Faculty Bibliography

OBJECTIVES/OBJECTIVE:Evidence for the impact of racial implicit bias and clinical reasoning remains conflicting. Our inability to characterize the relationship between racial implicit bias and clinical reasoning (CR) precludes development of comprehensive interventions seeking to address the impact of racial implicit bias on clinical encounters. To address this gap, we conducted a simulation-based investigation with clinical presentations with known health disparities, cognitive stressors common to clinical environments, and Black and White standardized patients (SPs). METHODS:We recruited 75 early-career generalist physicians from five academic medical centers in New York, NY, USA. Physicians engaged in a three-station simulation. The first was for level-setting, familiarizing physicians with the online platform. The second was a diagnostic dilemma - an atypical presentation of acute coronary syndrome (ACS). The third tested treatment decision-making in acute pain. Immediately afterward, physicians completed the Race Implicit Association Test (IAT) and Race Medical Cooperativeness (RMC) IAT measuring affective and cognitive implicit biases, respectively. Two investigators assessed CR accuracy by applying a scoring rubric to physicians' post-encounter notes. RESULTS:Statistical analyses revealed no significant correlations between physicians' Race-IAT scores and CR by SP race. However, for ACS, a moderate correlation was suggested between physicians' RMC-IAT scores and CR accuracy when seeing Black (R=0.36, CI -0.04 to 0.6), but not White, SPs (R=0.1, CI -0.44 to 0.24). CONCLUSIONS:This study expands our understanding of the complex impact of racial implicit bias on clinical encounters. Future, larger studies should explore affective and cognitive implicit biases' effects on CR across varied clinical scenarios and contexts with diverse SPs.

People often want to eat healthily but fail to do so. Sometimes people try and fail to exert control over unwanted food choices. But failing to eat healthily might also happen for a different, largely ignored reason: when encountering conflict between healthy and unhealthy food, people might fail to respond and initiate self-regulation. Accordingly, we tested in three studies (total N=542) if how responsive participants are to conflict between healthy and unhealthy food is an important part of eating regulation. We developed a conflict response measure that indicates responsiveness to conflict between healthy and unhealthy food via post-conflict slowing. We then show that the stronger participants are committed to healthy eating, the more they slowed down after goal-relevant conflict (Study 1, 2) but not after goal-irrelevant conflict (Study 2). Importantly, goal-relevant, but not goal-irrelevant, post-conflict slowing predicted subsequent healthy eating in participants' everyday life (Study 2). Finally, planning to act on a healthy eating goal via an implementation mindset manipulation increased post-conflict slowing compared to when healthy eating was deliberated (Study 3). Our findings suggest that conflict responsiveness might be important for understanding how people initiate self-regulatory processes.

BACKGROUND:Treatment for patients with bilateral adrenal tumours and cortisol excess is not standardised and poses a therapeutic dilemma. Untreated cortisol excess is associated with cardiometabolic morbidity and mortality, but bilateral adrenalectomy causes adrenal insufficiency and possibly life-threatening adrenal crises. Data on cardiovascular outcomes by treatment modality are scarce. In this study we aimed to evaluate mid-term and long-term clinical and biochemical outcomes in patients with bilateral adrenal tumours and cortisol excess by treatment strategy and diagnosis. METHODS:This retrospective, international cohort study (in 30 centres across 10 countries in Europe plus Singapore and the USA) included patients with bilateral adrenal tumours of 10 mm or larger, post-dexamethasone serum cortisol concentration of 50 nmol/L or higher, and at least 36 months of follow-up, with data collection beween Feb 2, 2024, and Jan 31, 2025. Patients were excluded if they had adrenocorticotropin hormone (ACTH)-dependent cortisol excess, ACTH-dependent nodular adrenal hyperplasia, partial glucocorticoid resistance syndrome, a diagnosis inconsistent with benign adrenocortical lesions, or received systemic oral or intravenous glucocorticoids other than replacement therapy following adrenalectomy. Primary endpoints were all-cause mortality and clinical and biochemical remission rates. Secondary endpoints were the incidence of cardiovascular events, prevalence of vascular and metabolic comorbidities, and incidence of adrenal crises. FINDINGS/RESULTS:Of 629 patients who were diagnosed between Jan 1, 2000, and Jan 31, 2022, 105 (17%) had Cushing's syndrome and 524 (83%) had mild autonomous cortisol secretion (MACS), median age was 62 years (IQR 54·0-68·0), and 426 (68%) were female. 85 (81%) of 105 patients with Cushing's syndrome underwent surgery, and 384 (73%) of 524 patients with MACS received non-specific symptomatic treatment (ie, never underwent adrenalectomy or received steroidogenesis inhibitors). Over a median follow-up of 6·8 years, biochemical remission was achieved in 46 (45%) of 102 patients with Cushing's syndrome and in 67 (13%) of 517 patients with MACS. In both groups, 7% of patients died (Cushing's syndrome: seven of 105; MACS: 38 of 524) and 12% (13 of 105) of patients with Cushing's syndrome and 16% (82 of 524) of those with MACS had at least one cardiovascular event, without substantial differences across treatments. Smoking emerged as key modifiable mortality and cardiovascular risk factor in all patients, and in patients with MACS who only received non-specific symptomatic therapy, post-dexamethasone cortisol was also associated with increased mortality. Bilateral adrenalectomy led to full biochemical remission, few non-fatal adrenal crises, and improved arterial hypertension. Unilateral adrenalectomy and steroidogenesis inhibitors yielded heterogeneous biochemical outcomes and no substantial comorbidity improvement. Non-specific symptomatic treatment in MACS was associated with worsening of all investigated comorbidities. INTERPRETATION/CONCLUSIONS:Although mortality and cardiovascular event rates were similar across treatments, surgery led to better biochemical control and more favourable comorbidity outcomes. FUNDING/BACKGROUND:None.

We queried pediatric infectious diseases physicians via the Emerging Infections Network regarding management preferences for Clostridioides difficile infection (CDI). We explored use of vancomycin, fidaxomicin, bezlotoxumab and fecal microbiota transplantation and found that physicians are increasingly considering newer and adjunctive therapies for pediatric CDI, highlighting the need for updated guidelines.

BACKGROUND:Understanding the current risk of inpatient mortality following hip fracture in the United States is of significant value to patient families and the health system. Currently, the literature lacks a national representation of the inpatient mortality following hip fracture. PURPOSE/OBJECTIVE:The purpose of this study was to investigate the incidence of inpatient mortality following hip fracture using Epic Cosmos-an aggregated, de-identified, multi-institutional data that includes over 280 million patients in the United States. METHODS:A "Cosmos hip fracture cohort" that included all adults (18 years or older) who sustained a femoral neck, intertrochanteric, or subtrochanteric hip fracture (ICD 72.0, S72.1, S72.2) between January 2019 and December 2024 was created. The dataset was queried for demographic data including age, sex, geographic location, incidence of inpatient mortality, and bone health medication use at the time of admission. RESULTS:The Cosmos database included 284,455,033 patients, of which 1,232,250 hip fracture hospital admissions between January 2019 and December 2024 were identified. Of these patients, 47,773 (3.9%) expired during their hip fracture hospital admission. The most common age bracket was 85 years or older (39.8%), followed by 75-85 (30.0%), and 65-75 (17.8%). Most patients were white (91%) females (55.5%). Most inpatient mortalities occurred in the South (38.4%), followed by the Midwest (31.8%), followed by the Northeast (23.6%), and last by the West (6.2%). CONCLUSION/CONCLUSIONS:The current inpatient mortality following hip fracture is 3.9%. Most inpatient mortalities occurred in white females above the age of 85 in the South of the country. LEVEL OF EVIDENCE/METHODS:Level III.

OBJECTIVE:To evaluate inhaled technosphere insulin (TI) in children with diabetes. RESEARCH DESIGN AND METHODS/METHODS:230 youth 4-17 years old with type 1 (98%) or type 2 (2%) diabetes treated with multiple daily injections of insulin were randomly assigned 1:1 to TI or rapid-acting analog (RAA) insulin plus continuation of long-acting basal insulin and continuous glucose monitoring (CGM) for 26 weeks. The primary outcome was change in HbA1c, tested for noninferiority with margin of 0.4%. RESULTS:In intent-to-treat analysis, mean HbA1c (% ± SD) was 8.22 ± 0.87 at baseline and 8.41 ± 1.38 at 26 weeks with TI and 8.21 ± 0.96 and 8.21 ± 1.10, respectively, with RAA (adjusted difference = 0.18; 95% CI -0.07, 0.43; noninferiority P = 0.091). CGM-measured time in range 70-180 mg/dL was not significantly different between groups (adjusted difference -2.2%; 95% CI -7.0, 2.7; P = 0.38). Two severe hypoglycemic events occurred in the TI group and one in the RAA group. Change in forced expiration volume in 1 s from baseline to 26 weeks did not differ comparing TI and RAA (P = 0.53). The TI group reported greater treatment satisfaction (P = 0.004) and had less gain in weight and BMI percentile (P = 0.009) than did the RAA group. CONCLUSIONS:The primary analysis did not meet the prespecified criteria for HbA1c noninferiority. However, TI use was safe over 26 weeks without affecting pulmonary function and was associated with greater treatment satisfaction and less weight gain compared with RAA, supporting TI as a treatment option for some pediatric patients with type 1 diabetes.

We developed and implemented a PrEP navigation program ("SNAPS") in a NYC safety-net hospital with the objectives to co-locate navigation, clinical PrEP services, and payment assistance. Adherence and retention to PrEP-related care were assessed by mean medication possession ratios (MPRs) and number of appointments over 12 months. Compared to the pre-SNAPS cohort, the post-SNAPS cohort was less likely to be cisgender male (64.8% vs. 84.2%), White (6.5% vs. 23%) and to speak English (33.3% vs. 80.6%) (all p < 0.001). Mean MPR was lower for post-SNAPS (0.68, SD = 0.33) compared to pre-SNAPS (0.89, SD = 0.22) (p = 0.001). Among post-SNAPS patients, cisgender men and MSM were more likely to be retained in PrEP care compared to cisgender women (p < 0.05). Although SNAPS linked diverse patients to PrEP-care, mean MPR was lower post-SNAPS compared to the pre-SNAPS. Continued investments to strengthen later stages of the PrEP cascade model for all populations vulnerable to HIV are needed.