Faculty Bibliography

Food assistance recipients have high smoking rates. Mental health factors that may affect their smoking are understudied. This study examined psychological distress and mental health service use among food assistance recipients enrolled in a smoking cessation trial. The trial sample comprised N = 352 adults aged ≥18, earning below 200% of the federal poverty level, smoking ≥5 cigarettes daily, and receiving public food assistance (e.g. SNAP). Psychological distress was assessed via the Kessler-6. Recent mental health service use (yes/no), therapeutic satisfaction (scale of 1-10), and potential usefulness of mental health services (scale of 1-10) were also assessed. Overall, 23% of participants had severe distress, 53% moderate distress, and 24% no/mild distress. Severe psychological distress was associated with younger age, high levels of financial stress, and food insecurity, but not with tobacco behaviors or motivations. Recent mental health service use was more common among individuals with severe distress, while therapeutic satisfaction was high across all distress levels. Participants who had not received mental health services reported a high level of potential usefulness if they were to receive services, especially among participants with severe distress. Results suggest that food assistance recipients who smoke may have unmet mental health care needs.

BACKGROUND/UNASSIGNED:Multilevel interventions targeting patients, providers, and health systems improve hypertension outcomes, but little is known about how well they are implemented in resource-limited settings. This study evaluated the implementation fidelity of ALTA, a multilevel approach for hypertension management, supported by practice facilitation, across six primary care practices in a Federally Qualified Health Center (FQHC). METHODS/UNASSIGNED:patients' BP and goals. We used a multi-method approach to assess implementation fidelity (adherence, dose, quality, responsiveness, differentiation) guided by Proctor's Implementation Outcome's Framework. Data sources included a structured EHR-embedded tool, narrative reports, and interviews over 12 months. ALTA adaptations were tracked using the Framework for Reporting Adaptations and Modifications-Expanded. RESULTS/UNASSIGNED: = 46) highlighted the need for team support, ongoing practice facilitation, and feedback on patients' progress as factors affecting fidelity. CONCLUSIONS/UNASSIGNED:Implementation fidelity varied across the ALTA components and participating sites, with the greatest variability observed in delivery of the site-level components of identify and refer. Centralized components delivered by the nurse-led team (coach, document, monitor) were delivered consistently with high fidelity. Contextual factors like staffing and patient engagement shaped implementation success. CLINICAL TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov, NCT03713515.

PurposeTo estimate the effect of the culturally-adapted Greenlight intervention on parent activation and locus of control (LOC) among Chinese-American immigrant parents.DesignProspective, quasi-experimental study.SettingA New York City-based federally-qualified health center with a large patient population of low-income, ethnically Chinese immigrant individuals and families.Sample444 Immigrant Chinese-American parents of infants (267 cross-sectionally enrolled historical controls and 177 Greenlight recipients followed prospectively).InterventionA culturally-adapted version of Greenlight, a health literacy- and communication-informed early childhood obesity prevention intervention in primary care which promotes certain healthy infant feeding practices at 12 months in the present sample.MeasuresParent activation and LOC were measured at 6, 12, 24, and 36 month well child visits.AnalysisGeneralized estimating equations were used to examine the effects of the Greenlight intervention on the outcome measures.ResultsCompared to historical controls, parents receiving Greenlight were more likely to strongly agree with the activation statements: "I know how to prevent my child from becoming overweight" (adjusted odds ratio (aOR): 9.62 [4.70, 19.73]); "I have been able to help my child maintain recommended changes like eating right or exercising" (aOR: 6.42 [4.14, 9.97]); and "I am confident I can keep my child eating and exercising right, even when I am busy or stressed" (aOR: 8.44 [5.35, 13.31]). Greenlight recipients also demonstrated increased internal LOC (aOR: 2.02 [1.35, 3.03]) and decreased powerful others external LOC (aOR: 1.76 [1.23, 2.51]).ConclusionTo reduce disparities in child obesity, especially among immigrant families, interventions must also prioritize parent factors like parent activation and LOC to build upon their inherent assets and promote long-term change.

IMPORTANCE/UNASSIGNED:In vivo biomarkers for detecting neuropathologies from repetitive head impacts (RHI), including chronic traumatic encephalopathy (CTE), are needed. OBJECTIVE/UNASSIGNED:To evaluate the utility of plasma phosphorylated tau 217 (p-tau217), assess its performance as a beta-amyloid (Aβ) biomarker in participants with RHI exposure at risk for CTE, and explore concordance with CTE neuropathology in a postmortem subsample. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This longitudinal, multicenter, case-control study used data from the Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of CTE (DIAGNOSE CTE) Research Project, collected from September 2016 to October 2023. Participants were former American football players (case participants) and asymptomatic men unexposed to RHI (control participants). A subsample had available neuropathologic data. EXPOSURES/UNASSIGNED:RHI, traumatic encephalopathy syndrome (TES) diagnoses, and levels of CTE certainty. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Plasma p-tau217 (classified as positive [≥0.63 pg/mL], intermediate [0.40-0.62 pg/mL], and negative [<0.40 pg/mL]), Aβ-positron emission tomography (PET; 18F-florbetapir; with Aβ-positive defined as a standardized uptake value ratio [SUVR] ≥1.10), and tau-PET (18F-flortaucipir). TES diagnoses were assigned by multidisciplinary consensus conference. Analyses of postmortem brains controlled for age, race, and APOE ε4 status. RESULTS/UNASSIGNED:Among 231 participants (mean [SD] age, 57.75 [8.25] years), 177 were former football players (117 professional and 60 college) and 54 were unexposed participants. Former football players had higher baseline mean (SD) p-tau217 concentrations than unexposed participants (0.35 [0.26] pg/mL vs 0.27 [0.14] pg/mL; P = .008), although this was driven by a higher proportion of Aβ-PET-positive participants among former players. Plasma p-tau217 increased over time across the sample (B = 0.207 [95% CI, 0.117-0.298]; P < .001), with no significant time × exposure group interactions. Among football players, p-tau217 showed no time × group interactions with TES diagnosis, TES-CTE certainty, or RHI metrics. Higher p-tau217 concentration correlated with higher global Aβ-PET SUVR (B = 0.058 [95% CI, 0.053-3.501; P = .01), with a few discordant cases (5 participants were p-tau217-negative and Aβ-PET-positive; 7 participants were p-tau217-positive and Aβ-PET-negative). P-tau217 had similar areas under the curve for projecting Aβ-PET positivity as cerebrospinal fluid (CSF) p-tau181/Aβ42 and CSF Aβ40/42 measures (p-tau217: AUC, 0.88 [95% CI, 0.80-0.96]; CSF p-tau181/Aβ42: AUC, 0.89 [95% CI, 0.79-1.00]; CSF Aβ40/42: AUC, 0.85 [95% CI, 0.72-0.98]). Among 9 brain donors, 6 had CTE (stages II-IV; none with Alzheimer disease). Seven had negative or intermediate p-tau217, concordant with Aβ-PET. Two p-tau217 outliers with stage III CTE had normal concentrations upon additional testing. CONCLUSIONS AND RELEVANCE/UNASSIGNED:The findings of this study suggest that plasma p-tau217 concentration is unlikely to be useful for the detection of CTE, but it does show utility for ruling out Aβ pathology in participants at risk for CTE.

OBJECTIVE:Studies have demonstrated that using milliliters (mL)-only in dosing instructions and on dosing devices for oral liquid medications (OLMs) can prevent patient/caregiver dosing errors. While previous studies have assessed the perceptions/practices of primary care providers (PCPs) regarding dosing units for OLMs, perceptions/practices of community-based pharmacists are not well described. METHODS:Data were collected in June 2024, through an online survey of retail pharmacists. Pharmacist perceptions/practices regarding OLMs were calculated overall and stratified by the number of years practicing pharmacy. Logistic regression was used to assess associations between certain characteristics and perceptions on pharmacist dispensing behaviors. RESULTS:A total of 201 pharmacists completed the survey. Pharmacists who had been practicing for <10 years were more likely to think that mL-only was safest to use in dosing instructions for OLMs (88.9%) and that patients/caregivers prefer dosing instructions in mL-only (73.3%) compared to those who had been practicing for ≥10 years (70.5% and 37.2%, respectively). Only one-third (33.8%) of all pharmacists reported that they would convert the dosing units dispensed on a prescription for oral liquid amoxicillin to mL-only if the prescriber wrote the dosing instructions in teaspoons; with pharmacist perception that mL-only was the safest to use in dosing instructions having the most significant impact on this dispensing behavior (adjusted odds ratio 11.37, 95% confidence interval 3.20-40.44). CONCLUSIONS:Educational efforts promoting the importance of using mL-only units on dosing instructions/devices for OLMs for pharmacists and PCPs may be necessary to promote safe dosing practices and reduce pediatric medication errors.

IMPORTANCE/UNASSIGNED:Buprenorphine-naloxone and extended-release (XR) naltrexone are both efficacious medications for opioid use disorder that reduce unregulated opioid use and improve opioid cravings and treatment retention. While prior comparative effectiveness studies demonstrated superiority of buprenorphine-naloxone over XR naltrexone for relapse and treatment retention, the comparative effectiveness of both treatments for all-cause mortality and nonfatal opioid overdose outcomes has not been rigorously tested. OBJECTIVE/UNASSIGNED:To compare the effectiveness of buprenorphine-naloxone vs XR naltrexone after medically managed opioid withdrawal (MMOW) treatment. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This observational comparative effectiveness study using a target trial emulation framework leveraged individually linked administrative data from the Massachusetts Public Health Data Warehouse to emulate the protocol of the Extended-Release Naltrexone vs Buprenorphine for Opioid Treatment randomized clinical trial. Participants included adults 18 years or older who were discharged from MMOW in Massachusetts between January 1, 2014, and December 31, 2018. Individuals could meet eligibility criteria more than once. Data were analyzed from December 22, 2023, to January 30, 2025. EXPOSURES/UNASSIGNED:Initiation of buprenorphine-naloxone or XR naltrexone therapy within 28 days of MMOW discharge. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Estimated 24-week cumulative incidence of all-cause mortality and nonfatal opioid overdose using inverse probability weighting to adjust for baseline and time-varying confounding. RESULTS/UNASSIGNED:A total of 36 752 unique individuals who met eligibility criteria were identified and contributed 106 052 MMOW discharge episodes; 79 089 (74.6%) episodes were among individuals who were male and 44 463 (42.1%) were among individuals aged 18 to 29 years. By 28 days after MMOW discharge, initiation of buprenorphine-naloxone was observed among 14 194 discharge episodes (13.4%) and initiation of XR naltrexone was observed among 4734 (4.5%) episodes. The adjusted 24-week cumulative incidence of all-cause mortality after MMOW discharge was 1.4% (95% CI, 1.2%-1.7%) for buprenorphine-naloxone and 1.4% (95% CI, 1.1%-1.8%) for XR naltrexone, corresponding to a risk difference of 0.0 percentage points (pp) (95% CI, -0.4 to 0.4 pp). The adjusted 24-week cumulative incidence of nonfatal opioid overdose after MMOW discharge was 11.6% (95% CI, 10.8%-12.3%) for buprenorphine-naloxone and 13.9% (95% CI, 12.9%-15.0%) for XR naltrexone, corresponding to a risk difference of 2.3 pp (95% CI, 1.2-3.6 pp). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this comparative effectiveness study of buprenorphine-naloxone vs XR naltrexone, initiating buprenorphine-naloxone after MMOW discharge was associated with a lower risk of nonfatal opioid overdose at 24 weeks than initiating XR naltrexone, but a similar risk of all-cause mortality.

BACKGROUND:Emerging data suggests that glyphosate, a non-selective herbicide, can influence reproductive health. We investigated associations of prenatal exposure to glyphosate and aminomethylphosphonic acid (AMPA), with preterm birth and its subtypes. METHODS:We used data from the NYU Children's Health and Environmental Study, a prospective birth cohort in New York City (2016-2019). Participants (n=1450) provided urine samples at 4 to <18 weeks and 18 to 25 weeks gestation. Exposure was adjusted for creatinine and natural log transformed. Preterm birth was defined as a birth occurring before 37 weeks of gestation. We also explored preterm birth subtypes, spontaneous preterm births and medically indicated preterm births as secondary outcomes. To examine associations between glyphosate and AMPA at both timepoints with preterm birth, we used generalized estimating equations with a logit link function. RESULTS:Overall, 7% (n=103) of births were preterm. Glyphosate concentrations at 18-25 weeks was associated with preterm birth (OR: 1.35, 95% CI: 1.04, 1.76) and spontaneous preterm birth (OR: 2.01, 95% CI: 1.40, 2.90). AMPA was not associated with preterm birth in any model. CONCLUSIONS:These results support evidence that glyphosate may act upon pathways leading to preterm birth and spontaneous preterm birth. Our study highlights pregnancy as a vulnerable period to glyphosate exposure.

BACKGROUND/UNASSIGNED:Skilled nursing facilities (SNFs) play a critical role in postacute recovery for older adults with heart failure (HF), yet the transition from SNF to home remains a vulnerable and understudied phase of care. Although discharge guidelines emphasize clear communication, HF-specific self-care education, medication management, and follow-up coordination, little is known about how these practices are implemented during SNF-to-home transitions. METHODS/UNASSIGNED:We conducted a convergent mixed-methods study across 4 nonprofit SNFs, integrating data from postdischarge patient and caregiver surveys, structured medical record abstraction of discharge instructions, and semi-structured staff interviews. Eligible patients were Medicare beneficiaries aged ≥65 years discharged from SNF to home following HF hospitalization, with SNF stays ≤60 days. Quantitative data were analyzed using descriptive statistics, while qualitative data underwent thematic and directed content analysis. Findings were triangulated across data sources to identify key challenges and actionable strategies. RESULTS/UNASSIGNED:Among 150 respondents, 59% reported receiving written discharge instructions; however, HF-specific self-care elements (eg, daily weight monitoring, low salt diet) were documented in only 15% to 41% of instructions. Although 87% reported receiving a medication list, only 53% had it reflected in the discharge instructions, and adherence support was infrequently addressed (24%). Follow-up coordination was similarly discordant: 37% of respondents reported a scheduled primary care appointment, compared with 13% documented in discharge instructions. Staff interviews revealed nonstandardized discharge workflows, workforce constraints, and reliance on verbal education, contributing to variability in patient preparation and communication across care settings. CONCLUSIONS/UNASSIGNED:SNF-to-home transitions after HF hospitalization are marked by discordance between patient-reported education and written documentation, as well as inconsistent medication and follow-up coordination. These gaps represent modifiable vulnerabilities during a high-risk recovery period. Standardized HF-focused discharge workflows and strengthened cross-setting communication may improve transitional care, while long-term solutions must address structural and workforce constraints.

Healthcare workers (HCWs) in emergency departments face significant mental health risk due to chronic stressors and repeated trauma, yet symptom underreporting and bias in self-reports hinder accurate assessments. Expressive flexibility, the ability to dynamically modulate and recover from stressor-related changes in emotional arousal as reflected in observable behavior, has been linked to resilience. This NIH-funded study (R01HL156134) utilized digital phenotyping and computer vision to analyze dynamic facial expressivity during video-recorded interviews about work-related stressful situations with 240 HCWs (278 assessments). Participants additionally completed validated questionnaires to assess burnout, PTSD, depression, anxiety, and resilience. Latent profile analysis revealed two clinical phenotypes: At-risk (57.6%) and Resilient/Adaptive (42.4%). Machine learning models demonstrated high classification performance (accuracy = 0.83 ± 0.06, F1-score = 0.87 ± 0.05). Our findings indicate that digital biomarkers of temporal facial dynamics may serve as objective behavioral proxies of expressive flexibility, potentially capturing dynamics consistent with underlying stress-regulatory processes. These findings highlight their potential to improve identification of resilience-related phenotypes and support well-being and mental health in HCWs.