatment in cerebral infarction (mTICI) grade 2C/3 after single device pass. Results Among 199 patients who were eligible for analysis, 81 (40.7%) were female. The median age was 69 (60-81) years, and National Institutes of Health Stroke Scale score was 13 (7–18). The BGC group (n=73) had higher rates of FPE (53.4% vs 13.7%; IPTW aOR 5.63, 95%CI (2.43 to 13.10), P<0.001) compared with the non-BGC group (n=126). The BGC group had higher rates of modified Rankin Scale (mRS) 0-1 (42.9% vs 27.1%; IPTW aOR 2.78, 95% CI (1.10 to 7.07), P=0.031), mRS 0-2 (60.3% vs 41.5%; IPTW aOR 4.31, 95% CI (1.66 to 11.19), P=0.003), and lower rates of mortality at 90-days (12.7% vs 25.4%; IPTW aOR 0.32, 95% CI (0.11 to 0.98), P=0.047) compared with the non-BGC group. The rates of successful reperfusion at the end of the procedure and symptomatic intracerebral hemorrhage were comparable between both groups. Conclusion The present study suggests that the use of BGC in DMVO undergoing MT may be associated with improved angiographic and clinical outcomes with no safety concerns. Prospective studies are warranted.

Background The ACTG A5360 trial demonstrated that HCV treatment without planned on-treatment monitoring is safe and effective. We report the health economic outcomes of MINMON. Methods A5360 was a 5-country, single-arm trial providing sofosbuvir/velpatasvir to people with HCV infection with no planned clinic visits between treatment initiation and week 24 sustained virologic response (SVR) evaluation. Trial records included planned/and most unplanned lab tests and visits. Participants completed a 4-week recall questionnaire at weeks 0, 24, 48, and 72 reporting hospital nights, emergency department visits, and ambulatory visits. We tabulated consumption and multiplied units of consumption by country-specific cost. We report the cost and cost per SVR of MINMON (2020 US$) from program and health sector perspectives. Sensitivity analyses compared MINMON costs to the standard of care (SoC). We consulted in-country experts to develop country-specific SoC treatment protocols and used micro-costing to estimate their costs. We compare the cost/SVR in MINMON with that of the simulated SoC, varying the expected SVR with the SoC. Results MINMON cost/SVR (program perspective) varied by country from$1692/SVR (Thailand) to $27,632/SVR (United States). The cost/SVR (health sector perspective) ranged from$6273/SVR (South Africa) to $123,974/SVR (United States) MINMON had a lower cost/SVR than SoC across broad assumptions about SVR proportions, especially in low- and middle-income countries. In the United States-, MINMON had an appealing cost per cure compared to the SoC, unless retention on treatment fell below the SoC. Conclusions MINMON is a cost-saving strategy for HCV treatment, particularly in low- and middle-income country settings.

Importance Alcohol use disorder (AUD) is common in hospital patients. AUD medications are not typically initiated in that setting. The comparative effectiveness between initiation of oral naltrexone and extended-release injectable naltrexone in the hospital is not known. Objective To compare the effectiveness of initiating oral naltrexone vs extended-release injectable naltrexone on reduction in alcohol use and health care utilization among medical inpatients with AUD. Design, Setting, and Participants The Alcohol Disorder Hospital Treatment (ADOPT) study is a randomized clinical trial conducted at an urban teaching hospital in the US, with enrollment between June 2016 and March 2020. Inpatients were screened for eligibility, and those with AUD and recent heavy drinking (defined as 5 or more drinks for men and 4 or more drinks for women) were enrolled. Outcomes were assessed at 3-month follow-up; assessors were not blinded to treatment assignment. Data were analyzed from May 2021 to September 2023. Interventions Participants received either daily oral naltrexone or monthly extended-release injectable naltrexone. All received medical management with a research nurse who specialized in addiction. Main Measures and Outcomes The primary outcome was change in percentage of heavy drinking days (HDDs) over the past 30 days from baseline to 3-month follow-up, assessed by validated instrument. The secondary outcome was any acute health care utilization (emergency department or hospitalization) at 3-month follow-up over the past 90 days. Results Of 248 participants, 199 (80.2%) were male, and the mean (SD) age was 49.4 (10.4) years. The baseline median (IQR) percentage of HDDs in the past 30 days was 80.0% (43.3-100). At 3-month follow-up, the mean percentage of HDDs in the past 30 days was reduced in both groups (oral naltrexone: baseline, 66.7% HDDs; 3-month follow-up, 27.4% HDDs; difference, −38.4 percentage points; 95% CI, −125.0 to 48.2; extended-release injectable naltrexone: baseline, 70.7% HDDs; 3-month follow-up, 23.8% HDDs; difference, −46.4 percentage points; 95% CI, −123.4 to 30.6; P = .14). At follow-up, 59 of 109 in the oral naltrexone arm (54.1%) and 66 of 108 in the extended-release injectable naltrexone arm (61.1%) reported acute health care utilization in the prior 3 months; the odds of this utilization were not significantly different between groups (adjusted odds ratio, 1.34; 95% CI, 0.77-2.33). Conclusions and Relevance In this randomized clinical trial, when initiated at hospital discharge, oral and extended-release injectable naltrexone did not differ in effectiveness. Participants had substantial reductions in HDDs in both treatment groups; however, there was not a significant difference in the reduction of percentage of HDDs in the past 30 days or acute health care utilization between groups. Hospitalization represents an opportunity to start AUD pharmacotherapy; choice of oral naltrexone vs extended-release injectable naltrexone should be directed by factors such as patient preference and insurance. Trial Registration ClinicalTrials.gov Identifier: NCT02478489

Background Successful recruitment of study participants is a challenging component of research, and recruitment barriers are amplified in safety-net hospital (SNH) settings. However, engaging historically underrepresented groups in research is critically important to improve health disparities and outcomes. We summarize challenges we encountered while recruiting patients with COVID-19 from the emergency department (ED), actions to improve inclusivity, and implementation hurdles in an SNH setting. Methods We conducted an observational study at the largest safety-net hospital in New England, recruiting patients in the ED with confirmed COVID-19. Investigators prioritized recruitment inclusivity through language translations of study materials, compensation (including transport and travel reimbursement), flexible sample delivery options, and clinical staff engagement. We identified and categorized major impediments to recruitment success. Results Recruitment and retention efforts were largely unsuccessful (n = 4 enrolled of n = 113 eligible by electronic medical record (EMR) review). Barriers to recruitment success included clinical teams’ perception of good candidacy, persistent language barriers, limited consent capacity, burden of participation, and ED discharge logistics. Conclusions Despite efforts to improve opportunities to participate in research, SNH EDs present unique challenges for recruitment. Study teams should prioritize clinical staff engagement and work with institutions to promote inclusivity and community engagement efforts to improve research engagement in these settings. Clinical trial number Not applicable.

Pediatric chronic pain is embedded within parent-youth relationships. Parent risk factors have been associated with poor functional outcomes in youth with chronic pain. Research delineating the role of parent psychological flexibility in the context of pediatric chronic pain remains limited. The study examines the influences of parental responses on youth’s functional outcomes. The study aims to examine associations between parent psychological flexibility and youth’s functional interference. 127 youth (66.1% female) with mixed etiology chronic pain, ranging in age from 8 to 17 years (M = 12.24; SD = 1.598), and their parent participated in the study at an interdisciplinary pediatric pain clinic and online pain peer support groups. Measures of demographic and pain characteristics, youth’s functional interference, pain acceptance, and parent psychological flexibility were collected. Regression results indicated that youth’s reported pain intensity [B = 3.01, SE = 0.441, p <.0005], and parent psychological flexibility [B = − 0.006, SE = 0.003, p = 0.042] were independently associated with youth’s self-reported functional interference. Findings underscore how parent psychological flexibility positively impacts youth’s pain related functioning. Implications highlight the need for parents’ inclusion as targets for change in clinical interventions and may further optimize treatments aimed at improving the functioning of youth with pain by addressing parent psychological flexibility.

BACKGROUND AND OBJECTIVES Pediatric HCV cases have increased in the United States. Guidelines recommend beginning treatment of HCV for children as young as 3 years old. However, no studies have evaluated pediatric linkage to HCV care and direct-acting antiviral (DAA) uptake on a national level. This study aims to characterize the HCV care cascade among a national cohort of children with HCV. METHODS This retrospective cohort analysis included children born between 2000 and 2018 who were diagnosed with HCV between the ages of 0 and 18 years. We analyzed TriNetX Research Network data, a US national electronic health records network. Primary HCV care cascade outcomes included the number of children diagnosed with HCV infection, linked to care, and prescribed DAAs. We assessed the association between race and ethnicity with linkage to care using logistic regression. RESULTS Among 928 children with HCV, 297 (32.0%) linked to HCV care and 111 (12.0%) were prescribed a DAA. Hispanic/Latinx children had double and white children had triple the odds of linkage compared with Black children (odds ratio [OR], 2.20; 95% CI, 1.05–4.59; OR, 3.44; 95% CI, 1.89–6.28) after adjusting for sex, birth cohort, and region. CONCLUSIONS Pediatric access to HCV care remains low. Fewer than 1 in 3 children linked to HCV care and fewer than 1 in 8 were treated. This study uncovers racial and ethnic disparities in HCV care access. Targeting interventions toward increasing linkage to care could represent an opportunity to advance HCV elimination goals and reduce disparities.

The National Cancer Database (NCDB) is widely used in US cancer outcomes research, but its reliance on Commission on Cancer-approved hospitals can underrepresent certain populations, skew data, and limit generalizability of findings. Current literature is representative up through 2014. We sought to adjust NCDB cancer cases to better reflect total US cancer population in a useful way for cancer outcomes research. Incident cancer cases in the NCDB from 2016–2020 were compared with the US Cancer Statistics (USCS) database, which contains nearly 100% of new cancer cases. NCDB case coverage was defined as percentage of cases the NCDB represents of USCS cases. Coverage was determined for the entire cohort (age 20+ years), and sub-analyses were performed for age, sex, race/ethnicity, residence location, and cancer sites. From 2016–2020, 6,515,675 cancer cases were diagnosed in the NCDB and 9,311,593 in the USCS, yielding 70% NCDB case coverage over 5 years, which increased from 68 to 73%. The lowest case coverage was among men, 85+-year-olds, American Indian/Alaskan Native people, and Hispanic/Latino individuals (65%, 59%, 42%, and 55%). The Mountain region was the least represented (49%) as was nonmetropolitan residence (64%). Similar underrepresentation was seen among top cancers. Missingness of data was also captured. Though NCDB’s representation of US cancer cases is improving, gaps remain, including age, sex, race/ethnicity, and residence location, further exacerbated by missing variables. We provide investigators using the NCDB with a way to represent cancer case data to better tailor research questions and frame outcomes.

Background High‐frequency low‐tidal‐volume (HFLTV) ventilation is a safe and cost‐effective strategy that improves catheter stability, first‐pass pulmonary vein isolation, and freedom from all‐atrial arrhythmias during radiofrequency catheter ablation (RFCA) of paroxysmal and persistent atrial fibrillation (AF). However, the incremental value of adding rapid‐atrial pacing (RAP) to HFLTV‐ventilation has not yet been determined. Objective To evaluate the effect of HFLTV‐ventilation plus RAP during RFCA of paroxysmal AF on procedural and long‐term clinical outcomes compared to HFLTV‐ventilation alone. Methods Patients from the REAL‐AF prospective multicenter registry, who underwent RFCA of paroxysmal AF using either HFLTV + RAP (500–600 msec) or HFLTV ventilation alone from April 2020 to February 2023 were included. The primary outcome was freedom from all‐atrial arrhythmias at 12‐month follow‐up. Secondary outcomes included procedural characteristics, long‐term clinical outcomes, and procedure‐related complications. Results A total of 545 patients were included in the analysis (HFLTV + RAP = 327 vs. HFLTV = 218). There were no significant differences in baseline characteristics between the groups. No differences were observed in procedural (HFLTV + RAP 74 [57–98] vs. HFLTV 66 [53–85.75] min, p = 0.617) and RF (HFLTV + RAP 15.15 [11.22–21.22] vs. HFLTV 13.99 [11.04–17.13] min, p = 0.620) times. Both groups showed a similar freedom from all‐atrial arrhythmias at 12‐month follow‐up (HFLTV + RAP 82.68% vs. HFLTV 86.52%, HR = 1.43, 95% CI [0.94–2.16], p = 0.093). There were no significant differences in freedom from AF‐related symptoms (HFLTV + RAP 91.4% vs. HFLTV 93.1%, p = 0.476) or AF‐related hospitalizations (HFLTV + RAP 98.5% vs. HFLTV 97.2%, p = 0.320). Procedure‐related complications were low in both groups (HFLTV + RAP 0.6% vs. HFLTV 0%, p = 0.247). Conclusion In patients undergoing RFCA for paroxysmal AF, adding RAP to HFLTV‐ventilation was not associated with improved procedural and long‐term clinical outcomes.

Purpose Training environments that embrace diversity, equity, inclusion, and accessibility (DEIA) in their mission, recruitment, and curriculum may foster development and retention of a diverse workforce and promote novel approaches to address inequities in addiction care. We sought to elicit perspectives regarding how addiction medicine training programs influenced the training experience and career trajectories for participants from underrepresented groups (URGs). Methods We conducted semi-structured interviews with 20 URG physician participants of addiction medicine programs at a single institution from 2016 to 2022 regarding their identities and experiences in the training program(s). We completed a rapid thematic analysis of qualitative interviews. Results The sample of participants was 55% women, 25% black or African American, 25% Asian, 25% white, 17% Hispanic or Latina/o/x, and 4% American Indian or Alaska Native. We identified over-arching themes: (1) areas for program improvement including increasing diversity in program leadership, educators, participants, and educational content; (2) URG identity positively influences physician choice to pursue addiction medicine careers working with communities that are underserved and/or experience health disparities; (3) addiction medicine programs impact participants’ short- and long-term goals as addiction health professionals including achieving research goals, attaining leadership roles, and finding opportunities for networking and mentorship. Conclusions We identified themes emphasizing addiction medicine program successes in creating welcoming educational environments, while also prioritizing areas for improvement around topic inclusion, faculty development and representation, and mentorship. Our results offer critical insights into the priorities and views of the next generation of the physician addiction medicine/research workforce and how to effectively improve DEIA efforts within training programs.

Clinic appointment compliance is a challenge to care continuity for people with chronic non-communicable diseases (NCD) globally. Short-message-service (SMS) text reminders have improved attendance in several settings but have not been tested in Haiti. This pilot study of an SMS reminder strategy to improve clinic attendance for NCD patients in Central Haiti assessed the feasibility and acceptability the messages. We included patients in the NCD clinic – adults with hypertension, type 2 diabetes, and heart failure; and children/young adults with type 1 diabetes (T1D) – at Hôpital Universitaire de Mirebalais. Patients with appointments between December 13-22, 2021, were sent SMS reminders 3 days and 1 day before their visit. Patients completed a survey at their appointment evaluating the usefulness, acceptability, and feasibility of the reminders. We assessed barriers to receiving the SMS and how they influence clinic attendance. Ninety-six patients had a scheduled appointment during the study period. SMS reminders were sent to all patients with recorded phone numbers (91.2%). 72 patients (75%) attended their visit. Half of those who attended their visit received the SMS. Of these patients, 100% liked the reminder, 97.2% wanted to receive future messages, and 22.2% reported they would not have attended their visit without the reminder. Of the 36 patients who did not receive the SMS, 38.9% changed their phone number while 33.3% did not have access to a phone. Barriers to receiving the SMS were inconsistent cellular signal (25%) and lack of access to a phone (22%). Sending SMS reminders was feasible and acceptable to NCD patients. The messages were universally liked by the patients and positively influenced the decision of some to attend their visit. Barriers to uptake include updating phone numbers and access to phones. If implemented at scale, SMS reminders may improve appointment attendance in rural Haiti for those with mobile phones.

Background While the rate of physician burnout has been characterized as relatively high among urologists compared to other specialties, a specific examination of burnout and predictors of burnout among urologists specializing in sexual medicine has not been conducted. Aim The aim of this study was to collect demographic characteristics of urologists specializing in sexual medicine, assess the occurrence of and risk factors for burnout, and characterize satisfaction with career, compensation and work-life balance. Methods We surveyed 96 urologists specializing in sexual medicine to characterize demographic and practice characteristics and assess their satisfaction with career aspects and levels of burnout. Univariable and multivariable modeling with stepwise variable selection was utilized to identify predictive variables of burnout. Outcomes The Copenhagen Burnout Inventory was used to assess personal burnout, work-related burnout, patient-related burnout, and overall burnout. Results Twenty-four percent (n = 23) of participants reported burnout with 35.4% (n = 34) reporting personal burnout, 38.5% (n = 37) reporting work-related burnout, and 24.0% (n = 23) reporting patient-related burnout. Younger age (P = 0.051), Black/African American or multiracial race compared to white race (P < 0.0001), Latino or Hispanic background (P = 0.034), female sex (P = 0.059), being unmarried (P = 0.047), and increased educational debt (0.030) were identified as predictive of overall burnout in adjusted analysis. Dissatisfaction with work-life balance was significantly related to an increase in all categories of burnout (P < 0.01). Clinical implications These findings may guide practice patterns and initiatives to support groups identified at increased risk of burnout, as well as function as a benchmark for future studies of burnout in the sexual medicine urology community. Strengths and limitations While this is the first study of burnout specifically among sexual medicine urologists and findings are consistent with the overall urology community, the small sample size may lead to a biased sample. Conclusion Several demographic and personal characteristics were identified to be predictive of burnout among the sexual medicine urology community, indicating opportunities for additional support.

Objective We sought to identify which absent firearm laws would have prevented the most firearm suicides (FS) in each state of the US. Summary Background Data Prior studies suggested efficacy for FS prevention varies greatly between different firearm laws. However, this body of work did not probe how this efficacy may differ by state. Methods This state-level, retrospective cohort study of firearm laws among the contiguous United States from 2010-2019 used Poisson models for the association between state FS per 100,000 population and implementation of state firearm laws lagged by 7 years, spatially weighted total firearm laws in surrounding states, and state demographics. These models were applied to each absent law in each state to estimate the reduction in FS associated with law implementation. The law associated with the greatest reduction in each state was the most impactful missing law. Results Eight of 12 law categories were significantly associated with decreased FS rates. The largest associated reductions in FS were with child access prevention, or CAP (IRR 0.53; 95% CI 0.48-0.59; P <0.001), and concealed carry permitting, or CCP (IRR 0.59; 95% CI 0.54-0.65; P <0.001). Five states had all law categories for the study duration, and CAP and CCP were the most impactful missing law categories in 22 (51%) and 9 (21%) of remaining states, respectively. A total of 114,106 FS were associated with all states not having implemented their most effective missing law category across the study period. Conclusions This study found that FS rates in most states would have decreased most with passage of CAP or CCP, which can inform policymaking in respective states.

The optimal conditioning schedule and CD34+ cell dose for autologous stem cell transplantation (ASCT) for AL amyloidosis is unknown. Patients (n = 1704) who underwent ASCT for AL amyloidosis between 2003 and 2020 in 9 centers were included. Data on melphalan conditioning dose, number of conditioning days, whether a rest day between conditioning and stem cell infusion was given or not, and infused CD34⁺ cell dose were collected. Full‐dose melphalan (≥ 180 mg/m²) was administered in 63.7% of the patients, and 80.4% had melphalan split into 2‐day conditioning. A rest day (day −1) between the conditioning regimen and stem cell infusion was provided in 52.5% of patients. The median infused CD34⁺ cell count was 4.7 × 10⁶/kg. An infused CD34⁺ cell count ≥ 4.5 × 10⁶/kg was associated with a shorter time to neutrophil and platelet engraftment. In a nominal regression analysis, full‐dose melphalan, 1‐day melphalan conditioning, and omitting a rest day between conditioning and stem cell infusion were independent predictors of post‐ASCT higher deep hematological response. The median follow‐up was 8.6 years, and 38% of patients died. Independent predictors of superior overall survival in multivariate Cox regression analysis included full‐dose melphalan, having no rest day, and infused CD34⁺ cells ≥ 4.5 × 10⁶/kg. Independent predictors of higher day‐100 transplant‐related mortality (TRM) in nominal logistic regression analysis included poorer performance status, NT‐proBNP/BNP ≥ 1800/400 pg/mL, serum albumin < 2.5 g/dL, CD34⁺ cells < 4.5 × 10⁶/kg, and not having a rest day. In conclusion, 1 day of melphalan conditioning and administration of CD34⁺ cells ≥ 4.5 × 10⁶/kg are recommended for ASCT in AL amyloidosis.