Faculty Bibliography

BACKGROUND:Graduate medical education (GME) on diversity, equity, and inclusion rarely teaches strategies for developing anti-racist mindsets and behaviors, and understanding of the impact of these programs and particular curricular components is lacking. OBJECTIVE:To evaluate the format, content, and impact of a longitudinal anti-racism conference series (ARC) on resident physicians within an urban internal medicine program through a qualitative analysis, with the goal of informing the development and implementation of other evidence-based anti-racism curricula in graduate medical education (GME). DESIGN/METHODS:The ARC consisted of eight mandatory, 60-min virtual conferences held between August 2020 and June 2021 within an internal medicine residency program's primary care track sub-group. The conference's content synthesized previous anti-racism curricula, scholarly readings, and practical experiences, and emphasized internal reflection and behavior change. PARTICIPANTS/METHODS:Thirty internal medicine resident physicians and six faculty members. MAIN MEASURES/METHODS:Seven voluntary, semi-structured, hour-long focus groups were conducted to document resident perspectives on the ARC's format, content, and impact of the curriculum on learner's professional and personal development. Constructivist grounded theory was used to analyze resident responses. KEY RESULTS/RESULTS:In total, 17/30 (57%) residents participated in focus groups. Analysis of course format, content, and impact revealed the following: (1) The most valued aspect of the course's instructional format was its perceived psychological safety. (2) Residents desired course content with more outward action steps than were offered. (3) Residents noted personal and professional impact across three main domains: intrapersonal, interpersonal, and institutional. CONCLUSIONS:In this longitudinal GME internal medicine anti-racism curriculum, participants felt that the curriculum format provided safe spaces to engage with topics on systemic racism and patient care, but content lacked sufficient action-oriented strategies. The curriculum's impact was multi-dimensional and could be studied more deeply in the future through simulation or direct observation.

BACKGROUND:Weight gain has been associated with the use of antiretrovirals in people with HIV, especially with integrase inhibitors or tenofovir alafenamide, and among women. In 2018, doravirine became the latest non-nucleoside reverse transcriptase inhibitor to be approved in the US. We assessed changes in weight over time among virologically suppressed individuals who switched to a regimen containing doravirine (DOR). METHODS:From the US-based OPERA cohort, treatment-experienced adults with HIV who switched to a DOR-containing regimen between 30AUG2018-30NOV2022 with a viral load < 50 copies/mL were included (followed through 31MAY2023). The study population was characterized and a linear mixed model was used to estimate rates of weight change on DOR. Results were stratified by sex, by patterns of efavirenz (EFV) and/or tenofovir disoproxil fumarate (TDF) use before/after switch to DOR, and by integrase inhibitor (INSTI) & tenofovir alafenamide (TAF) use combination (restricted to individuals who maintained the same combination before/after switch). RESULTS:Of 388 included individuals, 21% were women, 33% were Black, and 78% were obese or overweight at DOR switch. Overall, people who switched to DOR lost an average of 0.80 kg/year (95% CI: -1.32, -0.28). Both women and men experienced statistically significant weight loss; women (70% Black, 70% aged ≥ 40 years) lost weight at a rate of -1.67 kg/year (95% CI: -3.32, -0.02) and men at a rate of -0.60 kg/year (95% CI: -1.12, -0.08). When EFV and TDF were absent before and after switch to DOR, statistically significant weight loss was observed. Among those who had the same INSTI and TAF combination throughout and had any INSTI or TAF use, a statistically non-significant trend toward weight loss was observed. CONCLUSIONS:In one of the first real-world analyses of weight changes among virologically suppressed individuals who switched to a DOR-containing regimen in the US, DOR was associated with statistically significant weight loss. Patterns of use of other antiretrovirals did not fully explain the observed weight loss. These findings are clinically meaningful given that most individuals included were overweight or obese at switch to DOR and that women were predominantly of perimenopausal or menopausal age.

BACKGROUND:Sarcopenia has been associated with adverse postoperative outcomes in older age cohorts, but has not been assessed in older adults with inflammatory bowel disease (IBD). Further, current assessments of sarcopenia among all aged individuals with IBD have used various measures of muscle mass as well as cutoffs to define its presence, leading to heterogeneous findings. METHODS:In this single-institution, multihospital retrospective study, we identified all patients aged 60 years and older with IBD who underwent disease-related intestinal resection between 2012 and 2022. Skeletal Muscle Index (SMI) and Total Psoas Index (TPI) were measured at the superior L3 endplate on preoperative computed tomography scans and compared through receiver operating characteristic curve. We then performed multivariable logistic regression to assess risk factors associated with an adverse 30-day postoperative outcome. Our primary outcome included a 30-day composite of postoperative mortality and complications, including infection, bleeding, cardiac event, cerebrovascular accident, acute kidney injury, venous thromboembolism, reoperation, all-cause rehospitalization, and need for intensive care unit-level care. RESULTS:A total of 120 individuals were included. Overall, 52% were female, 40% had ulcerative colitis, 60% had Crohn's disease, and median age at time of surgery was 70 years (interquartile range: 65-75). Forty percent of older adults had an adverse 30-day postoperative outcome, including infection (23%), readmission (17%), acute kidney injury (13%), bleeding (13%), intensive care unit admission (10%), cardiac event (8%), venous thromboembolism (7%), reoperation (6%), mortality (5%), and cerebrovascular accident (2%). When evaluating the predictive performance of SMI vs TPI for an adverse 30-day postoperative event, SMI had a significantly higher area under the curve of 0.66 (95% CI, 0.56-0.76) as compared to 0.58 (95% CI, 0.48-0.69) for TPI (P = .02). On multivariable logistic regression, prior IBD-related surgery (adjusted odds ratio [adjOR] 6.46, 95% CI, 1.85-22.51) and preoperative sepsis (adjOR 5.74, 95% CI, 1.36-24.17) significantly increased the odds of adverse postoperative outcomes, whereas increasing SMI was associated with a decreased risk of an adverse postoperative outcome (adjOR 0.88, 95% CI, 0.82-0.94). CONCLUSIONS:Sarcopenia, as measured by SMI, is associated with an increased risk of postoperative complications among older adults with IBD. Measurement of SMI from preoperative imaging can help risk stratify older adults with IBD undergoing intestinal resection.

PurposeTo evaluate the association between demographic characteristics and weight-loss in response to financial incentives designed using behavioral economics.DesignRetrospective analysis of randomized clinical trial (RCT).SettingFIReWoRk RCT (NCT03157713), which found that financial incentives were more effective than provision of weight-management resources only for weight-loss.Subjects668 adults with obesity (221 in resources-only group, 447 in incentive groups) living in low-income neighborhoods.MeasuresDemographic characteristics and weight-loss.AnalysisLinear mixed-effects models with interaction terms to examine effect of incentives on weight-loss in different demographic groups.ResultsMean age of participants was 47.69 years, 81.0% were women, 72.6% were Hispanic, and mean BMI was 37.95 kg/m². Financial incentives increased percent weight loss at 6 months (difference in percent weight loss between financial incentive and resources-only group = -2.41%; 95% CI -3.23% to -1.58%). In fully adjusted models, participants who were Black lost less weight than participants who were White (difference in percent weight loss = 2.12%; 95% CI 0.25% to 3.99%). Differences in percent weight loss by sex, age, education and neighborhood income were absent. Models that tested for interactions between group assignment and percent weight loss did not demonstrate evidence of a heterogenous effect of incentives in sociodemographic subgroups.ConclusionBlack participants in the FIReWoRk intervention lost less weight than White participants, but effectiveness of financial incentives generally did not vary significantly by sociodemographic characteristics. However, it remains important to evaluate potential impacts of financial incentive programs on health disparities.

Recent changes to US research funding are having far-reaching consequences that imperil the integrity of science and the provision of care to vulnerable populations. Resisting these changes, the BJPsych Portfolio reaffirms its commitment to publishing mental science and advancing psychiatric knowledge that improves the mental health of one and all.

BACKGROUND:Online accessible patient education materials (PEMs) are essential for patient empowerment. However, studies have shown that these materials often exceed the recommended sixth-grade reading level, making them difficult for many patients to understand. Large language models (LLMs) have the potential to simplify PEMs into more readable educational content. OBJECTIVE:We sought to evaluate whether 3 LLMs (ChatGPT [OpenAI], Gemini [Google], and Claude [Anthropic PBC]) can optimize the readability of PEMs to the recommended reading level without compromising accuracy. METHODS:This cross-sectional study used 60 randomly selected PEMs available online from 3 websites. We prompted LLMs to simplify the reading level of online PEMs. The primary outcome was the readability of the original online PEMs compared with the LLM-simplified versions. Readability scores were calculated using 4 validated indices Flesch Reading Ease, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook Index. Accuracy and understandability were also assessed as balancing measures, with understandability measured using the Patient Education Materials Assessment Tool-Understandability (PEMAT-U). RESULTS:The original readability scores for the American Heart Association (AHA), American Cancer Society (ACS), and American Stroke Association (ASA) websites were above the recommended sixth-grade level, with mean grade level scores of 10.7,10.0, and 9.6, respectively. After optimization by the LLMs, readability scores significantly improved across all 3 websites when compared with the original text. Compared with the original website, Wilcoxon signed rank test showed ChatGPT improved the readability to 7.6 from 10.1 (P<.001); Gemini, to 6.6 (P<.001); and Claude, to 5.6 (P<.001). Word counts were significantly reduced by all LLMs, with a decrease from a mean range of 410.9-953.9 words to a mean range of 201.9-248.1 words. None of the ChatGPT LLM-simplified PEMs were inaccurate, while 3.3% of Gemini and Claude LLM-simplified PEMs were inaccurate. Baseline understandability scores, as measured by PEMAT-U, were preserved across all LLM-simplified versions. CONCLUSIONS:This cross-sectional study demonstrates that LLMs have the potential to significantly enhance the readability of online PEMs while maintaining accuracy and understandability, making them more accessible to a broader audience. However, variability in model performance and demonstrated inaccuracies underscore the need for human review of LLM output. Further study is needed to explore advanced LLM techniques and models trained for medical content.

PURPOSE OF REVIEW/OBJECTIVE:Colorectal cancer (CRC) is a leading cause of cancer-related mortality, with 44% of deaths occurring in individuals aged 75 years and older. With 78 million adults over 65 years projected by 2035, optimizing CRC screening and surveillance is crucial. This review examines guidelines, risks, and personalized approaches. RECENT FINDINGS/RESULTS:CRC screening reduces incidence by 17-33% and mortality by 11-53%. Colonoscopy lowers mortality by 61% but has a 6.8% complication rate in those aged 75 years and older. The risk of gastrointestinal bleeding is 8.7 per 1,000 for polypectomy, and perforation occurs in 0.6 per 1,000. Frailty indices assess suitability, but surveillance guidelines lack clear discontinuation criteria. Screening should balance risk, complications, and health status. It may be cost-effective up to age 86 years in healthy individuals, but more research is needed to refine surveillance strategies and reduce overtreatment in older adults.

IMPORTANCE/UNASSIGNED:Hispanic men experience higher rates of diabetes compared with non-Hispanic White men but remain underrepresented in preventive lifestyle interventions. OBJECTIVE/UNASSIGNED:To identify unique reasons for Hispanic men's low engagement in the National Diabetes Prevention Program (NDPP) compared with those with high engagement to inform strategies for improving participation. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study recruited Hispanic men aged 18 years and older and at risk for diabetes per electronic medical records from June 2023 to February 2024 from primary care sites affiliated with hospital-associated Montefiore Health Systems related to an ongoing clinical trial called Power Up. Patients were invited to participate in one-time phone interviews. Interviews were analyzed deductively, guided by behavior change frameworks. EXPOSURE/UNASSIGNED:Participant's level of engagement varied with representation balanced between those demonstrating low and high engagement in the NDPP (attendance at <4 and ≥4 sessions, respectively). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Planned study outcomes included NDPP notable factors associated with low engagement. RESULTS/UNASSIGNED:Of 32 Hispanic men who completed interviews (20 patients [62.5%]aged >50 years), 15 had low engagement in the NDPP, 13 (87%) were not born in the US, 12 (80%) had limited English proficiency, and 8 (53%) did not complete high school. Three major themes and 11 subthemes emerged. Hispanic men with low engagement discussed limited awareness of their prediabetes diagnosis, lifestyle change self-sufficiency, and skepticism about their diabetes risk and the benefits of NDPP. Also mentioned were financial barriers, restricted access to the program, and the perceived negatives of participation outweighing potential benefits. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Addressing the unique barriers faced by Hispanic men in engaging with the NDPP is critical to reducing diabetes-related inequities and may require tackling knowledge gaps, financial barriers, and perceptions of program relevance before, during, and after enrollment. Future research should explore how to tailor recruitment strategies and program content to Hispanic men's specific identities, motivations, and challenges.

Undergraduate medical educators seek to optimize student learning, improve grading transparency and fairness, and provide useful information to residency programs. Recently, the United States Medical Licensing Examination's shift to pass/fail scoring for Step 1 disrupted curricular and assessment operations, and schools' tiered grading practices have been scrutinized. In noting that significant institutional time and energy were being expended in addressing the current levels of student grade appeals, 6 public and private medical schools in the Northeastern United States engaged in an examination of grade appeals via a root cause analysis (RCA). From November 2021 to April 2022, the authors reviewed specific instances of grading challenges that the team of educators encountered previously. From May to June 2022, the authors met for a facilitated discussion of the question, "Why are students challenging grading processes and systems or outcomes?" From July to October 2022, the authors identified root causes by analyzing results from the fishbone diagram (process, equipment, materials, people, and environment) and using the "five whys" technique. Several potential explanations for grade appeals and challenging grading systems across institutions were identified, including variability in the quality or experience of evaluators, lack of clarity about the goals and expectations of clerkships and a lack of transparency about the grading process, having a tiered grading system, technical issues with equipment, and clinical productivity demands of faculty. In proposing solutions to root causes identified in the RCA, factors were mapped to Liaison Committee on Medical Education (LCME) standards to facilitate quality and process improvements in grading. Aiming to support the learning environment and a fair and equivalent assessment process, the authors present a novel RCA and LCME method that can contribute to improving grading systems and has the potential to enhance learning and success.