Faculty Bibliography

BACKGROUND/UNASSIGNED:Effective management of alcohol withdrawal syndrome during hospitalization is paramount to patient safety and quality care. NYC Health + Hospitals initiated a quality improvement project to pilot an electronic health record (EHR) integrated, nurse-driven CIWA-Ar symptom-triggered protocol, including recommendations for medications for alcohol use disorder (MAUD), in medical and surgical units at 3 public hospitals. OBJECTIVE/UNASSIGNED:To describe implementation processes and to report related implementation outcomes (appropriateness, feasibility, and adoption) of the updated CIWA-Ar protocol in a safety net hospital setting. METHODS/UNASSIGNED:NYC Health + Hospitals implemented a standardized CIWA-Ar symptom-triggered, nurse-driven EHR protocol on March 15, 2022. The protocol included order sets, practice advisories, task lists, and reminders for assessments and orders. We measured nursing perspectives on feasibility and appropriateness at 6 months via a survey. We measured provider adoption as the proportion of admissions with a CIWA-Ar protocol ordered among admissions that triggered a recommendation, and MAUD use as the proportion of admissions with a MAUD order during hospitalization among all patients with a protocol ordered. RESULTS/UNASSIGNED:= .249). CONCLUSIONS/UNASSIGNED:The CIWA-Ar protocol was appropriate, feasible, and adopted at NYC public hospitals. Quality improvements to ensure protocol fidelity with benzodiazepine dosing and MAUD prescribing are needed.

OBJECTIVE:In Nigeria, adolescents and young adults (AYA) who engage in multiple sexual partnerships, transactional sex, and needle-sharing are eligible for preexposure prophylaxis (PrEP) and are prioritized for HIV testing. AYA with PrEP-eligible behaviors should be using facility-based HIV testing services. We examined associations between these behaviors and facility-based HIV testing among AYA aged 14-24 years. DESIGN/METHODS:A longitudinal analysis of a stepped-wedge trial. METHODS:Using Innovative Tools to Expand Youth-friendly HIV Self-Testing (I-TEST) data, we fit generalized linear models using generalized estimating equations. We used a two-stage weighted approach to generalize I-TEST estimates to all AYA in Nigeria. RESULTS:Of 1429 trial participants, the median age was 20 years (IQR: 18-22), 50.3% were female, and 69.4% reported secondary education as highest level of education completed. Recent facility-based HIV testing uptake was higher among AYA with one [unadjusted risk difference: 11.7%, 95% confidence interval (95% CI): 8.1-15.2], two [11% (5.3, 16.8)], and three or more sexual partners in the past 3 months [17.3% (10.5, 24)], compared to AYA with no recent sexual partners. AYA who engaged in transactional sex had higher facility-based testing uptake [14.7% (9.8, 19.5)] than AYA who never engaged in transactional sex. AYA who shared needles had lower facility-based testing uptake [-3.3% (-6.7, 0.2)] than AYA with no needle-sharing history. The trial and generalized estimates were in the same direction. CONCLUSION/CONCLUSIONS:While facility-based testing may reach AYA who engaged in multiple sexual partnerships or transactional sex, AYA who shared needles may require more tailored HIV testing approaches.

BACKGROUND:Intensive care unit (ICU) staffing models increasingly use advanced practice providers (APPs), with unclear implications for clinical practice patterns. Sedation strategy is a modifiable determinant of clinical outcomes that might differ by staffing model. METHODS:This retrospective cohort study evaluated adults admitted to two medical ICUs in a quaternary teaching hospital, whose staffing differed only by APPs or residents. Patients requiring invasive ventilation for at least 48 h were included. The primary outcome was association of staffing model with sedative exposure during the first week of mechanical ventilation. Time to extubation and vital status at discharge were also assessed. RESULTS:Of 337 included patients, 96 % received continuous sedation on the day of intubation. Admission to the APP ICU was associated with significantly lower benzodiazepine exposure (adjusted OR 0.63; 95 % CI 0.40-0.99; p = 0.04) and higher propofol exposure (adjusted OR 1.73; 95 % CI 1.07-2.79; p = 0.03) on day of intubation. Cumulative benzodiazepine and opioid exposures over the first week after intubation were significantly less, and cumulative propofol exposure significantly more in the APP ICU despite similar sedation depth achieved between ICUs. Receipt of propofol on the first day was associated with shorter time to extubation (adjusted HR 1.45, 95 % CI 1.07-1.98; p = 0.02) and lower in-hospital mortality (adjusted OR 0.55, 95 % CI 0.33-0.93; p = 0.02). CONCLUSION/CONCLUSIONS:Patients admitted to an APP-staffed ICU were more likely to have sedation management reflective of best practice, and this practice was associated with shorter time to extubation and lower mortality.

OBJECTIVES/OBJECTIVE:To identify stakeholder perceived challenges and facilitators for implementing a clean fuel and clean stove intervention to reduce household air pollution and hypertension in Lagos, Nigeria. DESIGN/METHODS:Qualitative study guided by the Exploration and Preparation phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, using focus group discussions and in-depth semi-structured interviews with inductive and deductive thematic analysis. SETTING/METHODS:Peri-urban communities across the five administrative divisions of Lagos State, Nigeria. PARTICIPANTS/METHODS:128 stakeholders from 32 communities, including community, religious, market and youth leaders, primary healthcare staff, and household decision makers. Approximately half were female. INTERVENTIONS/METHODS:This was a pre-implementation needs assessment that included demonstrations of the clean stove and fuel. PRIMARY AND SECONDARY OUTCOME MEASURES/METHODS:Thematic domains describing barriers and enablers to adoption and implementation, mapped to EPIS inner, outer, and bridging factors. RESULTS:Stakeholders reported barriers that included stove stacking, upfront stove cost, concerns about long-term fuel price and availability, equipment durability and maintenance, safety, mistrust of new technology, and uncertainty about stove performance for dishes requiring high heat and long cooking times. Reported facilitators included payment flexibility and subsidies, opportunities to test the stove, perceived benefits of cleaner and faster cooking with less soot, endorsement by community leaders, and interest in local retail and distribution to improve access. CONCLUSIONS:Implementation planning for clean fuel and clean stove programmes should address affordability, reliable fuel supply chains, durability and service, culturally relevant cooking needs, and trust building through community leadership. These findings inform adaptation strategies for scale-up in similar low-resource settings. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

Advance care planning (ACP) completion rates are higher in patients with serious illness compared to the general population, however, ACP is overall under-utilized and sub-optimal, especially for patients with hematologic malignancies. This patient population can experience unique and significant physical and psychological symptoms due to their illness and the treatment, resulting in high rates of aggressive end of life care. This high healthcare utilization pattern often triggers ACP conversations and documentation, often facilitated by specialty palliative care clinicians. This review article examines existing literature about ACP for patients with hematologic malignancies with the intent to inform future prospective research to improve values-based patient care.

BACKGROUND:Increased chronological age correlates with reduced relapse rates and increased disability in multiple sclerosis (MS). Biological age may better capture ageing's impact on MS and might accelerate due to MS itself. Establishing accelerated biological ageing in adults is complicated by normal ageing and comorbidities. Telomere length, a well-recognised biological ageing marker, is shortened in adults with MS and associated with disability. Demonstrating accelerated biological ageing in paediatric-onset MS (POMS) would strengthen the hypothesis that MS drives premature biological ageing. This study aimed to determine if telomere length differs in POMS compared to age-similar healthy controls. METHODS:We performed a cross-sectional case-control study of whole blood samples and clinical data from The US Network of Pediatric MS Centers. Real-time quantitative PCR measured telomere length, expressed as a telomere to somatic DNA ratio (T/S ratio). T/S ratio was compared between cases and age-similar healthy controls using multivariate regression analysis adjusting for chronological age, sex, race, ethnicity, tobacco exposure, socioeconomic status and body mass index. RESULTS:We analysed 300 POMS cases and 200 controls. The unadjusted mean T/S ratios were 1.66 (SD 0.32) for cases and 1.71 (SD 0.29) for controls (mean difference -0.05, 95% CI -0.10 to 0.01, p=0.08). After adjusting for key covariables with face validity, POMS participants had a mean 0.086 shorter T/S ratio than controls (95% CI 0.015 to 0.157, p=0.018). CONCLUSIONS:POMS participants demonstrated shorter telomeres than age-similar controls in a multivariable model adjusting for sociodemographic variables, suggesting that MS may contribute to accelerated biological ageing.

OBJECTIVE:Indeterminate lesions on prostate-specific membrane antigen (PSMA)-PET are challenging to address. We aimed to develop, implement, and evaluate a multidisciplinary consensus algorithm that integrates existing interpretation systems with multimodality imaging and clinicopathological information for interpreting indeterminate bone and lymph node lesions on PSMA-PET. MATERIALS AND METHODS/METHODS:This was a retrospective single-center study on a prospectively implemented algorithm. We included all consecutive prostate cancer patients whose PSMA-PET findings for indeterminate bone lesions or lymph nodes were discussed at a multidisciplinary tumor board (MDT) in 2024-2025. An algorithm determining the level of suspicion for metastasis was developed in a multidisciplinary fashion, incorporating lesion location, conventional imaging features, PSMA-PET characteristics, and clinicopathological information. The application of the algorithm and outcomes were documented, compared against a composite reference standard. Comparisons were made with PSMA-RADS and PROMISE V2 PSMA-expression scores. RESULTS:81 patients (median age 68, interquartile range 64-75) were included. Algorithm results were benign (48.1% [39/81]), equivocal (4.9% [4/81]), metastasis (40.7% [33/81]), and mixed (benign and metastatic lesions, 6.2% [5/81]). The algorithm was correct in 94.1% (64 of 68 patients with a sufficient reference standard). The algorithm was discordant with PSMA-RADS in 54.3% (44/81) and with PROMISE V2 PSMA-expression score in 71.6% (58/81). The frequency of equivocal lesions was lower using the algorithm (4.9% [4/81]) compared with PSMA-RADS (53.1% [43/81]) and PSMA-expression score (64.2% [52/81]). CONCLUSION/CONCLUSIONS:A multidisciplinary consensus algorithm for interpreting indeterminate bone lesions and lymph nodes on PSMA-PET was developed and implemented. Integrating clinicopathological information and multimodality imaging in an MDT setting reduced equivocal interpretations. KEY POINTS/CONCLUSIONS:Question While prostate-specific membrane antigen (PSMA)-PET has become essential in the management of prostate cancer, indeterminate bone lesions and lymph nodes remain challenging to address. Findings A multidisciplinary algorithm for interpreting indeterminate bone lesions and lymph nodes on PSMA-PET, incorporating clinicopathological information and multimodality imaging, reduced the frequency of equivocal interpretations. Clinical relevance An algorithm for interpreting indeterminate bone lesions and lymph nodes on PSMA-PET, incorporating clinicopathological information and multimodality imaging in a multidisciplinary tumor board setting, decreases the frequency of equivocal interpretations and can potentially help management decisions.

OBJECTIVE:We aimed to better understand patients' treatment preferences and quantify the level of cancer risk at which treatment preferences change (risk threshold) to inform better counseling of patients with intraductal papillary mucinous neoplasms (IPMNs). SUMMARY BACKGROUND DATA/BACKGROUND:The complexity of IPMN management provides an opportunity to align treatment with individual preference. METHODS:We surveyed a sample of healthy volunteers simulating a common scenario: undergoing an imaging study that incidentally identifies an IPMN. In the scenario, the estimated risk of cancer in the IPMN was 5%. Patients were asked their treatment preference (surgery or surveillance), to quantify the level of cancer risk in the IPMN at which their treatment preference would change (i.e. risk threshold), and their level of cancer anxiety as measured on a 5-point Likert scale. We examined associations between participant characteristics, treatment preferences, and risk threshold using multivariable linear regression. RESULTS:The median risk threshold among the 520 participants was 25% (IQR 2.3-50%). The risk threshold had a bimodal distribution: 40% of participants had a risk threshold between 0-10% and 47% had a risk threshold above 30%. When informed that the risk of cancer was 5%, 62% of participants (n=323) preferred surveillance, and the remaining 38% (n=197) preferred surgery. After adjusting for potential confounders, participants who expressed "worry" or "extreme worry" about the malignancy risk of IPMN had significantly lower risk thresholds than participants who were "not at all worried" (Coefficient -12, 95%CI -21 to -2, P=0.015 and Coefficient -18, 95%CI -29 to -8, P<0.001, respectively). CONCLUSIONS:Participants varied in treatment preference and risk threshold of incidentally identified IPMNs. Given the uncertainty in estimating the true malignant potential of IPMNs, a better understanding of a patient's risk threshold, as influenced by patient concern about malignancy, will help inform the shared decision-making process.

The impact of COVID-19-related mental health effects on health behaviors among people living with HIV (PLWH) remains unknown. Our qualitative study explored the relationship between the mental health consequences of the COVID-19 pandemic and self-management of HIV and cardiovascular disease (CVD) among PLWH in the United States. Twenty-four PLWH enrolled in a multicenter, cardiovascular, clinical trial completed one-on-one semistructured interviews to assess changes in mood, health behaviors, and comorbid CVD management during the COVID-19 pandemic. The majority of participants (ages 43-70 years) were male (n = 17, 70.8%) and Black (n = 19, 79.2%). Participants reported increased mental distress during the COVID-19 pandemic, which they perceived to negatively affect heart-healthy behaviors. Despite mental health stressors, this population continued to adhere to medications, including antiretroviral therapy. Future initiatives should focus on improving mental health outcomes and promotion of healthy lifestyle choices among PLWH to mitigate adverse CVD outcomes.

BACKGROUND:Tenofovir alafenamide (TAF) has shown non-inferior efficacy to tenofovir disoproxil fumarate (TDF), with superior bone and renal safety. AIM/OBJECTIVE:To characterise 5-year TAF efficacy and safety in patients of East Asian ethnicity from pivotal Phase 3 studies. METHODS:Patients were randomised (2:1) to receive TAF or TDF for up to 3 years of double-blind treatment, followed by open-label TAF. Patients either continued TAF or switched from TDF to TAF at Week 96 (TDF → TAF 3 years) or Week 144 (TDF → TAF 2 years) of treatment. Efficacy endpoints (virologic, biochemical and serologic) and safety were assessed. RESULTS:Among 591 patients of East Asian ethnicity (TAF, n = 401; TDF → TAF 3 years, n = 84; TDF → TAF 2 years, n = 106), high rates of virologic control were achieved (89%, 94% and 92%, respectively) at Year 5 (missing = failure analysis). At Year 5, rates of alanine aminotransferase normalisation (85%, 90% and 78%) and hepatitis B e antigen loss (36%, 43% and 44%) were similar. Following the switch from TDF to TAF, changes in fasting lipid parameters were consistent with removal of the known lipid-lowering effect of TDF. However, changes in the total cholesterol to high-density lipoprotein ratio (marker of cardiovascular risk) were minimal and comparable in all groups by Year 5. Renal and bone parameters improved after switching. CONCLUSIONS:Through 5 years, rates of virologic suppression were high in East Asian patients treated with TAF or switched from TDF to TAF. TAF and TDF were well tolerated, with improved renal and bone safety observed in patients switching from TDF to TAF.