Publications

OBJECTIVE: To examine the prospective associations of metal mixtures during pregnancy with midlife adiposity and explore metal-folate interactions.

METHODS: In 500 participants from Project Viva, we measured six non-essential metals (arsenic, barium, cadmium, cesium, mercury, and lead) and five essential metals (copper, magnesium, manganese, selenium, and zinc) in red blood cells and folate in plasma collected during early pregnancy (mean gestational age: 10.0 weeks; mean age: 32.9 years). We assessed midlife (mean age: 51.2 years) adiposity using BMI and dual-energy X-ray absorptiometry (DXA) measures. We used multivariable-adjusted linear and multinomial logistic regression models to analyze individual exposures and Bayesian kernel machine regression to examine exposure mixtures.

RESULTS: Higher arsenic, cesium, and mercury levels were associated with lower midlife DXA percentage fat, total fat mass index, and/or trunk fat mass index, even after adjustments for diet in pregnancy. We observed an antagonistic interaction between folate and arsenic: arsenic was associated with higher obesity risk at lower folate levels but lower obesity risk at higher folate levels. The essential metal mixture tended to be associated with lower midlife BMI and obesity risk.

CONCLUSIONS: Higher pregnancy levels of arsenic, cesium, mercury, and the mixture of essential metals were associated with lower midlife adiposity.

OBJECTIVE: In October 2023, CMS approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, TCAR, and CEA in standard-risk and high-risk patients.

METHODS: All carotid revascularization procedures in the VQI following the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting (IPTW) was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. IPTW was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of SVS guidelines.

RESULTS: Overall, 57,843 patients underwent revascularization (9,123 tfCAS, 21,814 TCAR, and 26,906 CEA). Before weighting, tfCAS patients were more often symptomatic (standard-risk: tfCAS: 45% vs. TCAR: 25% vs. CEA: 31%, P<.01; high-risk: 35% vs. 24% vs. 28%, P<.01), more frequently had a modified Rankin score of 4 or 5 (standard-risk: 7.7% vs. 2.4% vs. 1.7%; high-risk: 6.6% vs. 2.6% vs. 2.4%, P<.01) and more frequently underwent urgent or emergent surgery (standard-risk: 33% vs. 11% vs. 16%, high-risk: 28% vs. 12% vs. 17%, P<.01). Standard-risk asymptomatic patients undergoing tfCAS had the highest rates of perioperative stroke/death (1.6% vs. 1.2% vs. 1.0%, P=.01), as did symptomatic patients (2.9% vs. 1.9% vs. 1.7%, P=.01). tfCAS was associated with higher overall odds of stroke/death compared to CEA (OR 1.89 [1.43, 2.48] P<.01) and TCAR (OR 1.59 [1.15,2.18] P<.01). Compared to CEA tfCAS was associated with higher odds of stroke/death in both asymptomatic (OR 1.71 [1.12, 2.55] P=.01) and symptomatic patients (aOR 1.78 [1.21, 2.56] P<.01). After weighting, there were no significant differences in perioperative stroke/death overall for either tfCAS or TCAR compared to CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared to CEA (1.5% vs. 2.1%, aOR 0.75[0.59, 0.94] P=.01) while tfCAS had higher odds of stroke/death compared to TCAR. (1.5% vs. 2.4%, aOR 1.57 [1.25, 1.98] P<.01).

CONCLUSION: In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS to CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared to TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared to both CEA and tfCAS.

BACKGROUND: Trial recruitment is a major determinant of study success, and participants' non-arrival at study visits represents a significant barrier to study completion. Little is known about the participant and study process characteristics associated with visit non-arrival.

OBJECTIVE: To investigate factors associated with non-arrival at initial in-person screening visits in two ongoing randomized controlled trials.

METHODS: The Groceries for Black Residents of Boston to Stop Hypertension trials (GoFresh and GoFreshRx) studied whether home-delivered, DASH-patterned groceries can reduce blood pressure among Black adults living in urban food priority areas. In this analysis, we examined sociodemographic and study-related factors associated with participant non-arrival at their initial study visit (defined as rescheduling or not showing up at all). Associations were determined using logistic regression with adjustment for age, estimated gender, and hypertension treatment status.

RESULTS: Among 2224 participants (mean age = 44.0 years, 72.5 % women), the non-arrival rate at screening visit 1 was 29.5 %. Older participants were more likely to arrive, while those with larger families and a longer duration between initial contact and visit were less likely to arrive. Participants' method of contacting the study, visit time, and season of visit were not associated with visit non-arrival.

CONCLUSION: In this large trial recruitment drive, older age, larger family size, and a longer time between initial contact and scheduled visit were associated with non-arrival at initial study visits. These factors represent potential targets for future interventions that either accommodate patient factors or intervene upon study process barriers to achieve timely recruitment goals.

Orthostatic hypotension (OH) is a common inpatient condition associated with falls, syncope, and mortality. However, standardized approaches for inpatient management of OH are lacking and may vary across clinical specialties. In this retrospective observational cohort study, we reviewed the electronic medical records of patients admitted to Beth Israel Deaconess Medical Center between April 1, 2015 and June 1, 2021 with a diagnosis of OH or medication-related hypotension. Variables of interest included admitting service, presenting symptoms, suspected etiology, and management. Among the 400 inpatients with OH, one-third had OH documented on admission. Dizziness and lightheadedness were the most common symptoms; medical patients experienced dizziness, falls, and other symptoms more frequently than surgical patients. Volume depletion and medications were the leading suspected causes of OH. Surgical patients were less likely to have medication-related OH and were more likely to lack an identified etiology. Cardiovascular disease was more frequently implicated in cardiology patients. Volume depletion, neurodegenerative disease, and other conditions were more often suspected among medical patients. Management commonly involved volume resuscitation and medication adjustment, though medication changes were less frequent in surgical patients. Nonpharmacologic interventions were more common among medical patients. By discharge, OH had resolved in only one-third of patients. In summary, inpatient OH was most often identified after admission, attributed to hypovolemia, treated with fluids, and unresolved at discharge, with differences in symptoms, etiology, and management between specialties. Prospective studies are needed to formalize diagnostic and treatment strategies for OH in the hospital setting.

BACKGROUND: Chronic hepatitis B is a leading cause of cirrhosis and hepatocellular carcinoma globally. In 2022, only 13% of the 254 million people with chronic hepatitis B were diagnosed and 3% were treated, highlighting a major gap in care provision. We aimed to comprehensively review service delivery models and their outcomes across the hepatitis B care cascade.

METHODS: For this systematic review and meta-analysis, we searched PubMed, Embase, and Scopus for observational and interventional studies of chronic hepatitis B service delivery models that reported care outcomes, published between May 1, 2013, and July 15, 2024, with no language restrictions. Care cascade outcomes were the proportion of people diagnosed with hepatitis B who were assessed for treatment eligibility; the proportion of eligible people who started antiviral therapy; the proportion retained in care; and the proportion on therapy who had HBV DNA viral suppression. We evaluated pooled outcomes across hospital-based specialist care; co-managed care between primary and specialist care; community screening with linkage to specialist care; community screening with passive linkage to care; community test and treat clinics; primary care; and integrated care with antenatal, non-communicable disease, HIV, prison health, and substance misuse services and clinics, using a generalised linear mixed model with logit link and study random effects. For within-study comparisons of different models, we used inverse variance weighting to estimate the pooled risk ratio (RR). Heterogeneity was assessed with I2. This study is registered with PROSPERO (CRD42023410009).

FINDINGS: Of 4883 studies identified in the search, we included 106 studies comprising 110 cohorts from 50 countries in our meta-analysis. 45 (41%) of 110 cohorts were from low-income and middle-income countries and 65 (59%) were from high-income countries. 76 (72%) of 106 studies were observational, 23 (22%) were non-randomised interventional studies, and seven (7%) were randomised trials. Treatment eligibility assessment occurred in 73·9% (95% CI 65·8-80·6; I2=98·5%) of patients for hospital-based specialist care (20 cohorts), 63·1% (53·0-72·2; I2=99·9%) for co-managed care (23 cohorts), 50·4% (25·9-74·8; I2=99·7%) for primary care (four cohorts), 82·3% (58·7-93·8; I2=96·1%) for community screening with linkage to specialist care (ten cohorts), 33·2% (23·1-45·1; I2=98·6%) for community screening with passive linkage to care (three cohorts), 56·9% (40·2-72·1; I2=98·8%) for diagnosis in antenatal clinics and post-delivery linkage to specialist care (five cohorts), 75·0% (37·7-93·7; I2=0·0%) for integrated care with harm reduction services (two cohorts), and 85·4% (78·0-90·6; I2=0·0%) for integrated care with prison health services (two cohorts). Initiation of antiviral therapy when eligible was 78·1% (95% CI 68·1-85·7; I2=99·2%) in hospital-based specialist care (25 cohorts), 67·2% (55·5-77·1; I2=95·8%) in co-managed care (11 cohorts), 49·3% (32·4-66·4; I2=87·9%) in primary care (four cohorts), 97·7% (80·6-99·8; I2=39·2%) in community screening with linkage to specialist care (seven cohorts), and 49·4% (22·1-77·0; I2=84·0%) for integrated care with non-communicable disease clinics (two cohorts). Higher rates of treatment eligibility assessment (RR 2·07 [95% CI 1·65-2·59], p<0·0001; I2=97·1%; three cohorts) and initiation of antiviral therapy (1·45 [1·13-1·85], p=0·0031; I2=0·0%; three cohorts) were observed in hospital-based specialist versus primary care models. Retention in care, assessed between 12 and 48 months, was 87·7% (95% CI 79·9-92·8, I2 =96·7%) in patients on antiviral therapy in hospital-based specialist care (13 cohorts) and 47·2% (95% CI 22·2-73·6, I2=99·5%) in patients not receiving antiviral therapy (two cohorts). Overall, retention was higher in patients with versus without antiviral therapy (RR 1·72 [95% CI 1·16-2·54]; p=0·019). HBV DNA viral suppression for patients on antiviral therapy in specialist care (nine cohorts) was 73·1% (95% CI 64·3-80·4; I2=92·0%) after a median of 12 months on antiviral therapy (IQR 12-33).

INTERPRETATION: Considerable attrition was seen across the chronic hepatitis B care cascade, with low rates of retention especially in patients not on antiviral therapy. Assessment for treatment eligibility and initiation of antiviral therapy were lower in primary versus hospital-based specialist care models. Chronic hepatitis B services need to adopt strategies to optimise linkage to care after diagnosis, initiation of antiviral therapy if eligible, adherence to antiviral therapy and retention in care, as promoted in 2024 WHO hepatitis B guidelines. Further research is also needed to explore simplified care models integrated with existing services to promote access.

FUNDING: World Health Organization.

BACKGROUND: Black adults are underrepresented in cardiovascular disease clinical trials. Individual and social circumstances may limit when they are available to complete trial prescreening requirements. Characterizing preferences related to callback times and the impact of calling during preferred times could inform strategies to improve the recruitment of Black adults into clinical research. Our objectives were to characterize prescreening call preferences and successfully reaching a potential participant among adults inquiring about participation in two trials for Black residents of Boston.

METHODS: The GoFreshRx and GoFresh trials examine the effect of a home-delivered Dietary Approaches to Stop Hypertension (DASH)-patterned grocery intervention on blood pressure among Black adults with or without hypertension treatment in Boston. With the exception of the study population, both trials were identical and used the same recruitment apparatus for outreach. Interested persons completed a common online form for both trials and indicated their preferred callback time. Staff call attempts and participant screening status were logged prospectively. Gender was estimated based on first name, using a published algorithm. Odds ratios (OR) were determined via logistic regression models with adjustment for estimated gender, recruitment source, method of inquiry, and first call during preferred callback time.

RESULTS: Of 2870 inquiries (September 2022-July 2023), 1740 participants were called and 1286 were reached. Out of the 1740 participants, 25% preferred to be called before noon and 22% after 4 pm, yet only 10% of the latter were called after 4 pm. Calling during preferred times significantly increased the odds of reaching participants (OR: 1.44; 95% CI: 1.12, 1.85) and completing a prescreening interview (OR: 1.39; 95% CI: 1.14, 1.71). Staff outreach 8-12 weeks (vs 0-4 weeks) after inquiry submission was significantly associated with lower odds of completing a prescreening interview (OR: 0.41; 95% CI: 0.23, 0.73). Participants who made inquiries via return mail were significantly less likely to be reached outside work hours (OR: 0.49; 95% CI: 0.27, 0.90) and in the afternoon (OR: 0.51; 95% CI: 0.30, 0.88). Participants recruited through community events were more likely to be reached in the afternoon (OR: 2.71; 95% CI: 1.06, 6.97).

CONCLUSION: Contacting participants during their preferred callback time was associated with reaching them and completing a prescreening interview. These data highlight the importance of study teams' flexibility in outreach time to enhance the recruitment of Black adults into cardiovascular clinical trials.

BACKGROUND: Despite evidence that use of patient portals and telehealth is associated with many health benefits, disparities exist in awareness, adoption, and use. Understanding factors and strategies specific to underserved populations is key to achieving digital equity and better health.

OBJECTIVE: This study assesses portal and telehealth experiences among residents of a minoritized and lower-resource area of Dallas, Texas.

METHODS: Using an explanatory sequential design, we conducted surveys and semistructured interviews with English- and Spanish-speaking adults in 15 ZIP Codes surrounding a community-based clinic. We recruited participants via a patient portal, flyers, emails distributed by clinic and community partners, and in person. Surveys were offered online and on paper. We used Fisher exact tests to identify factors associated with telehealth and/or portal use. We also recruited a subsample of survey participants to expound on survey findings in semistructured interviews. Our thematic analysis assessed convergence in survey and interview findings.

RESULTS: Among 182 survey respondents, most were older (n=109, 66%; age ≥60 years), African American or Black (n=120, 65%), and female (n=142, 79%); a little more than half (n=97, 54%) had completed ≥1 telehealth appointment, and a majority (n=131, 72%) had used a patient portal at least once. Compared with those who used the portal and/or telehealth, those reporting no use of portal or telehealth were more likely to have a high school education or less (P<.001) or be Spanish speakers (P<.011). A majority, regardless of portal or telehealth use, agreed with health promotion activity survey statements like "Using the Internet for health-related activities makes me feel actively involved with my health care" (n=103, 59%) and "I find the Internet useful for monitoring my health" (n=100, 58%). In interviews with 20 individuals, most of whom were older, Black, female, and had digital technology experience, seven factors were key to increased engagement in portals and telehealth: (1) improving patient autonomy, (2) integrating digital health technology into daily life, (3) receiving recommendations from trusted individuals, (4) appreciating the value of digital health technologies, (5) enlisting the support of care partners or peers, (6) managing severe or chronic illness, and (7) accessing test results rapidly.

CONCLUSIONS: This study builds on previous work by confirming and contributing insights about factors key to technology uptake and use among underserved populations. Interventions using digital health technologies should focus on these factors to promote digital and health equity and achieve better health outcomes. Future research should explore which clinical settings and contexts are most conducive to increasing digital technology uptake and use, and implementation should leverage partnerships with community groups.

OBJECTIVE: Messaging about breast cancer screening cessation may reduce over-screening by raising awareness of the harms of screening, but in a background of strongly positive beliefs about screening among the public, such messaging may be perceived negatively. We aimed to assess whether older women perceived it to be ethically appropriate for clinicians to share a message that encourages breast cancer screening cessation.

METHODS: As part of a large national online survey experiment with women 65+ years, we presented a message (hereafter referred to as primary message) describing the rationales for stopping breast cancer screening (e.g., guideline recommendation, harms of screening) and assessed how ethical women thought it would be for doctors to share this information with patients. We assessed open-ended reactions. We also tested two variations of the primary message with different wordings of the recommendation to consider stopping screening.

RESULTS: Of 683 participants, 75.9 % agreed that the primary message is ethically appropriate for doctors to share with patients., 13.2 % neither agree or disagree, and 10.9 % disagreed. Themes in open-ended responses suggested that the difference in participant response was partly attributed to whether participants perceived the message as informative or persuasive. Comparing across message variations, messages with stronger recommendations to stop screening were perceived to be less ethically appropriate than the primary message.

CONCLUSIONS: Most older women perceived that it was ethically appropriate for doctors to share messages aimed at reducing breast cancer over-screening with patients.

PRACTICE IMPLICATIONS: Interventions should be developed to deliver messages to reduce over-screening among older women in practice settings, with evaluations to monitor their response.

RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) disproportionately affects Black adults and those with lower socioeconomic status in the United States. The aim of this study was to examine the associations between socioeconomic status and CKD, albuminuria/stage 1-2 CKD, and stage 3-5 CKD, and to assess differences between Black and White adults.

STUDY DESIGN: We used data from the 2017-2020 National Health and Nutrition Examination Survey. CKD was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2 based on the race-free CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation (stage 3-5 CKD) and/or a urinary albumin-creatinine ratio of >30 mg/g (albuminuria/stage 1-2 CKD).

SETTING & PARTICIPANTS: Respondents to the 2017-2020 National Health and Nutrition Examination Survey with Black or White race.

EXPOSURE: Measures of socioeconomic status (income to poverty ratio, insurance status, education, employment status, and health care access).

ANALYTICAL APPROACH: We examined the relationship between measures of socioeconomic status and CKD, albuminuria/stage 1-2 CKD, and stage 3-5 CKD using survey-weighted Poisson regressions controlling for age, sex, and medical comorbid conditions.

RESULTS: The weighted sample (N = 182,622,525) was 52.2% women and 15.5% Black, with a mean age of 49.1 years. The prevalence of CKD was 15.6% in the overall sample, 20.9% among Black adults, and 14.7% among White adults. Higher income, higher education levels, and having health insurance were associated with a lower prevalence of CKD in the overall sample and among White adults, but not among Black adults. This pattern was consistent for those with albuminuria/stage 1-2 CKD, but not for those with stage 3-5 CKD.

LIMITATIONS: This study is limited by its cross-sectional design. In addition, data were based on single measurements and thus may be less precise in estimating the prevalence of chronic disease.

CONCLUSIONS: Higher socioeconomic status was inversely associated with albuminuria/stage 1-2 CKD and CKD among White but not Black adults. Future work should investigate the mechanisms by which albuminuria/stage 1-2 CKD remains independent of socioeconomic status among Black adults.