James C. Hudspeth’s research while affiliated with University of Massachusetts Boston and other places

Background Global health (GH) interest is rising among graduate medical education (GME) trainees, yet GH engagement is marred by the impact of colonization or racism, and there remains a lack of training to confront these challenges. Objective To develop a modular, open-access curriculum that provides training in decolonization for GH GME and evaluate its feasibility and impact on learners’ critical reflection on decolonization. Methods From 2019 to 2022, 40 GH educators, including international and indigenous scholars from diverse organizations, created the Global Health Education for Equity, Anti-Racism, and Decolonization (GHEARD) curriculum. Using Kern’s 6 steps of curriculum development, critical gaps were identified and shaped into 8 modules, including a facilitator training module. Learning objectives and activities were developed using strategies grounded in transformative learning theory and trauma-informed educational approaches. The curriculum was peer-reviewed and piloted at multiple national conferences and institutions to assess feasibility and effectiveness in fostering critical reflection on decolonization. Results Pilot testing demonstrated GME implementation feasibility. Based on initial educator feedback, facilitator tools and an implementation guide were incorporated to enhance usability. Nearly all (59 of 61) trainees felt GHEARD was effective or very effective in encouraging reflection on decolonization, and 72% (32 of 44) felt GHEARD encouraged reflection on motivations for engaging in GH. GHEARD was launched as a free online resource in June 2023 and garnered 3192 views by December 2024. Conclusions To our knowledge, GHEARD is the first comprehensive decolonization curriculum designed specifically for GME. Program evaluation indicates GHEARD is feasible to implement and effective in promoting critical reflection on decolonization.

There is a growing interest to address pervasive racist and colonialist practices in global health (GH). However, there is a paucity of information on anti-racist and anti-colonial (ARAC) education for GH trainees. This study aimed to identify curricular strengths and gaps in ARAC content for pediatric, family medicine and emergency medicine trainees participating in GH. We conducted a cross-sectional survey of GH programs’ ARAC curricular content from May 2021 to January 2022. The survey was distributed to 148 GH program educational leaders via email. Descriptive statistics were used to describe quantitative data and comments were reviewed for common themes. The survey response rate was 44% (n = 65). The most represented programs were pediatric residency GH tracks (n = 24, 37%) and emergency medicine (n = 13, 20%), family medicine (n = 4, 6%) and pediatric emergency medicine (n = 6, 9%) GH fellowships. 28% of programs (n = 18) did not have faculty who identify as underrepresented minorities or international medical graduates. 56 programs (86%) had a formal GH pre-departure curriculum. The following areas were the least covered in respondents’ curricula: anti-racism (n = 34, 53%), white saviorism (n = 34, 53%), history of GH (n = 24, 37.5%). 63% (n = 40) had bidirectional exchanges of trainees or faculty, but often with significant limitations. While most GH programs recognized the need for formal pre-departure training prior to international experiences, we identified a lack of diversity among GH faculty, significant areas for improvement in curricular content, and a need for more robust bi-directional partnerships. A more equitable future in GH hinges on addressing these educational gaps.

Extreme disease phenotypes can provide key insights into the pathophysiology of common conditions, but studying these patients is challenging due to their rarity and the limited statistical power of existing methods. Herein, we used a novel approach to pathway-based mutational burden testing, the rare variant trend test (RVTT), to investigate genetic risk factors for an extreme form of sepsis-induced coagulopathy, infectious purpura fulminans (PF). In addition to prospective patient sample collection, we electronically screened over 10.4 million medical records from four large hospital systems and identified historical cases of PF for which archived specimens were available to perform germline whole exome sequencing. We found a significantly increased burden of rare, putatively function-altering variants in the complement system in patients with PF compared to unselected patients with sepsis (p=0.01). A multivariable logistic regression analysis found that the number of complement system variants per patient was independently associated with PF after controlling for age, sex, and disease acuity (p=0.01). Functional characterization of PF-associated variants in the immunomodulatory complement receptors CR3 and CR4 revealed that they result in partial or complete loss of anti-inflammatory CR3 function and/or gain of pro-inflammatory CR4 function. Taken together, these findings suggest that inherited defects in CR3 and CR4 predispose to the maladaptive hyperinflammation that characterizes severe sepsis with coagulopathy.

The credo of the generalist physician has always been the promotion of health for all, in every aspect: not just multiple vulnerable organ systems, but multiple social, cultural, and political factors that contribute to poor health and exacerbate health inequity. In recent years, the field of global health has also adopted this same mission: working across both national and clinical specialty borders to improve health for all and end health disparities worldwide. Yet within the Society for General Internal Medicine, and among American generalists, engagement in global health, both within and outside the USA, remains uncommon. We see this gap as an opportunity, because in fact generalists in America already have the skills and experience that global health badly needs. SGIM could promote generalists to global health’s vanguard, with three core steps. First, we generalists must continue to integrate health for the vulnerable into our domestic work, generating care models applicable in low-resource settings around the globe. Conversely, we must also engage with and implement international ideas and solutions for universal access to primary care for vulnerable patients in the USA. And lastly, we must build platforms to connect ourselves with colleagues worldwide to exchange these learnings.

Background: The COVID-19 pandemic caused significant disruptions in international communications and travel for academic global health programs (AGHPs) in both high-income countries (HICs) and low- and middle-income countries (LMICs). Given the importance of international travel and communication to AGHPs, the pandemic has likely had considerable impact on the education, research, and administrative components of these programs. To date, no substantive study has determined the impacts of the COVID-19 pandemic on AGHPs in HICs and LMICs. This study assessed the impacts and resultant adaptations of AGHPs to pandemic realities with the goal of sharing strategies and approaches. Methods: This study applied a mixed methods sequential explanatory design to survey AGHPs in HICs and LMICs about the impacts of the COVID-19 pandemic on three program domains: education, research, and administration. First, we surveyed a range of AGHP stakeholders to capture quantitative data on the pandemic’s impact. Subsequently we conducted semi-structured interviews with select survey participants to gather qualitative data expanding on specific survey responses. Data from both phases were then compared and interpreted together to develop conclusions and suggest adaptive/innovative approaches for AGHPs. Results: AGHPs in both HICs and LMICs were significantly impacted by the pandemic in all three domains, though in different ways. While education initiatives managed to adapt by pivoting towards virtual learning, research programs were impacted more negatively by the disruptions in communication and international travel. The impact of the pandemic on scholarly output as well as on funding for education and research was quite variable, although LMIC programs were more negatively impacted. Administratively, AGHPs implemented a range of safety and risk mitigation strategies and showed a low risk tolerance for international travel. The pandemic posed many challenges but also revealed opportunities for AGHPs. Conclusions: The COVID-19 pandemic disrupted AGHPs in HICs and LMICs in expected and unexpected ways. Programs noted some unanticipated reductions in education program funding, negative impacts on research programs, and reduced scholarly output. Many programs reported well-coordinated adaptive responses to the pandemic including, for instance, virtual (in place of in-person) collaboration in research. The pandemic will likely have lasting impacts with regard to education, research collaborations, and administration of programs.

OBJECTIVES Identify the impact of experiences in global health (GH) on the Accreditation Council for Graduate Medical Education (ACGME) competencies in emergency medicine (EM) residents and describe the individual characteristics of EM residents with global health experience compared to those without. METHODS From 2015 to 2018, 117 residents from 13 nationally accredited United States EM residency training programs were surveyed. Specifically, the survey gathered demographic data and information regarding timing, type, location and duration of short term experiences in global health (STEGH). The survey collected both qualitative and quantitative data regarding resident experiences, including number of procedures performed and self-assessment of the impact on their residency milestones. ACGME milestone data from survey respondents was collected from each resident's training program coordinators. Chi-squared analysis and t-tests were conducted to assess differences between residents with STEGH and those without. A generalized linear model (GLM) was utilized to assess the effects of time and experience with interaction on achieving milestones in each of the competency domains, to compare milestone achievement over time between residents with STEGH and those without. RESULTS Out of 117 EM residents, 60 were female (44%), the mean age was 30 years (standard deviation = 3.1), and 84 (71.8%) reported STEGH in general, including prior to residency (64.5%). 33 (28.2%) reported having completed STEGH during residency. The results of the GLM analysis showed that residents with STEGH during residency had significantly higher scores compared to those without the experience or STEGH pre-residency across all six competencies CONCLUSIONS STEGH in EM residents was associated with higher milestone achievement in certain ACGME competency domains including medical knowledge, practice-based learning and improvement, and professionalism. Participation in STEGH during residency appeared to show the strongest effect, with higher scores across all six competencies.

Background: Faculty development for nurse and physician educators has a limited evidence base in high income countries, and very little research from low- and middle-income countries. Health professions educators in many global settings do not receive training on how to educate effectively. Objective: To pilot and assess a faculty development program aimed at nurse and physician educators at a teaching hospital in rural Haiti. Methods: We developed a program covering a total of 22 topics in health professions education, including applied learning theory as well as nurse and physician targeted topics. We assessed impact through participant assessment of personal growth, participant evaluation of the program, knowledge testing pre and post program, and structured observations of program participants providing teaching during the program. Findings: Nineteen out of 37 participants completed the program. While participant reviews were uniformly positive, a pre- and post-test on general educational topics showed no significant change, and the effort to institute observation and feedback of teaching did not succeed. Conclusions: Our project showcases some benefits of faculty development, while also demonstrating the challenges of instituting faculty development in situations where participants have limited time and resources. We suspect more benefits may emerge as the program evolves to fit the learners and setting.

Extreme disease phenotypes have the potential to provide key pathophysiologic insights, but the study of these conditions is challenging due to their rarity and the limited statistical power of existing methods. Herein, we apply a novel pathway-based approach to investigate the role of rare genomic variants in infectious purpura fulminans (PF), an extreme phenotype of sepsis with hyperinflammation and coagulopathy for which the role of inherited risk factors is currently unknown. Using whole exome sequencing, we found a significantly increased burden of rare, putatively function-altering coding variants in the complement system in patients with PF compared to unselected patients with sepsis (p-value = 0.01). Functional characterization of a subset of PF-associated variants in integrin complement receptors 3 and 4 (CR3 and CR4) revealed that they exhibit a pro-inflammatory phenotype. Our results suggest that rare inherited defects in the complement system predispose individuals to the maladaptive hyperinflammatory response that characterizes severe sepsis.

Importance: Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. Objective: To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. Design, setting, and participants: This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. Interventions: The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). Main outcomes and measures: Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). Results: All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6$412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30$100 000 per LY threshold. Conclusions and relevance: In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.

Background Drug use-associated infective endocarditis (DUA-IE) is typically treated with 4-6 weeks of in hospital intravenous antibiotics (IVA). Outpatient parenteral antimicrobial therapy (OPAT) and partial oral antibiotics (PO) may be as effective as IVA, though long-term outcomes and costs remain unknown. We evaluated the clinical outcomes and cost-effectiveness of four antibiotic treatment strategies for DUA-IE. Methods We used a validated microsimulation model to compare: 1) 4-6 weeks of inpatient IVA along with opioid detoxification, status quo (SQ); 2) 4-6 weeks of inpatient IVA along with inpatient addiction care services (ACS) which offers medications for opioid use disorder (SQ with ACS); 3) 3 weeks of inpatient IVA with ACS followed by OPAT (OPAT); and 4) 3 weeks of IVA with ACS followed by PO antibiotics (PO). We derived model inputs from clinical trials and observational cohorts. All patients were eligible for either in-home or post-acute care OPAT. Outcomes included life years (LYs), discounted costs, incremental cost-effectiveness ratios (ICERs), proportion of DUA-IE cured, and mortality attributable to DUA-IE. Costs (&US) were annually discounted at 3%. We performed probabilistic sensitivity analyses (PSA) to address uncertainty. Results The SQ scenario resulted in 18.64 LY at a cost of &416,800/person with 77.4% hospitalized DUA-IE patients cured and 5% of deaths in the population were attributable to DUA-IE. Life expectancy was extended by each strategy: 0.017y in SQ with ACS, 0.011 in OPAT, and 0.024 in PO. The PO strategy provided the highest cure rate (80.2%), compared to 77.9% in SQ with ACS and 78.5% in OPAT and X in SQ. OPAT was the least expensive strategy at &412,300/person, Compared to OPAT, PO had an ICER of &141,500/LY. Both SQ strategies provided worse clinical outcomes for money invested than either OPAT or PO (dominated). All scenarios decreased deaths attributable to DUA-IE compared to SQ. Findings were robust in PSA. Table 1 Selected cost and clinical outcomes comparing treatment strategies for drug-use associated infective endocarditis including the status quo, status quo with addiction care services, outpatient parenteral antimicrobial therapy, and partial oral antibiotics. Conclusion Treating DUA-IE with OPAT along with ACS increases the number of people completing treatment, decreases DUA-IE mortality, and is cost-saving compared to the status quo. The PO strategy also improves clinical outcomes, but may not be cost-effective at the willingness-to-pay threshold of &100,000. Disclosures Simeon D. Kimmel, MD, MA, Abt Associates for a Massachusetts Department of Public Health project to improve access to medications for opioid use disorder in nursing facilities (Consultant)