Publications

This study examined changes in health-related quality of life (HRQOL) among people living with HIV in Vietnam over three years following antiretroviral therapy (ART) initiation. We analyzed data from a randomized trial of 639 ART-naïve patients in which HRQOL was measured using the SF-8 instrument. Mixed effects logistic regression was used to assess changes in HRQOL over time and identify associated factors. At baseline, 57.5% reported low HRQOL. HRQOL improved rapidly after ART initiation, with 89.0% reporting good HRQOL at 3 months and 96.4% at 36 months. Compared with men, women had slower improvement in HRQOL over time. Factors positively associated with HRQOL included higher BMI and alcohol use, while food insecurity, history of tuberculosis, advanced clinical stages, and TDF-based regimens were negatively associated. Older age was linked to poorer HRQOL outcomes. These findings highlight the effectiveness of ART in improving HRQOL while also revealing disparities in HRQOL improvements.

IMPORTANCE: Conversations between seriously ill patients and clinicians about values and goals (ie, serious illness conversations [SICs]) can lead to patient-centered care toward the end of life. However, many patients have not had SICs when arriving in the emergency department (ED) and are at risk of receiving undesired care.

OBJECTIVE: To determine the effect of an ED-based, multimodal SIC intervention (known as ED GOAL) compared with usual care on patient-reported engagement in advance care planning (ACP) and clinician-documented SICs after leaving the ED.

DESIGN, SETTING, AND PARTICIPANTS: This 2-armed, 1:1, parallel-design randomized clinical trial was conducted at 3 participating EDs (2 academic medical centers and 1 community hospital) in Boston, Massachusetts, within a single health system between March 1, 2022, and July 1, 2024, with a follow-up duration of 6 months. Eligible participants were English-speaking adults 50 years or older with serious illnesses, including mild cognitive impairment or mild dementia, along with their caregivers. For patients with moderate to severe dementia, caregivers were the primary participants in the study. Patients with documented goals for medical care or physician orders in the last 3 months in medical records or deemed clinically inappropriate by the treating ED team were excluded.

INTERVENTION: SIC-trained research nurses conducted (1) a motivational interview about SICs, (2) a structured SIC, and (3) communication priming for the patients and their primary clinicians to reinitiate SICs on a tablet computer in the ED or within 1 week after leaving the ED.

MAIN OUTCOMES AND MEASURES: The primary outcome was a validated survey of patient-reported engagement in ACP at 1 month, with total possible scores ranging from 1 to 5, with higher scores indicating more engagement. Secondary outcomes included clinician documentation of end-of-life values and preferences in the medical record and completed advance directives.

RESULTS: A total of 141 patients (mean [SD] age, 66.7 [9.2] years; 73 [51.8%] female), predominantly diagnosed with metastatic cancer (85 [60.3%]), were enrolled and randomized to the intervention (n = 70) or usual care (n = 71). At 1 month, no difference was observed in patient-reported engagement in ACP (mean [SD] score, 3.32 [1.28] for control vs 3.37 [1.07] for intervention; maximum possible score, 5.00; P = .58), yet 12 patients in the intervention group (17.1%) discussed care preferences with their physicians compared with 5 (7.0%) control group patients (P = .07). Medical record documentation of end-of-life values and goals was significantly higher in the intervention group at 3 months (17 [24.3%] vs 7 [9.9%]; P = .03) and 6 months (22 [31.4%] vs 9 [12.7%]; P =  .008).

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of seriously ill older adults in the ED, while a nurse-led SIC intervention did not significantly improve patient-reported engagement in ACP, it did increase clinician-documented SICs in the medical records. ED visits may serve as a critical access point to enhance SICs for seriously ill yet clinically stable older adults.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05209880.

BACKGROUND: We sought to determine the comparative effectiveness of two strategies for assigning care coordinators to people living with dementia (PLWD) and their caregivers.

METHODS: We conducted a pragmatic randomized clinical trial embedded in a Medicare accountable care organization (ACO) in New York, NY in 2022-2024. We included community-dwelling PLWD ≥ 65 years who were attributed to the ACO and had highly fragmented ambulatory care in the previous year (reversed Bice-Boxerman Index ≥ 0.86). The trial compared usual care (assigning care coordinators to PLWD after hospital discharge) to usual care plus proactive outreach, which assigned care coordinators to PLWD if they or their caregivers reported difficulty with care coordination on a telephone survey. Participants were followed for the combined outcome of emergency department (ED) visit or hospitalization.

RESULTS: Among the 385 PLWD in the trial, the mean age was 82.6 years (SD 6.9), and 56.4% were female. Overall, participants had had a mean of 14.9 ambulatory visits to 8.9 different providers the previous year. The acceptance rate of care management was higher in the control group (73.7%) than in the intervention group (38.0%). Care coordinators were ultimately assigned to 14 of 192 PLWD in the control group (7.3%) and 19 of 193 PLWD in the intervention group (9.8%). The intention-to-treat analysis (N = 385) found a trend toward fewer ED visits in the intervention group (0.14 ED visits per 100 person-days alive vs. 0.18 ED visits per 100 person-days alive, p = 0.07) but no difference in the combined outcome of ED visit or hospitalization (p = 0.71).

CONCLUSION: Although the particular intervention we tested was not more effective than usual care, this trial is novel in that it used highly fragmented care as an inclusion criterion and shows that more work is needed to address fragmented care among PLWD.

BACKGROUND: Prenatal per- and polyfluoroalkyl substance (PFAS) exposures may influence offspring blood pressure (BP), but long-term studies in diverse populations remain limited.

METHODS: Participants were from the Boston Birth Cohort. We measured PFAS in maternal plasma collected 24 to 72 hours after delivery and extracted children's BP from medical records. We calculated age-, sex-, and height-specific BP percentiles and defined elevated BP as systolic/diastolic BP ≥90th percentile (ages 3 to <13 years) or ≥120/80 mm Hg (ages 13 to <18 years). We used adjusted mixed-effects linear and modified Poisson models to examine associations of PFAS with BP percentiles and elevated BP. We used linear spline mixed-effects models to predict BP trajectories at ages 3 to 18 years by PFAS levels.

RESULTS: We included 13 404 BP measurements from 1094 children (median follow-up: 12 years [interquartile range, 9-15 years]; 61% Black and 22% Hispanic). Overall, higher perfluorodecanoic acid (PFDeA), perfluorononanoic acid (PFNA), and perfluoroundecanoic acid (PFUnA) were associated with higher systolic BP percentile. The associations differed by child life stage, sex, race and ethnicity. For example, associations of PFDeA with systolic BP percentile were stronger in older (β3-5y=0.40; β6-12y=1.06; β13-18y=2.55), male (βmale=1.51; βfemale=0.52), and Black (βBlack=1.75; βHispanic=0.45) children. In male children, each doubling of perfluoroheptanesulfonic acid (PFHpS) was associated with a 9% higher risk of elevated BP at ages 6 to 12 years and a 17% higher risk at 13 to 18 years, with no increased risk at 3 to 5 years. PFHpS was associated with a dose-dependent divergence in BP trajectories beginning at age 13 years.

CONCLUSIONS: Prenatal exposures to certain PFAS were associated with offspring BP, with stronger associations in adolescents, male children, and Black children. Prenatal PFAS exposures may have intergenerational, long-term, and latent hypertensive effects.

Alcohol is one of the most commonly consumed substances in the world, exhibiting complex relationships with multiple aspects of cardiovascular health and disease. The majority of the research on the topic is observational and therefore prone to bias and confounding. The available evidence suggests no risk to possible risk reduction when alcohol is consumed in low amounts (such as no more than 1 to 2 drinks a day) in regard to coronary artery disease, stroke, sudden death, and possibly heart failure. The risk associated with consuming 1 to 2 drinks a day on atrial fibrillation remains unknown. More randomized trials of low to moderate alcohol consumption are needed for more definitive conclusions. In stark contrast, heavier alcohol consumption such as binge drinking or consuming on average ≥3 drinks/d is consistently associated with worse outcomes in every cardiovascular disease entity studied. Considering the level of evidence, it remains unknown whether drinking is part of a healthy lifestyle and therefore clinicians should reinforce healthy lifestyle behaviors such as regularly engaging in physical activity, avoiding tobacco use, and maintaining healthy body weight.

BACKGROUND: The 21st Century Cures Act Information Blocking Rule mandates patient access to all information in their electronic medical record (EMR) without delay, cost, or special effort. Prior research into patient portal use in hospitalized adults is limited.

OBJECTIVE: To better understand the characteristics of hospitalized adults who have an existing patient portal account and identify demographic factors associated with accessing information via the patient portal while hospitalized.

METHODS: This single-center, cross-sectional observational study analyzed adult hospitalizations from April 5, 2021, to March 31, 2023, at Beth Israel Deaconess Medical Center (BIDMC). The primary outcome was the proportion of hospitalized patients who had an active BIDMC EMR account ("PatientSite").

RESULTS: Of the 43,588 patients included in our analytic cohort, 13,517 (31.0%) had an active PatientSite account during their hospitalization and of those, 7311 (54.0%) accessed their account while hospitalized. A total of 62% of patients who logged into their portal also accessed clinician notes. After multivariable adjustment, patients who were older, Black, male, non-English speaking, covered by Medicaid, or from out-of-state were less likely to have an active PatientSite account. Similar disparities were found in PatientSite login and accessing clinician notes, albeit smaller in magnitude than the observed disparities in having an active account.

CONCLUSIONS: This study highlights low patient portal utilization among hospitalized patients and disparities in access based on race/ethnicity, gender, age, and insurance status.

IMPORTANCE: People with type 2 diabetes and hypertension are at high risk for blood pressure-related cardiovascular events. Few trials have tested the blood pressure-lowering effects of dietary interventions other than weight loss in this population.

OBJECTIVE: To determine the effects of dietary patterns and sodium reduction on blood pressure in adults with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS: Dietary Approaches to Stop Hypertension for Diabetes (DASH4D) was a randomized 4-period crossover feeding study conducted at a community-based study center from June 2021 to June 2024. It included adults with type 2 diabetes, a systolic blood pressure of 120 to 159 mm Hg, and a diastolic blood pressure of less than 100 mm Hg. The DASH4D diet is a Dietary Approaches to Stop Hypertension (DASH)-style diet optimized for people with type 2 diabetes (lower carbohydrates, higher unsaturated fats, and lower potassium than the original DASH diet). Participants were provided all of their food and ate no outside food. Weight was held constant. Data analysis was completed in November 2024.

INTERVENTIONS: Participants were randomized to a sequence of 4 diets, each for 5 weeks: (1) DASH4D diet with lower sodium, (2) DASH4D diet with higher sodium, (3) comparison (typical US) diet with lower sodium, and (4) comparison diet with higher sodium (reference).

MAIN OUTCOMES AND MEASURES: The primary and secondary outcomes were end-of-period systolic and diastolic blood pressure, respectively. The primary dietary contrast compared the DASH4D lower sodium diet vs a comparison higher sodium diet.

RESULTS: Of 102 participants, 85 (83.3%) completed all diet periods. The mean (SD) age was 66 (8.8) years, 67 (66%) were women, 6 (6%) were self-reported Asian, 89 (87%) were Black, 2 (2%) were Hispanic, 6 (6%) were White, mean (SD) baseline blood pressure was 135 (9)/75 (9) mm Hg, and 67 (66%) used 2 or more antihypertensive medications. Compared with the comparison diet with higher sodium, the DASH4D diet with lower sodium reduced end-of-period systolic blood pressure by 4.6 mm Hg (95% CI, 7.2-2.0; P < .001) and diastolic blood pressure by 2.3 mm Hg (95% CI, 3.7-0.9). Most blood pressure reduction occurred during the first 3 weeks of each diet, and the effect of sodium reduction appeared stronger than the effect of the DASH4D diet. Adverse events were infrequent in each diet.

CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that, for adults with type 2 diabetes, most of whom were treated with multiple antihypertensive medications, the DASH4D diet combined with sodium reduction achieved a clinically relevant reduction in blood pressure, primarily from sodium reduction.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04286555.

Coronary artery calcification (CAC) is the most reliable noninvasive predictor of major adverse cardiovascular events (MACE). Individuals with no detectable or minimal CAC (Agatston score 1-100) are considered at the lowest risk. However, MACE do occur in these groups. This study evaluated whether quantification of cardiac vagal activity by heart rate fragmentation (HRF) improved MACE risk prediction beyond CAC imaging. Our study population is a cohort of the Multi-Ethnic Study of Atherosclerosis (MESA). Cox regression models were used to assess the association between HRF, derived from polysomnographic ECGs, and incident MACE in the overall cohort with concurrent polysomnographic ECG and CAC data, and three non-overlapping subgroups: "very-low-risk" (CAC = 0), "low-risk" (0 < CAC < 100), and "higher-risk" (CAC ≥ 100). Over a median (1st; 3rd quartiles) follow-up period of 8.9 (8.4; 9.4) years, there were 164, 29, 47 and 88 incident MACE in the overall cohort (n=1,354), very-low-risk (n=495), low-risk (n=422) and higher-risk (n=437) subgroups, respectively. A one-standard deviation increment in HRF was associated with a 22% (3% - 44%) and a 60% (16% - 122%) increase in the rate of MACE in the overall cohort and those without detectable CAC, respectively. Neither the Framingham nor MESA-CAC index was predictive of MACE in the lowest-risk subgroup until nearly a decade of follow-up. From a physiologic perspective, our results suggest that vagal dysfunction precedes the onset of overt cardiovascular disease (CVD). From a translational perspective, they indicate that HRF enhances risk stratification, especially in populations traditionally classified as very-low risk.