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.

The rapid evolution of generative artificial intelligence (AI) is poised to transform medicine and medical education. Large language models (LLMs) have begun to demonstrate capabilities in reasoning, diagnosis, documentation, and patient communication that can rival or exceed those of clinicians. In medical education, AI is reshaping how students learn and how faculty teach-offering individualized, context-sensitive guidance at scale. This article outlines the current state of AI integration in health care, examines how systems can responsibly implement it to enhance patient care and education, and raises critical questions about ethics and safety as we harness its transformative potential.

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.

RATIONALE AND OBJECTIVES/OBJECTIVE:Prostate multiparametric magnetic resonance imaging (MRI) is recommended for prostate cancer detection, staging, and surveillance. Incidental bladder lesions are encountered on these studies but remain under-characterized in the literature. The patient characteristics associated with malignancy for these lesions are not well defined. We evaluated the prevalence, histopathologic outcomes, clinical characteristics, and associations with malignancy for incidental bladder lesions on prostate MRI. MATERIALS AND METHODS/METHODS:A retrospective review included 31,241 patients undergoing prostate MRI examinations from January 2013 to January 2023. Imaging reports and medical records were analyzed for incidental bladder lesions, demographic data, clinical symptoms, urinalysis findings, and histopathologic outcomes. Lesions were categorized based on biopsy results or negative clinical follow-up for bladder tumors in chart review. Logistic regression analysis and receiver operating characteristic analyses were performed. RESULTS:Incidental bladder lesions occurred in 0.74% (230/31,241) of examinations, with biopsy-confirmed bladder cancer in 0.11% of patients (34/31,241) or 14.8% (34/230) of cases with lesions. In multivariable analysis, gross hematuria had the strongest association with biopsy-proven bladder cancer (OR 9.26, 95% CI 4.12-20.79, p<0.001). A logistic regression model incorporating age, smoking status, and gross hematuria yielded area under the curve of 0.762 for bladder cancer. CONCLUSION/CONCLUSIONS:Incidental bladder lesions on prostate MRI may represent opportunities for early detection of bladder cancer, but also have potential for harms related to unnecessary procedures. Considering the presence of gross hematuria, possibly stated as part of the MRI referral or patient questionnaire, could improve risk stratification of encountered bladder lesions and early cancer detection.

INTRODUCTION/UNASSIGNED:The OncotypeDX test for patients with breast cancer with early-stage, hormone-receptor-positive, HER2-negative disease can predict the benefit of adjuvant chemotherapy in addition to hormone therapy. Delivering OncotypeDX results in a timely manner is important to inform treatment decisions. We implemented a strategy to reduce the turnaround time (TAT) from breast surgery to OncotypeDX report at a large urban public safety-net hospital in New York City. METHODS/UNASSIGNED:The Plan-Do-Study-Act model was used to implement quality improvement changes. The goal was to improve efficiency to get treatment information for treatment decisions for patients with breast cancer and encourage teamwork with existing resources in the large public hospital. The primary measure was TAT from surgery to receiving OncotypeDX results in the electronic medical record (EMR). We compared TAT before and after the implementation of our strategy. The historical control included patients from May 2021 through March 2022, whereas the timeline after strategy implementation was from June 2023 to February 2024. The strategy involved the creation of a smartphrase in the EMR for breast surgery to identify and order OncotypeDX in eligible patients, and collaboration between breast surgery, pathology, vendor, and medical oncology. RESULTS/UNASSIGNED:= 0.65). Our strategy reduced the average TAT from 42 to 30 days. CONCLUSION/UNASSIGNED:We developed a strategy to optimize the OncotypeDX workflow in a large safety net health system despite an increase in patients from MUAs and MUPs. Initiating ordering of OncotypeDX by breast surgery, along with communication with pathology, vendor, and medical oncology, significantly reduced TAT.

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.

Activation of transcription factor NRF2 in pancreatic ductal adenocarcinoma (PDAC) promotes aggressive tumor phenotype and protection from therapy-induced oxidative stress. We postulated that NRF2^high PDAC can be selectively targeted by C29h, a prodrug that is activated by the NRF2-induced enzyme NAD(P)H:quinone oxidoreductase-1 (NQO1), which is elevated in human pancreatic tumors. Initial evaluations of C29h alone or together with the standard-of-care chemotherapeutic drug gemcitabine were conducted on NQO1^high human and mouse PDAC cell lines and patient-derived organoids. As PDAC is enriched in collagen-containing extracellular matrix (ECM) that activates NRF2 and induces NQO1 expression, we examined the ECM effect on the response to C29h, as well as in vivo tumor control in IKKα-deficient Kras^G12D/Ikkα^ΔPEC