Rationale and Design of the Groceries for Black Residents of Boston to Stop Hypertension Among Adults Without Treated Hypertension (GoFresh) Trial.

BACKGROUND: Poor diet quality significantly contributes to hypertension disparities affecting Black adults. While the Dietary Approaches to Stop Hypertension (DASH) eating pattern lowers blood pressure (BP), access to DASH-patterned groceries is a major barrier for residents of urban food deserts. METHODS: The Groceries for Black Residents of Boston to Stop Hypertension among Adults without Treated Hypertension (GoFresh) study is one of five projects in the RESTORE Network, an AHA-funded initiative focused on hypertension prevention. GoFresh is testing whether online, dietitian-assisted, home-delivered, DASH-patterned groceries lowers BP among Black adults with elevated BP. This individual-level, parallel-arm trial will enroll up to 176 Black adults with SBP (systolic blood pressure) between 120 and <150 mm Hg residing in Boston-area communities with reduced grocery store access. Following randomization, half of the participants will be assigned to weekly sessions with a dietitian who will assist participants in ordering DASH-patterned groceries online for home delivery; the remainder will receive a $500 monthly stipend. Both interventions will last 3 months, followed by a 9-month maintenance phase. RESULTS: The primary outcome is the difference in SBP after 3 months. Secondary outcomes include a change in 24-hour ambulatory BP, body mass index, 24-hour urine sodium and potassium, hemoglobin A1C, lipids, fruit and vegetable intake, and saturated fat intake. Qualitative interviews with 45 participants 6 months after baseline assessments will determine barriers and facilitators to long-term maintenance of DASH-patterned grocery shopping. DISCUSSION: Findings from this study will inform ongoing work on scalable interventions to prevent hypertension among Black adults with implications for public and healthcare-based food supplementation programs. TRIAL REGISTRATION: NCT05121337. Registered on 16 November 2021, at ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/NCT05121337.

Effects of Vitamin D with Calcium and Associations of Mean 25-Hydroxyvitamin D Levels with 3-Year Change in Muscle Performance in Healthy Older Adults in the Boston STOP IT Trial.

PURPOSE: The purpose of this analysis was to assess whether (1) daily vitamin D3 plus calcium supplementation vs. placebo or (2) the mean 25-hydroxyvitamin D [25(OH)D] level achieved during a 3-year trial was associated with muscle performance or balance in the Boston STOP IT study. Methods We conducted exploratory analyses in 386 men and women age 65 years and older who participated in the Boston STOP IT trial and had one or more muscle performance or balance assessments at baseline and 3 years. Participants were treated with 700 IU of vitamin D3 plus 500 mg of calcium or with double placebo daily for 3 years. Plasma 25(OH)D was measured at baseline, 6, 12, 18, 24, and 36 months; muscle performance (timed walk, grip strength, and chair-rise) and two balance tests, the one-leg stand and tandem stand, were assessed at baseline and 3 years only. Results Supplementation with vitamin D3 and calcium had no favorable effect on any muscle performance measure. The 3-year mean 25(OH)D levels were 22.7 ± 6.3 (SD) in the placebo and 30.8 ± 7.5 ng/ml in the supplemented groups (p < 0.001). The 3-year mean 25(OH)D level was positively associated with change in one-leg stand time (p = 0.04), but not with the other measures. Conclusion Vitamin D3 and calcium supplementation had no favorable effect on muscle performance or balance in this relatively healthy older population. A higher 3-year mean 25(OH)D level may favor balance, as indicated by longer one-leg stand time, but this observation should be confirmed.

Manual Therapy and Related Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis.

Objective: Systematic review and meta-analysis to assess the efficacy of Manual therapy and related interventions in the treatment of carpal tunnel syndrome (CTS) based on Boston carpal tunnel questionnaire. Design: Systematic review and meta-analysis. Subjects: Carpal tunnel syndrome. Interventions: Manual therapy and related interventions versus other therapies or manual therapy and related interventions plus other therapies versus other therapies. Outcomes measures: Boston carpal tunnel questionnaire. Results: A total of 6 studies were included, including 211 cases in the manual therapy group and 211 cases in the control group. The quality of the included articles was high, and the results of meta-analysis showed that manual therapy and related interventions were superior in terms of improving the Boston carpal tunnel questionnaire Symptom Severity score in patients with CTS (standardised mean difference [SMD] -1.13, 95% CI -1.40 to -0.87), were superior to control groups in terms of improving the Boston carpal tunnel questionnaire functional capacity scale in patients with CTS (SMD -1.01,95% CI -1.24 to -0.77). Conclusion: The results of this meta-analysis suggested that manual therapy and related interventions were better than control groups in treating CTS. Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS. Registration: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; No. CRD 42020201389). Contribution of the Article: Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS.

Intra-trial Mean 25(OH)D and PTH Levels and Risk of Falling in Older Men and Women in the Boston STOP IT Trial.

CONTEXT: Supplementation with vitamin D has the potential to both reduce and increase risk of falling, and parathyroid hormone (PTH) may contribute to fall risk. OBJECTIVE: To assess the associations of intra-trial mean circulating levels of 25-hydroxyvitamin D [25(OH)D] and PTH on incident falls in healthy older adults. DESIGN: Observational within a clinical trial. SETTING: The Bone Metabolism Laboratory at the USDA Nutrition Center at Tufts University. PARTICIPANTS: 410 men and women age ≥65 years who participated in the 3-year Boston STOP IT trial to determine the effect of supplementation with 700 IU of vitamin D3 plus calcium on incident falls (secondary endpoint). Intra-trial exposures of 25(OH)D and PTH were calculated as the mean of biannual measures up to and including the first fall. MAIN OUTCOME MEASURES: Incidence of first fall. RESULTS: Intra-trial mean 25(OH)D was significantly associated with risk of falling in a U-shaped pattern; the range associated with minimal risk of falling was approximately 20 to 40 ng/mL. PTH was not significantly associated with risk of falling. CONCLUSIONS: The findings highlight the importance of maintaining the circulating 25(OH)D level between 20 and 40 ng/mL, the range that is also recommended for bone health. At PTH levels within the normal range, there was no detectible independent association of PTH with fall risk.

Reflection on young adult transitional care in the Boston Children's Hospital Perioperative Care Coordination Clinic.

THEORETICAL PRINCIPLES: The complexity of pediatric healthcare has increased due to advancement in research and identification of new treatment modalities. With these advancements, life expectancy has increased creating a greater need for young adult transition into adult medical settings and specialty care (Marani et al., 2020). The holistic approach of nursing care is essential in assisting young adults during this transitional period. PHENOMENON ADDRESSED: Many pediatric hospitals and subspecialties continue to care for young adults ≥18 years of age that have not transitioned to adult care. In the perioperative care coordination clinic at Boston Children's Hospital, pediatric nurses and advanced practice nurse practitioners provide care to patients from infancy to adulthood, throughout many specialties, to ensure safe perioperative care for a medically complex surgical population. The purpose of this paper is to describe the PCCC young adult care coordination process that provides engaging opportunities for the young adult to advocate for oneself and promote autonomy as they proceed through the stages of transition to adult care. RESEARCH LINKAGES: The perioperative care coordination process at Boston Children's Hospital aligns with the Society of Pediatric Nurses position statement that recommended pediatric nurses utilize a framework (Betz, 2017) and Meleis' middle-range theory of Transitions that identified the nursing role during the transitional process (Meleis et al., 2000). A suggestion for future nursing research includes development of a nursing framework that nurses can utilize when supporting young adults during their progression through the steps of transition from pediatric to adult perioperative programs.

Sufficient Plasma Vitamin C Is Related to Greater Bone Mineral Density among Postmenopausal Women from the Boston Puerto Rican Health Study.

BACKGROUND: Vitamin C may benefit bone as an antioxidant. OBJECTIVES: This cross-sectional study evaluated associations between dietary, supplemental, and plasma vitamin C with bone mineral density (BMD) among Puerto Rican adults. METHODS: Diet was assessed by food-frequency questionnaire (n = 902); plasma vitamin C, measured in fasting blood (n = 809), was categorized as sufficient (≥50 µmol/L), insufficient (20-49 µmol/L), or low (<20 µmol/L). Associations between vitamin C and BMD (measured by DXA) were tested, with false discovery rate correction for multiple comparisons, and interactions by smoking, sex, and estrogen status. Least-squares mean BMDs were compared across tertiles of diet and plasma vitamin C. RESULTS: Participants' mean age was 59 ± 7 y (range: 46-78 y), 72% were women, mean dietary vitamin C was 95 ± 62 mg/d, and plasma vitamin C ranged from 1.7 to 125 µmol/L. No associations were observed between dietary vitamin C and BMD (P-value range: 0.48-0.96). BMD did not differ by vitamin C supplement use (P-value range: 0.07-0.29). Total femur BMD was higher (P = 0.04) among plasma vitamin C-sufficient participants (mean: 1.06; 95% CI: 1.035, 1.076 g/cm2) compared with low plasma vitamin C participants (1.026; 0.999, 1.052 g/cm2) in adjusted models. Findings at the trochanter were similar (P = 0.04). Postmenopausal women without estrogen therapy, with sufficient plasma vitamin C, showed greater total femur BMD (1.004 ± 0.014 g/cm2) compared to those with low plasma vitamin C (0.955 ± 0.017 g/cm2; P = 0.001). Similar findings were observed at the trochanter (P < 0.001). No significant associations were observed among premenopausal women or those with estrogen therapy or men. Interactions with smoking status were not significant. CONCLUSIONS: Dietary vitamin C was not associated with BMD. Low plasma vitamin C, compared with sufficiency, was associated with lower hip BMD, particularly among postmenopausal women without estrogen therapy. Future research is needed to determine whether vitamin C status is associated with change in BMD or reduction in fracture risk.

Effective recruitment strategies in an exercise trial for patients with fibromyalgia.

BACKGROUND: Recruitment of fibromyalgia populations into long-term clinical trials involving exercise interventions is a challenge. We evaluated the cost and randomization yields of various recruitment methods used for a fibromyalgia trial in an urban setting. We also investigated differences in participant characteristics and exercise intervention adherence based on recruitment source. METHODS: We recruited individuals with fibromyalgia in the greater Boston area to a randomized controlled trial (RCT) using six recruitment strategies: newspaper advertisements, web advertisements, flyers, clinic referrals, direct mailing to patients in a clinic database, and word of mouth. We used the American College of Rheumatology 1990 and 2010 diagnostic criteria to screen and enroll participants. During an initial phone call to an interested participant, the study staff asked how they heard about the study. In this study, we compared the cost and yield of the six recruitment strategies as well as baseline characteristics, adherence, and attendance rates of participants across strategies. RESULTS: Our recruitment resulted in 651 prescreens, 272 screening visits, and 226 randomized participants. Advertisements in a local commuter newspaper were most effective, providing 113 of 226 randomizations, albeit high cost ($212 per randomized participant). Low-cost recruitment strategies included clinical referrals and web advertisements, but they only provided 32 and 16 randomizations. Community-based strategies including advertisement and flyers recruited a more racially diverse participant sample than clinic referrals and mailing or calling patients. There was no evidence of difference in adherence among participants recruited from various strategies. CONCLUSIONS: Newspaper advertisement was the most effective and most expensive method per randomized participant for recruiting large numbers of individuals with fibromyalgia in an urban setting. Community-based strategies recruited a more racially diverse cohort than clinic-based strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT01420640 . Registered on 19 August 2011.

Folate Deficiency in an Urban Safety Net Population.

PURPOSE: Since mandatory fortification of grain products with folic acid in the United States in 1998, folate deficiency has become rare. Some have suggested that serum folate levels should be tested rarely in countries with mandatory folic acid fortification, given low rates of deficiency, high cost per deficiency diagnosis, and low rates of supplementation for those diagnosed as deficient. Given persistent racial, ethnic, and socioeconomic disparities in folate deficiency, these suggestions may not apply to all populations. We examine the rate at which serum testing detected folate deficiency in an urban safety net hospital and the characteristics of folate-deficient patients. METHODS: We reviewed the charts of all inpatients and emergency department patients with low serum folate results at a safety net hospital in Boston in 2018. We collected data concerning demographics, social determinants of health, clinical factors, and whether folate supplementation was prescribed. Finally, we performed a cost analysis. RESULTS: Of 1368 patients tested, 76 (5.5%) met criteria for folate deficiency. Overall, 86.8% of these patients were anemic, and 17.1% had macrocytic anemia; 42% were diagnosed with malnutrition. Common social determinants in folate-deficient patients included birth outside of the United States, homelessness, and alcohol use disorder. Of folate-deficient patients, 88% were newly prescribed folic acid supplementation at discharge. The estimated charge per deficient test was $1278. CONCLUSION: Compared with a nearby institution, serum folate testing at our safety net hospital detected deficiency at a higher rate, incurred a lower charge per deficient test, and was more likely to impact management.

Effectiveness of Conservative Treatment According to Severity and Systemic Disease in Carpal Tunnel Syndrome: A Systematic Review.

(1) Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the upper extremity. Conservative treatment has been effective for mild and moderate idiopathic CTS. However, severe CTS and systemic conditions were an exclusion criterion from the studies. The aim of this study is to review the effectiveness of conservative treatment in patients with CTS regardless of the level of severity and the presence or not of systemic diseases in the last ten years. (2) Methods: Randomized controlled clinical trials that compared the effect of conservative treatment on the Boston questionnaire and pain were selected. PubMed, PEDro, Scopus, Cochrane, and Web of Science databases were used. PRISMA statement checklist was performed. (3) Results: 876 studies were recorded, 29 were selected. Pharmacology, Electrotherapy and Manual Therapy had benefits for CTS. Electrotherapy and manual therapy could be effective for severe CTS patients with a systemic condition in the short term, but there was a low percentage of these patients included in the studies. (4) Conclusion: Some pharmacological treatments, manual therapy and electrotherapy have shown benefits for handling CTS, although the most effective combination of techniques is unknown. It would be necessary to include patients with systemic conditions in the selection criteria for future studies.

Risk Factors Associated with Vitamin D Status among Older Puerto Rican Adults.

BACKGROUND: Vitamin D deficiency has been associated with health problems globally, but there is limited information on vitamin D status and associated risk factors among adults in underserved populations. OBJECTIVE: This study aimed to identify risk factors for vitamin D deficiency/insufficiency among Puerto Rican adults from the Boston Puerto Rican Health Study (BPRHS). METHODS: A total of 822 adults (45-75 y, at baseline) were included in these analyses. Deficiency was defined as serum 25-hydroxyvitamin D [25(OH)D] <30 and insufficiency as 30 to <50 nmol/L. Dietary intake was assessed with a validated FFQ. Associations between risk factors, including dietary vitamin D, supplement use, ancestry, skin pigmentation, months in the past year spent in a southern climate, and serum 25(OH)D were assessed with multivariable general linear models. RESULTS: Approximately 13% of participants were deficient in 25(OH)D and another 43% insufficient. Skin pigment was associated with 25(OH)D using 3 measures, greater African ancestry (ß ± SE) (-7.74 ± 2.91, P = 0.01); interviewer assessed dark or medium, compared with white, skin tone, (-5.09 ± 2.19, P = 0.02 and -5.89 ± 1.58, P < 0.001, respectively); and melanin index of the upper inner right arm, assessed using a spectrophotometer (-2.04 ± 0.84, P = 0.02). After adjusting for ancestry, factors associated with lower serum 25(OH)D included smoking (-4.49 ± 1.58, P = 0.01); BMI (-0.21 ± 0.10, P = 0.04); and spring compared with autumn blood draw (-4.66 ± 1.68, P = 0.004). Factors associated with higher serum 25(OH)D included female sex compared with male (4.03 ± 1.58, P = 0.01); dietary vitamin D intake µg/d (0.71 ± 0.25, P < 0.004); vitamin D supplement use (4.50 ± 1.87, P = 0.02); income to poverty ratio (0.01 ± 0.01, P = 0.06), and months in a southern climate during the past year (0.96 ± 0.56, P = 0.09). CONCLUSIONS: Vitamin D deficiency/insufficiency was prevalent in this Puerto Rican population living in the northeastern USA. Several factors were associated with this, which may assist in identifying those at risk. Interventions are needed to improve serum 25(OH)D concentration, particularly among those with limited exposure to sunlight.

Temporal Assessment of Prognostic Factors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Neoadjuvant Treatment and Resection.

BACKGROUND: The clinicopathologic factors associated with the survival of patients with pancreatic ductal adenocarcinoma (PDAC) during the different phases of neoadjuvant treatment (NT)-at diagnosis, restaging, or postoperatively-remain unclear. METHODS: Data of patients with PDAC who underwent pancreatic resection after NT between 2008 and 2018 were retrospectively collected. Clinicopathologic characteristics and outcomes were compared stratified by resection margin status. Three multivariable regression models (at diagnosis, restaging, and postoperatively) were constructed to assess the temporal impact of different prognostic factors on all-cause survival (ACS) and disease-free survival (DFS). RESULTS: All patients were diagnosed with a nonmetastatic PDAC and were appropriate candidates for NT according to the current National Comprehensive Cancer Network guidelines. From a total of 83 patients, 57 (68.7%) had a negative resection margin >1 mm (R0), whereas 26 patients (31.3%) had a positive resection margin (R1). At diagnosis, planned procedure (P = 0.017) and CA19-9 >100 U/mL (P = 0.047) were independent prognostic factors of decreased ACS. At restaging, planned procedure (P = 0.017), FOLFIRINOX (P = 0.026), and tumor size >30 mm (P = 0.030) were independent prognostic factors for increased and decreased ACS, respectively. Postoperatively, R0 was an independent prognostic factor for improved ACS (P = 0.005) and DFS (P = 0.002), whereas adjuvant therapy (P = 0.006) was associated with increased ACS. Lymph node involvement (P = 0.019) was associated with decreased DFS. CONCLUSIONS: At diagnosis, restaging, and postoperatively, different, relevant clinicopathologic factors significantly impact the survival of patients with nonmetastatic PDAC undergoing NT. An R0 resection remains the most important prognostic factor and therefore should be the primary goal of surgical treatment in the neoadjuvant setting.

Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features: Epidemiology and Long-Term Outcomes in a Strictly Defined Cohort.

Background: A subset of encapsulated/circumscribed follicular variant of papillary thyroid carcinoma (FVPTC) was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in 2016 to reduce overtreatment of a low-risk tumor. Study objectives were to describe the epidemiology and long-term outcomes of NIFTP in a high-volume, urban, tertiary referral center. Methods: Among patients enrolled in the Boston Medical Center (BMC) Thyroid Cancer Registry, 110 cases of FVPTC underwent index thyroid surgery at BMC between 2000 and 2016. Historically, BMC pathologists assess all malignant nodules using sections ≤0.3 cm with evaluation of the entire nodule and capsule. After review of pathology reports to identify potential NIFTPs, slides were rereviewed using criteria established by the NIFTP Working Group in 2016 and 2018. We evaluated interobserver reliability using Cohen's Kappa coefficient. Results: Among 110 FVPTCs, 15 (13%) met NIFTP criteria; 11 women and 4 men, age range 31-64 (mean 47.5) years. Mean tumor diameter was 1.7 cm (compared with 2.2 cm for FVPTC). Among NIFTP cases, there were no lymph node metastases, distant metastases, or tumor recurrences. All NIFTP cases were American Thyroid Association (ATA) low risk compared with only 68% of FVPTC (p = 0.011). Among FVPTCs, 14% had positive lymph nodes at index operation. Four patients (4%) had distant metastases. Mean follow-up time was 46 and 69 months for FVPTC and NIFTP, respectively. Among FVPTCs with an excellent response to therapy (2015 ATA guidelines), there were no recurrences. Just over half (n = 8) of patients with NIFTP received postoperative radioactive iodine (RAI) therapy. Concordance between pathologists was high for ruling out NIFTP (75%), but only 36% for ruling in NIFTP. Overall, for NIFTP designation, Cohen's Kappa was 0.39, which is considered fair. Conclusions: Although this is a relatively small cohort, all NIFTP specimens underwent updated pathology review consistent with current guidelines; mean follow-up was nearly 6 years. NIFTP represents a small fraction of the total papillary neoplasia diagnosed at this tertiary referral center (2.3%). None of the NIFTP cohort experienced an adverse oncologic event, and there were no regional or distant metastases. Over 50% of patients with NIFTP received RAI. Thus, the NIFTP reclassification may substantially reduce the number of patients who require adjuvant therapies, such as completion surgery or RAI.

Avoidable Serum Potassium Testing in the Cardiac ICU: Development and Testing of a Machine-Learning Model.

OBJECTIVES: To create a machine-learning model identifying potentially avoidable blood draws for serum potassium among pediatric patients following cardiac surgery. DESIGN: Retrospective cohort study. SETTING: Tertiary-care center. PATIENTS: All patients admitted to the cardiac ICU at Boston Children's Hospital between January 2010 and December 2018 with a length of stay greater than or equal to 4 days and greater than or equal to two recorded serum potassium measurements. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected variables related to potassium homeostasis, including serum chemistry, hourly potassium intake, diuretics, and urine output. Using established machine-learning techniques, including random forest classifiers, and hyperparameter tuning, we created models predicting whether a patient's potassium would be normal or abnormal based on the most recent potassium level, medications administered, urine output, and markers of renal function. We developed multiple models based on different age-categories and temporal proximity of the most recent potassium measurement. We assessed the predictive performance of the models using an independent test set. Of the 7,269 admissions (6,196 patients) included, serum potassium was measured on average of 1 (interquartile range, 0-1) time per day. Approximately 96% of patients received at least one dose of IV diuretic and 83% received a form of potassium supplementation. Our models predicted a normal potassium value with a median positive predictive value of 0.900. A median percentage of 2.1% measurements (mean 2.5%; interquartile range, 1.3-3.7%) was incorrectly predicted as normal when they were abnormal. A median percentage of 0.0% (interquartile range, 0.0-0.4%) critically low or high measurements was incorrectly predicted as normal. A median of 27.2% (interquartile range, 7.8-32.4%) of samples was correctly predicted to be normal and could have been potentially avoided. CONCLUSIONS: Machine-learning methods can be used to predict avoidable blood tests accurately for serum potassium in critically ill pediatric patients. A median of 27.2% of samples could have been saved, with decreased costs and risk of infection or anemia.

Serum Vitamin D and Depressive Symptomatology among Boston-Area Puerto Ricans.

BACKGROUND: Low vitamin D status, assessed using serum 25-hydroxyvitamin D [25(OH)D] concentration, has been associated with depression, but research among minority populations, such as Puerto Ricans is limited. We examined the association between serum 25(OH)D and self-reported depressive symptomatology across 3 waves of follow-up in a cohort of Puerto Rican adults residing in Massachusetts. OBJECTIVES: We evaluated the cross-sectional and longitudinal associations between serum 25(OH)D and self-reported depressive symptoms in the Boston Puerto Rican Health Study (BPRHS) cohort. METHODS: Participants of the BPRHS were evaluated for depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). Serum 25(OH)D was measured at baseline (n = 1434), year 2 (n = 1218), and year 5 (n = 914). We categorized serum 25(OH)D concentration as sufficient (≥20 ng/mL), insufficient (12 to <20 ng/mL), and deficient (<12 ng/mL). Multivariable linear regression was used for cross-sectional analyses at baseline, and repeated measures mixed effects modeling was used over 3 waves of follow-up for longitudinal analyses. We conducted sensitivity analyses in vitamin D supplement nonusers and participants with complete data on baseline serum 25(OH)D and CES-D at all 3 visits. RESULTS: Serum 25(OH)D concentration was not associated with CES-D score in cross-sectional analysis [ß = -0.85; 95% CI: -2.80, 1.10 for deficient compared with sufficient 25(OH)D; P-trend = 0.59] or in longitudinal analyses over 5 y [ß = -0.41; 95% CI: -1.95, 1.13 for deficient compared with sufficient 25(OH)D; P-trend = 0.93]. Results were similar in sensitivity analyses restricted to vitamin D supplement nonusers (n = 1371) and in analyses conducted in participants with complete measures of baseline serum 25(OH)D and CES-D score at all 3 visits (n = 887) [ß = -0.12; 95% CI: -1.98, 1.74 for deficient compared with sufficient 25(OH)D; P-trend = 0.93]. CONCLUSIONS: We did not observe a significant association between serum 25(OH)D and depressive symptomatology in the BPRHS cohort.

Trends in reported industry payments to physicians practicing cardiac electrophysiology from 2013 to 2018 in the United States.

INTRODUCTION: The need for transparency in financial relationships in the healthcare system, has culminated in Open Payments database, managed by the Center for Medicare and Medicaid Services (CMS). Since its inception in 2013, the trend in such payments to physicians practicing cardiac electrophysiology was not examined. METHODS AND RESULTS: Payment information reported to CMS from January 2013 to December 2018 was obtained from the publicly available Open Payments data set using the online query tool. The data were analyzed by an individual provider and by state. An in-depth analysis of payments in the year 2018 payments was performed. From 2014 to 2018, there was an 18% increase in the total number of payments reported from 88 877 payments in 2014 to 105 000 in 2018. Despite the increase in the total number of payments reported, the average payment steadily decreased over time, resulting in an overall reduction in the total amount of payments from 2014 to 2018 ($34.9 million to $28.2 million). Payments to the top 5% of individual recipients have also decreased over this time. In 2018, 2888 unique providers received reportable payments, a total of 105 000 payments, with a median payment amount of $1378 (interquartile range: $165-$5781). The majority of these payments were for food and beverage (82%) and travel/lodging (10%). The top five payers include Boston Scientific, Medtronic Vascular, Abbott Laboratories, Janssen Pharmaceuticals, and Biotronik. CONCLUSION: Among cardiac electrophysiologists, there is increased reporting of payments in the Open Payments program over time, with a notable decrease in the payment amount.

A Yoga-Based Program Decreases Physician Burnout in Neonatologists and Obstetricians at an Academic Medical Center.

BACKGROUND: Nearly half of U.S. pediatricians have symptoms of burnout. This pilot study examined the feasibility of a 6-week yoga-based program (RISE) for neonatologists and obstetricians at Brigham and Women's Hospital and studied the effects on burnout, professional fulfillment, and psychological health. METHODS: Participants were recruited via email to participate either in both program and research study, or exclusively the program. RISE was delivered 1 hour/week during the workday for 6 consecutive weeks either in-person or remotely; 18 physicians participated, 12 completed post-program, and 11 completed 2-month follow-up. The questionnaires assessed burnout and measures of psychological health, professional fulfillment, work exhaustion, interpersonal disengagement/burnout (PFI), mindfulness (FFMQ), perceived stress (PSS), positive/negative affect (PANAS), resilience (RS), anxiety/depression/sleep disturbances (PROMIS), at baseline, post-program, and 2 months after RISE. FINDINGS: Average attendance in-person was 2.8 sessions and remotely 1.4 sessions (4.2/6 sessions). Participants demonstrating total burnout reduced from 50.0% at baseline to 9.1% post-program. Participants demonstrating professional fulfillment were 8.3% at baseline and 27.3% post-program. Paired samples t-tests revealed statistically significant improvements in burnout, professional fulfillment, interpersonal disengagement, stress, resilience, anxiety, and depression at post-program compared with baseline (N = 12, all ps < .05). At 2-month follow-up, statistically significant improvements in interpersonal disengagement, resilience, and mindfulness (N = 11, all ps < .05) compared with baseline were reported. CONCLUSIONS/APPLICATION TO PRACTICE: RISE is feasible within a workday and may address burnout and other psychological health measures in physicians with effects potentially sustainable over 2 months. Occupational health practitioners in health care should consider this type of intervention for their workers.

Transcending the Profession: Psychiatric Patients' Experiences of Trust in Clinicians.

Classical medical sociological theory argues patients trust doctors in part because they are professionals. Yet in the past half-century, medicine has seen a crisis of trust as well as fundamental changes to the nature of professionalism. To probe the relationship between professionalism and trust today, we analyzed interviews with 50 psychiatric patients receiving care in diverse clinical settings. We found patients experience trust when they perceive clinicians transcending the formal bounds of professionalism. Patients find clinicians to be trustworthy when clinicians pursue connections to their patients beyond organizational strictures, cross boundaries of professional jurisdiction to provide holistic care, and embrace the limits of their professional knowledge. This dynamic of trust in professionals who transcend the profession highlights novel dimensions of contemporary professionalism, and it makes sense of a seeming contradiction in which patients have high trust in individual clinicians but low trust in institutions.

Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission.

BACKGROUND: Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS: We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS: An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

Targeting cognitive and emotional regulatory skills for smoking prevention in low-SES youth: A randomized trial of mindfulness and working memory interventions.

Research to date provides striking evidence that youth from low socio-economic status (SES) households are at an increased risk for smoking. Converging evidence from developmental studies, psychopathology studies, intervention studies, and basic research on self-control abilities have identified working memory and distress tolerance as potential crucial modifiable risk factors to prevent smoking onset in this cohort. To confirm the value of these mechanistic targets, this randomized trial was designed to evaluate the influence of working memory and distress tolerance interventions on risk of smoking initiation. Recruiting primarily from low-income community afternoon programs, we randomized 93 adolescents to one of three intervention conditions, all of which were a prelude to a smoking-prevention informational intervention: (1) a working memory intervention, (2) a mindfulness training intervention to target distress tolerance, and (3) a wellness-focused control condition. Despite a number of adherence efforts, engagement in treatment was limited, and under these conditions no significant evidence was found either for differential efficacy for smoking prevention or for intervention effects on mechanistic targets. However, working memory capacity and distress tolerance were found to be negatively related to smoking propensity. As such, our mechanistic targets-working memory and distress tolerance--may well be processes undergirding smoking, despite the fact that our interventions did not adequately engage these targets.