Faculty Bibliography

The objective of this study was to establish recommendations for thromboprophylaxis in patients with endogenous Cushing's syndrome (CS), addressing the elevated risk of venous thromboembolism (VTE) associated with hypercortisolism. A Delphi method was used, consisting of 4 rounds of voting and subsequent discussions. The panel included 18 international experts from 11 countries and 4 continents. Consensus was defined as ≥75% agreement among participants. Recommendations were structured into the following categories: thromboprophylaxis, perioperative management, and VTE treatment. Consensus was reached on several critical areas, resulting in 14 recommendations. Key recommendations include: thromboprophylaxis should be considered at time of CS diagnosis and continued for 3 months after biochemical remission, provided there are no obvious contraindications. The standard weight-based prophylactic dose of low molecular-weight heparin is the preferred agent for thromboprophylaxis in patients with CS. Additionally, perioperatively and around inferior petrosal sinus sampling, thromboprophylaxis should be reconsidered if not already initiated at diagnosis. For VTE treatment, extended thromboprophylaxis is advised continuing for 3 months after Cushing is resolved. These Delphi consensus-based recommendations aim to standardize care practices and enhance patient outcomes in CS by providing guidance on thromboprophylaxis, including its initiation and continuation across various disease states, as well as the preferred agents to use. The panel also highlighted key areas for further research, particularly regarding the use of direct oral anticoagulants in CS and the management of mild CS and mild autonomous cortisol secretion. Additionally, the optimal duration of anticoagulant prophylaxis following curative treatment remains uncertain.

IMPORTANCE/UNASSIGNED:Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters. OBJECTIVE/UNASSIGNED:This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics. RESULTS/UNASSIGNED:A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.

BACKGROUND:Inflammatory bowel disease (IBD) is a chronic, immune-mediated inflammatory disorder of the gastrointestinal tract. In IBD, systemic inflammation and immune dysregulation may also impact extraintestinal organs, such as the thyroid gland. Despite this, little is known about the influence of concomitant hypothyroidism on the clinical course of IBD. METHODS:A retrospective analysis was conducted among adult patients with IBD and at least one thyroid stimulating hormone (TSH) measurement within a large healthcare network. Patient charts were reviewed, and baseline demographics, disease characteristics, biomarkers, healthcare utilization, medication use, and other comorbidities were extracted. Patients were stratified by those with IBD only and those with concomitant IBD and hypothyroidism. Multivariable logistic regression was used to identify factors associated with concomitant hypothyroidism. Concomitant disease as an independent predictor for lab abnormalities and increased healthcare utilization was also assessed using multivariable logistic and negative binomial regression. RESULTS:IRR: 1.89, 95% CI 1.08, 3.32). CONCLUSION/CONCLUSIONS:Patients with both IBD and hypothyroidism have an increased likelihood of other extraintestinal manifestations compared to individuals who have IBD without hypothyroidism. Furthermore, patients with concomitant disease exhibited greater healthcare utilization, specifically, increased rates of RBAI studies. The presence of concomitant hypothyroidism may be associated with a more severe course of IBD.

OBJECTIVE:To explore how Sesame Workshop resources are perceived by Latino families with economic hardship and to highlight approaches for early heart healthy routine promotion. METHODS:We performed a purposive sampling of Latina mothers (n = 40) with young children experiencing economic hardship. Using an interview guide informed by the Consolidated Framework for Implementation Research, we recorded Spanish and English semistructured interviews, which were translated and transcribed verbatim. Partnering with Sesame Workshop, we iteratively incorporated Sesame Resources into interviews to query for acceptability. Using reflexive thematic analysis, we coded transcripts through textual analysis until saturation, prioritizing in vivo coding to capture participant voices. RESULTS:We constructed 3 themes. Parents connected with resources that 1) Reflect lived and multicultural experiences containing recognizable family scenes that can serve as tools to transfer a parent's own early routines or cultural rituals to their child. They appreciated resources that 2) Engage caregivers and children together, featuring elements for both children and adult caregivers with activities to highlight important caregivers and encourage shared play. Participants also reflected on how 3) Routines amplify family strengths and foster resilient reactions with feelings of decreased stress when daily practices become routines, promoting resilient reactions and supporting long-term goals when facing setbacks. CONCLUSIONS:An interdisciplinary partnership leveraged strengths of pediatric practitioners and Sesame Workshop to align future initiatives with the values and priorities of mothers of young children at risk for early obesity. Resultant themes inform strategies to promote heart healthy routines and relational health in young children with economic hardship.

AIM/OBJECTIVE:To describe the self-reported mental health of nurses from 35 countries who worked during the COVID-19 pandemic. BACKGROUND:There is little occupationally specific data about nurses' mental health worldwide. Studies have documented the impact on nurses' mental health of the COVID-19 pandemic, but few have baseline referents. METHODS:A descriptive, cross-sectional design structured the study. Data reflect a convenience sample of 9,387 participants who completed the opt-in survey between July 31, 2022, and October 31, 2023. Descriptive statistics were run to analyze the following variables associated with mental health: Self-reports of mental health symptoms, burnout, personal losses during the pandemic, access to mental health services, and self-care practices used to cope with pandemic-related stressors. Reporting of this study was steered by the STROBE guideline for quantitative studies. RESULTS:Anxiety or depression occurred at rates ranging from 23%-61%, with country-specific trends in reporting observed. Approximately 18% of the sample reported experiencing some symptoms of burnout. The majority of nurses' employers did not provide mental health support in the workplace. Most reported more frequently engaging with self-care practices compared with before the pandemic. Notably, 20% of nurses suffered the loss of a family member, 35% lost a friend, and 34% a coworker due to COVID-19. Nearly half (48%) reported experiencing public aggression due to their identity as a nurse. CONCLUSIONS:The data obtained establish a basis for understanding the specific mental health needs of the nursing workforce globally, highlighting key areas for service development. IMPLICATIONS FOR NURSING POLICY/CONCLUSIONS:Healthcare organizations and governmental bodies need to develop targeted mental health support programs that are readily accessible to nurses to foster a resilient nursing workforce.

BACKGROUND:Minoritized populations face many barriers to accessing evidence-based diabetes intervention. OBJECTIVES/OBJECTIVE:To evaluate the feasibility, acceptability, and potential efficacy of a social media-based intervention to improve glycemic control among Chinese Americans with type 2 diabetes. DESIGN/METHODS:A pilot randomized controlled trial (RCT) with 3-month and 6-month follow-ups. PARTICIPANTS/METHODS:Chinese Americans (n = 60, mean age 54.3 years old) with limited education (70.0% with high school or less) and low income (50.0% with annual household income < $25,000), and 88.3% have limited English proficiency. INTERVENTION/METHODS:Culturally and linguistically tailored diabetes videos (two videos/week for 12 weeks) delivered via social media and support calls from community health workers. MAIN MEASURES/METHODS:Primary outcomes include feasibility (video watch rate, biweekly call completion rate, and retention rates), acceptability (patient satisfaction), and HbA1c. Secondary health-related outcomes include body weight, BMI, physical activity, and dietary intake. Video watch rate and biweekly call completion rate were assessed at baseline and 3 months, while others were measured at baseline, 3 months, and 6 months. RESULTS:We observed high feasibility and acceptability of the intervention, with retention rates over 87%, an 89% video watch rate, 80% biweekly phone call completion, and a satisfaction rating of 9 out of 10. The intervention group showed a significantly greater increase in fruit intake compared to the control group (0.15 cups vs. - 0.44 cups, adj_p = 0.023) at 3 months. While no significant differences in other outcomes were observed between the groups, the intervention group showed significant improvements in key outcomes, including reduced HbA1c levels (- 1.08%, adj_p < 0.001), weight loss (- 5.15 lbs, adj_p = 0.004), lower BMI (- 0.83, adj_p = 0.023), and reduced starchy food intake (- 0.33 cups, adj_p = 0.033) at 6 months. CONCLUSIONS:The observed high feasibility and acceptability suggest the intervention's feasibility. However, due to the limited sample size, a larger-scale RCT is warranted to test the efficacy of the intervention. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03557697; https://clinicaltrials.gov/ct2/show/NCT03557697.

BACKGROUND/UNASSIGNED:Usability testing is valuable for assessing a new tool or system's usefulness and ease-of-use. Several established methods of usability testing exist, including think-aloud testing. Although usability testing has been shown to be crucial for successful clinical decision support (CDS) tool development, it is often difficult to conduct across multisite development projects due to its time- and labor-intensiveness, cost, and the skills required to conduct the testing. OBJECTIVE/UNASSIGNED:Our objective was to develop a new method of usability testing that would enable efficient acquisition and dissemination of results among multiple sites. We sought to address the existing barriers to successfully completing usability testing during CDS tool development. METHODS/UNASSIGNED:We combined individual think-aloud testing and focus groups into one session and performed sessions serially across 4 sites (snowball group usability testing) to assess the usability of two CDS tools designed for use by nurses in primary and urgent care settings. We recorded each session and took notes in a standardized format. Each site shared feedback from their individual sessions with the other sites in the study so that they could incorporate that feedback into their tools prior to their own testing sessions. RESULTS/UNASSIGNED:The group testing and snowballing components of our new usability testing method proved to be highly beneficial. We identified 3 main benefits of snowball group usability testing. First, by interviewing several participants in a single session rather than individuals over the course of weeks, each site was able to quickly obtain their usability feedback. Second, combining the individualized think-aloud component with a focus group component in the same session helped study teams to more easily notice similarities in feedback among participants and to discuss and act upon suggestions efficiently. Third, conducting usability testing in series across sites allowed study teams to incorporate feedback based on previous sites' sessions prior to conducting their own testing. CONCLUSIONS/UNASSIGNED:Snowball group usability testing provides an efficient method of obtaining multisite feedback on newly developed tools and systems, while addressing barriers typically associated with traditional usability testing methods. This method can be applied to test a wide variety of tools, including CDS tools, prior to launch so that they can be efficiently optimized.

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.

BACKGROUND:Incidence estimates of post-acute sequelae of SARS-CoV-2 infection, also known as long-COVID, have varied across studies and changed over time. We estimated long-COVID incidence among adult and pediatric populations in three nationwide research networks of electronic health records (EHR) participating in the RECOVER Initiative using different classification algorithms (computable phenotypes). METHODS:This EHR-based retrospective cohort study included adult and pediatric patients with documented acute SARS-CoV-2 infection and two control groups-- contemporary COVID-19 negative and historical patients (2019). We examined the proportion of individuals identified as having symptoms or conditions consistent with probable long-COVID within 30-180 days after COVID-19 infection (incidence proportion). Each network (the National COVID Cohort Collaborative (N3C), National Patient-Centered Clinical Research Network (PCORnet), and PEDSnet) implemented its own long-COVID definition. We introduced a harmonized definition for adults in a supplementary analysis. RESULTS:Overall, 4% of children and 10-26% of adults developed long-COVID, depending on computable phenotype used. Excess incidence among SARS-CoV-2 patients was 1.5% in children and ranged from 5-6% among adults, representing a lower-bound incidence estimation based on our control groups. Temporal patterns were consistent across networks, with peaks associated with introduction of new viral variants. CONCLUSION/CONCLUSIONS:Our findings indicate that preventing and mitigating long-COVID remains a public health priority. Examining temporal patterns and risk factors of long-COVID incidence informs our understanding of etiology and can improve prevention and management.