Jamaica Plain Research Articles

Amnesia as an Adverse Event Associated With Fentanyl: An Analysis of the US Food and Drug Administration Adverse Event Reporting System, 2011-2021.

*Department of Medicine, Soldiers’ Home, Chelsea ‡Massachusetts Department of Public Health, Jamaica Plain, MA †Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA W.A.K.: funded by 1R01NS082309-01A1. Serves as a legal consultant for multiple legal and health care entities. Receives royalty payments Oxford University Press and Elsevier, as well as honoraria from National Institutes of Health study sections. Serves on editorial boards for Neurocritical Care and Journal of Neurosurgical Anesthesiology. Coauthored provisional patent number 17-8261/103241.000816 Trustees of the University of Pennsylvania. The remaining authors have no conflicts of interest to declare. Address correspondence to: Jed A. Barash, MD, Department of Medicine, Soldiers' Home, 91 Crest Avenue, Chelsea, MA 02150; telephone: (617) 884-5660; e-mail: [email protected]

Addressing inequities in headache care by embedding services in a community health center in Boston, MA.

There is a critical need to diagnose and treat headache disorders in primary care settings. This is especially true for those who face systemic barriers to healthcare access due to racism or poverty. In order to target those at higher risk of disability associated with neurologic disease in our healthcare system, we embedded a specialized headache and neurology clinic within the Brigham and Women's Hospital Southern Jamaica Plain Community Health Center in Boston, MA. The goal was to create a sustainable, integrated clinic consistent with the CHC's racial justice mission, with an emphasis on equitable care, awareness of structural barriers to care, improved communication with primary care and inclusion of trainees as important members of a healthcare team. In its' first year, the clinic had over 400 patient visits, with a near-perfect rate of completion of consults. In addition to improved access to tertiary care headache services, successes have included improving continuity of care, cultivating a model of shared care with primary care practitioners and stimulating interest in headache medicine among staff and trainees. Challenges have included the use of staff time to complete prior authorizations, and the need to find or develop Spanish-language and culturally appropriate patient educational resources. By providing care within the patient's medical home, the headache specialist gains a deeper appreciation of a patient's social determinants of health and can readily access resources to navigate barriers. The personal and professional fulfillment that headache specialists may experience while doing this important work could help protect against burnout. Sustainability depends on ensuring equitable provider reimbursement; departmental and institutional support is essential. We believe this clinic can serve as a model for specialists throughout the United States who wish to improve the delivery of care to patient populations who face access barriers.

It's Time to Talk About Fear.

It's Time to Talk About Fear.

Non-S Sickling Hemoglobin Variants: Historical, Genetic, Diagnostic, and Clinical Perspectives.

Apart from hemoglobin-S (HbS), there are other Hb variants (non-S sickling Hb variants) that cause sickle cell disease. However, the profiles of these non-S sickling Hb variants have neither been collated nor harmonized. A literature search revealed 14 non-S sickling Hb variants (HbC-Harlem, HbC-Ziguinchor, HbS-Travis, HbS-Antilles, HbS-Providence, HbS-Oman, HbS-Cameroon, HbS-South End, Hb Jamaica Plain, HbC-Ndjamena, HbS-Clichy, HbS-San Martin, HbS-Wake, and HbS-São Paulo). Generally, the non-S sickling Hb variants are double mutants with the HbS mutation (GAG>GTG: βGlu6Val) and additional β-chain mutations. Consequently, non-S sickling Hb variants give positive solubility and sickling tests, but they differ from HbS with respect to stability, oxygen affinity, and electro-chromatographic characteristics. Similarities and discrepancies between HbS and non-S sickling Hb variants create diagnostic pitfalls that can only be resolved by elaborate electro-chromatographic and/or genetic tests. It is therefore imperative that tropical hematologists should have a thorough understanding of these atypical sickling Hb variants. Collated and harmonized appraisal of the non-S sickling Hb variants have not been previously undertaken. Hence, this paper aims to provide a comprehensive but concise historical, genetic, comparative, diagnostic, and clinical overview of non-S sickling Hb variants. The elaborate techniques often required for precise diagnosis of non-S sickling Hb variants are regrettably not readily available in low resource tropical countries, which paradoxically carry the heaviest burden of sickling disorders. We strongly recommend that tropical countries should upgrade their diagnostic laboratory facilities to avoid misdiagnosis of these atypical Hb mutants.

530 Restless Legs Syndrome Prevalence and Severity Among Patients Treated with Buprenorphine and Naloxone for Opioid Use Disorder

Abstract Introduction Restless Legs Syndrome (RLS) is a sensory-motor neurological disorder which is associated with sleep disturbance and emotional distress. Opioid medications are effective treatments for RLS, and a high percentage of patients undergoing opioid withdrawal exhibit symptoms of RLS. Despite the known connection between RLS and opioids, there has been no assessment of RLS in patients actively treated with buprenorphine and naloxone for opioid use disorder (OUD). Methods We conducted a study to determine the prevalence of RLS among patients with OUD at an outpatient buprenorphine and naloxone clinic at Lemuel Shattuck Hospital in Jamaica Plain, Massachusetts. With the help of nurses, participants completed questionnaires which inquired about demographic information, previous opioid use, current medications, and RLS. Patients were categorized as having RLS if, according to the Cambridge-Hopkins Questionnaire, they answered positively to the four essential RLS criteria and if common mimics were not endorsed. A final determination of RLS status in those with ambiguous answers to RLS mimics was made by a trained sleep medicine physician (JWW). Results Participants (n=129) were primarily male (n=86; 66.7%), white (n=101; 78.3%), and the median age was 37.5 years. Approximately half of the sample (n=59; 45.7%) used medications for depression and/or anxiety. The median duration of buprenorphine and naloxone use was 3 years. 13.2% were judged to have RLS. RLS symptoms tended to be of moderate severity, disturb sleep to a moderate degree, and occur 5–15 days per month. There were no significant demographic or clinical differences in those with and without RLS. Of the 103 participants without suspected RLS, 15.5% (n=16) were taking a non-opioid medication known to treat RLS symptoms (e.g. gabapentin). Only 1/17 people (5.9%) with RLS were taking a treatment that would control such symptoms. Conclusion Approximately 13% of this sample currently taking buprenorphine and naloxone for OUD had RLS. RLS can greatly interfere with sleep and quality of life, and those with untreated or partially treated symptoms may be motivated to use unprescribed opioids to control them. With this in mind, clinicians treating OUD should be aware that there are effective non-opioid medications that can treat RLS. Support (if any):

The 60° Doppler Angle Correction Paradigm: Reality or Myth? (an Uncomfortable Truth?).

Journal of Ultrasound in MedicineVolume 40, Issue 10 p. 2227-2233 Commentary The 60° Doppler Angle Correction Paradigm Reality or Myth? (an Uncomfortable Truth?) Joseph F. Polak MD, MPH, Corresponding Author Joseph F. Polak MD, MPH [email protected] orcid.org/0000-0002-2459-083X Tufts University School of Medicine and Boston University School of Medicine, Boston, Massachusetts Address correspondence to Joseph F. Polak MD, MPH, Department of Radiology, Lemuel Shattuck Hospital, 170 Morton St, Jamaica Plain, Massachusetts 02130, USA. E-mail: [email protected]Search for more papers by this authorFrederick W. Kremkau PhD, Frederick W. Kremkau PhD Center for Experiential and Applied Learning, Wake Forest University School of Medicine, Winston-Salem, NCSearch for more papers by this author Joseph F. Polak MD, MPH, Corresponding Author Joseph F. Polak MD, MPH [email protected] orcid.org/0000-0002-2459-083X Tufts University School of Medicine and Boston University School of Medicine, Boston, Massachusetts Address correspondence to Joseph F. Polak MD, MPH, Department of Radiology, Lemuel Shattuck Hospital, 170 Morton St, Jamaica Plain, Massachusetts 02130, USA. E-mail: [email protected]Search for more papers by this authorFrederick W. Kremkau PhD, Frederick W. Kremkau PhD Center for Experiential and Applied Learning, Wake Forest University School of Medicine, Winston-Salem, NCSearch for more papers by this author First published: 23 December 2020 https://doi.org/10.1002/jum.15603Citations: 1 Received December 2, 2020, from the Department of Radiology, Lemuel Shattuck Hospital, Boston University School of Medicine, Boston Massachusetts, USA (J.F.P.); and Center for Experiential and Applied Learning, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA (F.W.K.). Manuscript accepted for publication December 3, 2020. All of the authors of this article have reported no disclosures. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume40, Issue10October 2021Pages 2227-2233 RelatedInformation

A case series of rapidly growing mycobacterial catheter-related bloodstream infections among immunocompetent patients

Rapidly growing mycobacteria (RGM) are ubiquitous in the environment and can cause a variety of human infections. Catheter-related bloodstream infections (CRBSI) caused by RGM have been reported predominantly among immunocompromised patients. Removal of central lines and antimicrobial therapy with at least 2 active agents are generally recommended for immunocompromised patients. RGM bloodstream infections (BSIs) are rare in immunocompetent patients and clinical data are very limited. Retrospective medical record review was conducted on patients with blood cultures positive for RGM from July 2012 through March 2015 at Lemuel Shattuck Hospital, a public teaching hospital in Jamaica Plain, Massachusetts, United States. RGM was suspected by presence of beaded Gram-positive bacilli on Gram staining of positive conventional blood cultures and it was confirmed as RGM by Massachusetts State Public Health Laboratory. Nineteen episodes of RGM BSI were identified in 17 patients who had no known immunocompromised conditions that predispose them to opportunistic pathogens. They were predominantly young male with history of intravenous drug use. Peripherally inserted central catheter (PICC) was present in all episodes of RGM BSI and 74% of them clinically improved with PICC removal alone without specific antibiotic therapy for RGM. They were followed up for median duration of 45 days (interquartile range 25–385). The patients remained alive and asymptomatic until the end of follow-up periods. In immunocompetent patients, removal of catheters alone without adding specific antibiotics may be sufficient for RGM CRBSI.

The Potential of Smartphone Apps in Informing Protobacco and Antitobacco Messaging Efforts Among Underserved Communities: Longitudinal Observational Study.

BackgroundPeople from underserved communities such as those from lower socioeconomic positions or racial and ethnic minority groups are often disproportionately targeted by the tobacco industry, through the relatively high levels of tobacco retail outlets (TROs) located in their neighborhood or protobacco marketing and promotional strategies. It is difficult to capture the smoking behaviors of individuals in actual locations as well as the extent of exposure to tobacco promotional efforts. With the high ownership of smartphones in the United States—when used alongside data sources on TRO locations—apps could potentially improve tobacco control efforts. Health apps could be used to assess individual-level exposure to tobacco marketing, particularly in relation to the locations of TROs as well as locations where they were most likely to smoke. To date, it remains unclear how health apps could be used practically by health promotion organizations to better reach underserved communities in their tobacco control efforts.ObjectiveThis study aimed to demonstrate how smartphone apps could augment existing data on locations of TROs within underserved communities in Massachusetts and Texas to help inform tobacco control efforts.MethodsData for this study were collected from 2 sources: (1) geolocations of TROs from the North American Industry Classification System 2016 and (2) 95 participants (aged 18 to 34 years) from underserved communities who resided in Massachusetts and Texas and took part in an 8-week study using location tracking on their smartphones. We analyzed the data using spatial autocorrelation, optimized hot spot analysis, and fitted power-law distribution to identify the TROs that attracted the most human traffic using mobility data.ResultsParticipants reported encountering protobacco messages mostly from store signs and displays and antitobacco messages predominantly through television. In Massachusetts, clusters of TROs (Dorchester Center and Jamaica Plain) and reported smoking behaviors (Dorchester Center, Roxbury Crossing, Lawrence) were found in economically disadvantaged neighborhoods. Despite the widespread distribution of TROs throughout the communities, participants overwhelmingly visited a relatively small number of TROs in Roxbury and Methuen. In Texas, clusters of TROs (Spring, Jersey Village, Bunker Hill Village, Sugar Land, and Missouri City) were found primarily in Houston, whereas clusters of reported smoking behaviors were concentrated in West University Place, Aldine, Jersey Village, Spring, and Baytown.ConclusionsSmartphone apps could be used to pair geolocation data with self-reported smoking behavior in order to gain a better understanding of how tobacco product marketing and promotion influence smoking behavior within vulnerable communities. Public health officials could take advantage of smartphone data collection capabilities to implement targeted tobacco control efforts in these strategic locations to reach underserved communities in their built environment.

Impact of Cardiovascular Disease Risk Factors on Subfoveal Choroidal Thickness by Enhanced-depth Spectral Domain Optical Coherence Tomography.

Risk stratification plays a large role in cardiovascular disease (CVD) management. Spectral-domain optical coherence tomography (SD-OCT) allows for noninvasive analysis of the ophthalmic vasculature, with potential for systemic disease surveillance. Subfoveal choroidal thickness (SFCT) may serve as a marker for CVD risk and play a role in risk stratification. This study aimed to explore the association of major CVD risk factors CVD on SFCT measured from SD-OCT images in a general population of U.S. veterans. One hundred fifty veterans were prospectively recruited at the Jamaica Plain VA Hospital (Boston, MA). A total of 143 participants were included in the final analysis. The SFCT was manually measured from Spectralis SD-OCT macular scans, and medical chart review was analyzed for CVD data. The SFCT measurements were correlated with CVD risk factors and CVD clinical makers while controlling for age and refractive error. Mean differences in SFCT between those with and without CVD risk factors were analyzed. In multivariate analysis, diabetes diagnosis was independently associated with thinner subfoveal choroid (P = .001) and hypertension and hyperlipidemia with thicker subfoveal choroid (P = .006 and P = .05). After adjusting for age and refractive error, veterans with diabetes had thinner choroids than those without (P = .02), and veterans with hypertension and hyperlipidemia had thicker choroids than those without, although these differences did not reach statistical significance (P = .07 and P = .1). Comorbid risk factors for CVD are independently associated with optical coherence tomography-derived measurements of subfoveal choroidal thickness in a vasculopathic population of U.S. veterans, and there are detectable differences in subfoveal choroidal thickness between groups with and without CVD risk factors. Larger studies with adequate controls and longitudinal design are necessary to assess the clinical role of SFCT measurements in CVD risk analysis.

Reply.

*Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts †Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts ‡Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts None of the authors has any financial/conflicting interests to disclose.

Comparison of training effect on tremor using 2 training modules

To compare training effect of 2 training models-a surgical simulator anti-tremor module and a paper version-on tremor and time-to-task completion. Ophthalmology Department, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA. Prospective crossover study. Trainees completed simulator and paper training modules (baseline test, 3 training sessions, posttraining test, and final test) with their dominant and nondominant hands. The change in tremor, number of paper errors, and time-to-task completion in dominant and nondominant hands were compared. The 2 training modules were compared using nonparametric tests. The study comprised 19 trainees. There was a moderate correlation between average tremor values (simulator, 3-dimensional module) and paper errors (paper, 2-dimensional module) (Spearman ⍴=0.35, P<.0001). Practice on the simulator or paper modules did not reduce tremor significantly from baseline to final tasks for both hands combined (P=.12, simulator; P=.2, paper). Practice on the training modules improved time-to-task completion in the simulator module and paper module (both P<.0001). The improvement in time from baseline to final tasks was greater in the nondominant hands in the simulator module (improvement 64.5% over baseline time) than in the paper module (53.6% over baseline time). Practice might not reduce tremor but improved the outcome measure of time, and results suggest that trainees can learn to compensate for tremor in both hands, which is important in bimanual microsurgery.

Fostering diverse friendships: The role of beliefs about the value of diversity

Encouraging dialogue between people of differing social backgrounds and beliefs can reduce prejudice and lead to greater appreciation of diversity, which in turn fosters attitudinally diverse friendships. We investigated how beliefs about the value of diversity relate to attitudinal diversity within relationship dyads. In a field study of naturally occurring relationship pairs in two neighborhoods of Boston ( N = 89 dyads), participants completed measures of diversity beliefs and sociopolitical attitudes. People placed higher value on diversity in the Jamaica Plain neighborhood compared to people in the North End neighborhood, and relationship pairs were more attitudinally diverse in Jamaica Plain than in the North End. Attitudinal diversity within pairs was predicted by how highly the pair jointly valued diversity. Further, pairs’ greater valuing of diversity in Jamaica Plain mediated the effect of neighborhood on attitude diversity. These findings suggest that individual differences in appreciation for diversity are meaningful predictors of diverse relationships.

Alternative food provision conflicts in cities: Contesting food privilege, injustice, and whiteness in Jamaica Plain, Boston

Food justice studies have exposed that lower-income residents and people of color tend not to participate in alternative food initiatives. Much of this marginalization originates in the often exclusionary practices and discourses from members of the alternative food movement. In this paper, I contribute to the scholarship on urban food justice by examining how Latino residents experience, reflect on, and confront new exclusionary practices in the spaces and discourses of alternative food activism and practices in the city. Through empirical research conducted on a conflict related to the opening of a Whole Foods store replacing a Latino supermarket in Jamaica Plain, Boston, I analyze how food injustice and food privilege have been produced in a neighborhood that used to have a variety of culturally-sensitive food options. Findings highlight a loss of a large variety of Latino products and of socio-cultural practices around food for Latinos and low-income customers. Such changes have created feelings of alienation, displacement, and of becoming out-of-place in the neighborhood. Results also show the slow disappearance of affordable or community-based food options in Hyde Square, turning the neighborhood in a “food unjust” neighborhood. Last, the paper brings to light the whitened and colorblind discourse about healthy and natural food of middle-class Whole Foods’ supporters. Such positions show how environmental racism, food privilege, and whiteness can affect the relationships that a community has with its food, invisibilize its members and its cultural and social food practices, and in turn affect their place-making and their territorialization in the neighborhood.

Abstracts fromThe 32nd AnnualNational Neurotrauma SymposiumJune 29–July 2, 2014San Francisco, California

Abstracts fromThe 32^nd AnnualNational Neurotrauma SymposiumJune 29–July 2, 2014San Francisco, California

Power, politics, and community development

Across the US, vulnerable communities have been adversely affected by large-scale development led by universities, hospitals, and medical facilities. More often than not, much of the tension around university or hospital expansion has been around traffic congestion, rising land, and housing costs, displacement of lower income individuals, gentrification, and environmental pollution. Using interviews, focus groups, archival data and observant participation, this article analyzes how Jamaica Plain Neighborhood Development Corporation (JPNDC) and other nonprofit community-based organization partners were able to form a public–private partnership with local hospitals, medical facilities, and research organizations that led to a community-focused workforce development and community benefits program in Boston. In addition, this case study demonstrates how Boston became one of the first cities in the country to link development to community-based outcomes and investments aimed at helping some of Boston's most disadvantaged and vulnerable residents.

α-chain hemoglobin variants with electrophoretic mobility similar to that of hemoglobin S in newborn screening programs

Hemoglobin (Hb) S is a β-chain structural variant of human hemoglobin that undergoes polymerization in its deoxygenated form, making red blood cells stiff and undeformable and causing hemolysis and vaso-occlusion, with tissue damage and pain. Heterozygotes (Hb AS) are generally asymptomatic, while homozygotes (Hb SS) have sickle cell anemia (SCA). Combinations of Hb S and other hemoglobin variants, such as Hb C and D, or β-thalassemia can produce clinical pictures similar to that of SCA and are known as sickle cell diseases (SCD)(1). Around 1 to 2% of the world's population are Hb S heterozygotes, but in some regions of Africa that are endemic for malaria (against which Hb AS individuals are protected) the frequency of the βS gene can be greater than 40%(2). In Brazil, the Southeast and Northeast regions have the greatest prevalence (around 8% of individuals of African descent are heterozygotes), although in some populations, such as that in Salvador, Bahia, the prevalence can be higher than 10%(3,4). Correct diagnosis of this hemoglobinopathy is extremely important, particularly during the neonatal period, as early detection of SCD is fundamental if morbidity and mortality of these diseases are to be reduced. Laboratory diagnosis of SCD generally involves techniques based on the electric charge of the variants, such as cellulose acetate or gel electrophoresis, isoelectric focusing, high-performance liquid chromatography (HPLC) and capillary electrophoresis(5). However, as more than 1,000 variants have been described to date(6), the probability of finding another variant with electrophoretic behavior similar to that of Hb S (Hb S-like hemoglobins) is quite high, particularly in a population with a high degree of miscegenation, like that of Brazil. For this reason it is important to use confirmatory tests (which are also frequently used in screening programs), such as the sickling test and the hemoglobin solubility test (based on the insolubility of deoxy-HbS in high molarity phosphate buffer)(5). In the case of Hb S in association with other variants, whether Hb S-like or not, correct identification of the second variant is fundamental to distinguish between those variants that will lead to SCD, those that evolve without any symptoms and those that produce specific symptoms(7). Molecular techniques, such as restriction enzyme analysis and globin gene sequencing, are the most commonly used techniques for known mutations and new or rare mutations, respectively(8,9). It should also be mentioned that some Hb S-like variants can cause red blood cell sickling, hemolysis and vaso-occlusion even in a heterozygous state. Examples include Hb Jamaica Plain(10) and Hb S Sao Paulo(11), the latter recently described in the Brazilian population. It should also be stressed that Hb S in association with an Hb S-like hemoglobin can lead to an incorrect diagnosis of SCA if the appropriate confirmatory tests are not carried out(12).

Editorial Commentary: Accounting for Pertussis

The resurgence of measles and pertussis in the United States [1, 2] is a reminder of the importance of maximum immunization coverage, even in a developed country with relatively high rates of childhood immunization. The exact parameters of herd immunity may not be established for some vaccine-preventable diseases, but maximal effective use of available vaccines providespopulation-level immunity toprevent or reduce transmission. Evidencebased strategies published by the Advisory Committee on Immunization Practices (ACIP) for improved control of pertussis promote effective use [3, 4]. Observation of vaccine effectiveness in routine clinical use provides insight that may not be available from clinical efficacy trials and may be used to inform recommendations. The article by Witt et al [5] in this issue of Clinical Infectious Diseases presents a retrospective study of acellular pertussis vaccine effectiveness made possible by the unique circumstances of a community-wide outbreak of Bordetella pertussis infection affecting a large population under the care of an integrated healthcare system.This allowedestimation of vaccine effectiveness by age group. The relative duration of protection achieved with diphtheria toxoid–tetanus toxoid–acellular pertussis (DTaP) vaccines (introduced in theUnited States in the 1990s) remains a question [6], one made more relevant by the possibilities arising from the availability of pertussis antigen containing vaccines (tetanus toxoid– reduced diphtheria toxoid–acellular pertussis vaccine for adolescents and adults [Tdap]) that allow for booster dosing of individuals >7 years of age. The authors were able to demonstrate less than expected effectiveness of DTaP in 8to 12year-olds, while also demonstrating substantial overall effectiveness of pertussis vaccines. On the basis of their observations, they suggest evaluation of earlier and more frequent doses of pertussis containing vaccine (Tdap) in outbreak settings, and even on a routine basis. More studies of strategic use of Tdap as a booster dose vaccine would be worthwhile, especially after the broad experience with the vaccine and its safety profile. The ACIP already recommends Tdap use in undervaccinated children as young as 7 years of age [3]. A question might be raised as to the use of polymerase chain reaction (PCR) as the exclusive diagnostic test for pertussis in the Witt et al study, especially as the minimal cough duration in the practice guidance was only 1 week. PCR is a widely used, sensitive test that is faster and easier to perform than culture and can identify evidence of B. pertussis infection in situations where culture results are negative. However, high sensitivity and low specificity, with pseudo-outbreaks described due to false positives and environmental contamination with B. pertussis genome [7, 8], suggest that PCR only be used with care and for patients with cough duration of≥2 weeks and a clinical picture consistent with pertussis. However, the observations by Witt et al [5] occurred in the presence of a widespread, welldocumented stateand community-wide outbreak of pertussis (high prevalence of diseaseimprovingpositivepredictivevalue), and testing was done in a central laboratory, using a closed system test platform, and simultaneous testing for Bordetella parapertussis. Furthermore, rates of testing were high across the spectrum of ages, but rates of positive PCR results are very different by age, so false-positive test results do not seem to be a factor contributing to the results unless there was a systematic bias in selection for testing by age. Pertussis remains a threat to infants, in whom protection awaits the initial doses of the DTaP vaccine series. Public health recommendations for the use of Tdap vaccines have been a work in progress since licensure in the United States, and approaches have been designed to protect older children, adolescents, and adults, in large part to protect infants they may expose to pertussis (as symptomatic and asymptomatic cases to the extent that overall reduction in incidence may reduce asymptomatic carriage). Initially, Tdap Received 27 February 2011; accepted 1 March 2012; electronically published 15 March 2012. Correspondence: Altred De Maria Jr, Bureau of Infectious Disease, Massachusetts Department of Public Health, William A. Hinton State Laboratory Institute, 305 South St, Jamaica Plain, MA 02130 (Alfred.DeMaria@state.ma.us). Clinical Infectious Diseases 2012;54(12):1736–8 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cis313

Nuestro furturo saludable: connecting public health research and community development in partnership to build a healthy environment

Caribbean Latinos are the largest Latino group in Boston, primarily located in the Jamaica Plain (JP) neighborhood. There are various macro-level public health issues that result from the built environment in JP, factors which can create and sustain health disparities. Caribbean Latino youth are a priority group in JP, and it is important to address the causes of disparities early in life to promote good health. Presented here is an integrated research-and-action model to engage community stakeholders and researchers in designing an intervention to mitigate the negative health effects of the built environment and maximize community assets. The approach operates from a community empowerment model that allows public health practitioners, policy makers, researchers and residents to take an up-stream approach to improve health by focusing on the built environment, which is integral to community development.

Going Live: Implementing a Telesurgery Program

Telesurgery is the real-time transmission of surgery to an audience in a location separate from the OR suite. Staff members at Faulkner Hospital, Jamaica Plain, Massachusetts, established an annual telesurgery event as a method of teaching health care providers about specific orthopedic and gynecology procedures. In October 2009, staff members at Faulkner Hospital successfully completed five separate live transmissions during a four-day period. Extensive planning, attention to detail, and cooperation among team members and hospital service line members are essential to conducting a safe and successful telesurgery event.

Early Resuscitation with Lactated Ringerʼs Reduces Systemic Inflammation in Acute Pancreatitis: A Multi-Center Randomized-Controlled Trial: 2010 ACG Governors Award Recipient for Excellence in Clinical Research

Purpose: Aggressive fluid resuscitation is recommended for early management of acute pancreatitis (AP). Our aims were to 1) evaluate the impact of a goal-directed fluid resuscitation protocol vs. standard resuscitation on systemic inflammation and 2) evaluate impact of resuscitation with Lactated Ringer's (LR) versus normal saline (NS) on systemic inflammation during the initial 24 hours of hospitalization. Methods: Study design: open-label four-arm parallel group randomized-controlled trial. Study sites: Brigham and Women's Hospital, Boston MA, Faulkner Hospital, Jamaica Plain, MA and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Study dates: May 2009-February 2010. Patients with major comorbid or concurrent illness that precluded aggressive fluid resuscitation were excluded. Subjects were enrolled within 6 hours of presentation and randomized to one of four treatment arms: 1) Goal-directed with LR, 2) Goal-directed with NS, 3) Standard with LR, or 4) Standard with NS. Subjects randomized to goal-directed resuscitation had rate of fluid administration adjusted every 8 hours by study investigators according to protocol. Primary outcome was point-prevalence of systemic inflammatory response syndrome (SIRS) at 24-hours post-randomization. Secondary outcome was C-reactive protein (CRP) level at 24-hours post-randomization. All data were analyzed on an intent-to-treat basis. Results: A total of 40 subjects were randomized and included in analysis. Aim 1: 19 subjects were randomized to goal-directed and 21 to standard fluid resuscitation. Total volume of fluid administered during the 24 hour intervention period was similar between treatment arms (mean 4,300 mL goal-directed vs. 4,600 mL standard, p=0.87). There was no difference with respect to prevalence of SIRS (11.8% goal-directed vs. 13.0% standard, p=0.9) or CRP level at 24 hours (87.1 mg/dL goal-directed vs. 69.2 mg/dL standard, p=0.97) based on resuscitation strategy. Aim 2: 19 subjects were randomized to LR and 21 to NS. Mean CRP level at 24 hours was lower among patients resuscitated with LR (51.5 mg/dL LR vs. 104 mg/dL NS; p=0.037). There was a trend toward reduced prevalence of SIRS at 24 hours among subjects resuscitated with LR (5.3% LR vs. 19.1% NS, p=0.11). Adverse Events: One subject resuscitated with the goal-directed protocol developed acute respiratory distress syndrome. Conclusion: 1) Goal-directed fluid resuscitation did not lead to reduction in systemic inflammation at 24 hours compared to standard resuscitation. Volume of fluid administered during the initial 24 hours was similar between treatment arms. 2) Patients resuscitated with Lactated Ringer's had reduced systemic inflammation at 24 hours compared to those that received normal saline. (NCT00853515).