Faculty Bibliography

AIMS/OBJECTIVE:Rural communities experience a higher prevalence of type 2 diabetes and diabetes-related mortality than urban populations. This study sought to disaggregate the influences of demographic and socioeconomic factors, food environment, diet quality, and dietary chemical exposures on diabetes risk in rural areas. MATERIALS AND METHODS/METHODS:We enrolled participants from rural Sullivan County in an observational cohort study involving surveys and biospecimen collection measuring bisphenols and phthalates. We measured these endocrine disrupting chemicals found in food packaging, as rural residents generally consume canned foods and other shelf-stable foods more frequently than their urban counterparts. We used LASSO regression to compare the relative influence of these factors had on rural diabetes risk. RESULTS:Based on values for LASSO regression coefficients among 276 participants, the strongest risk factors for diagnosed diabetes included: older age (+0.486), lower household income (+0.172), Hispanic ethnicity (+0.124), red meat intake (+0.093), proportion of fast food restaurants among nearby restaurants (+0.071), and two phthalates (+0.149 and + 0.107). Among study participants without a history of diabetes, high HbA1c levels were associated with older age (+0.106), being non-Hispanic Black (+0.064), more trans-fat and red meat intake (+0.044 and +0.028), higher BMI (+0.014), higher levels of total bisphenols (+0.005), and higher levels of high-molecular weight phthalates (+0.002). CONCLUSIONS:Demographic and socioeconomic factors were the strongest predictors of rural diabetes risk; however, diet quality, food environment, and dietary chemical exposures also each played a key role. Our study identified modifiable risk factors, which could help reduce the burden of rural diabetes.

PURPOSE/OBJECTIVE:To evaluate the association of patient characteristics, community-level social determinants of health, and cyst risk categories with completion of follow-up recommendations for incidental Pancreatic Cystic Lesions (PCLs). METHODS:We retrospectively identified consecutive patients (2013-2023) whose MRI radiology reports described PCLs. A fine-tuned LLaMA-3.1 8B Instruct large language model was used to extract PCL features. Lesions were classified using the 2017 ACR white paper: Category 1 (low risk), Category 2 (worrisome features), or Category 3 (high-risk stigmata). We recorded demographics and follow-up imaging or endoscopic ultrasound dates. Community-level factors were characterized by the 2020 CDC Social Vulnerability Index (SVI), stratified into quartiles. The primary outcome, "inappropriate follow-up," combined late and no follow-up. Multivariable binomial regression was applied to evaluate associations with inappropriate follow-up. RESULTS:In 7,745 patients (mean age 66.3 years; 4,796 women), 92.9% (7,198/7,745) of cysts were Category 1, 6.4% (498/7,745) were Category 2, and 0.6% (49/7,745) were Category 3. Only 36.3% of patients completed appropriate follow-up, 12.1% were late, and 51.6% were lost to follow-up. Inappropriate follow-up was high in every cyst category: 64.2% in Category 1, 59.4% in Category 2 and 49.0% in Category 3. In multivariable analysis, non-English primary language (RR 1.08; 95% CI, 1.02-1.14) and residing in more vulnerable communities of the 3rd quartiles of the socioeconomic Social Vulnerability Index subcategory (RR 1.07; 95% CI, 1.02-1.12) were associated with inappropriate follow-up. Higher age-adjusted Charlson Comorbidity Index (CCI ≥ 4) (RR .84; 95% CI, .79-.88), CCI 2-3 (RR .84; 95% CI, .79-.88), and higher-risk cysts in patients under 65 years of age (RR .76; 95% CI, .65-.89) were associated with completed follow-up. CONCLUSION/CONCLUSIONS:Follow-up completion for incidental PCLs was low. Factors most consistently associated with follow-up completion were language barriers, residence in socioeconomically vulnerable communities, age-adjusted CCI and higher-risk features among those under 65 years.

INTRODUCTION/BACKGROUND:Measuring plasma biomarkers effectively assesses early-stage Alzheimer's disease. METHODS:Subjects were categorized as cognitively unimpaired (CU) (n = 66), CU with subjective cognitive decline (SCD) (n = 100), and mild cognitive impairment (MCI) (n = 25). Plasma biomarkers measured were amyloid beta (Aβ) 40, Aβ42, neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), tau phosphorylated at threonine 181 (pTau181), neuroinflammatory biomarkers, and blood-brain barrier biomarkers. Amyloid and tau positron emission tomography (PET) imaging was performed in 186 and 144 subjects, respectively. RESULTS:Comparing those having MCI, both CU and SCD participants had significantly lower amyloid PET standardized uptake value ratio (SUVR) (p < 0.001; p = 0.005). Higher amyloid PET SUVR was significantly associated with higher pTau181 (p = 0.001) and a higher pTau181/Aβ42 ratio (p < 0.001). Higher tau PET SUVR was associated with lower plasma Aβ42 (p = 0.020), older age (p = 0.005), higher GFAP (p = 0.020), and lower interleukin-8 levels (p < 0.001). DISCUSSION/CONCLUSIONS:Our study supports plasma biomarker monitoring of at-risk patients at various stages of pre-dementia.

BACKGROUND:Uncontrolled hypertension (HTN) is a leading preventable cause of death. Interventions are needed that activate patients and motivate them to work with clinicians to control their blood pressure (BP). OBJECTIVE:To test whether mailing patients a letter including information about their hypertension and a summary of computerized algorithm-generated medication adjustment suggestions improves BP control processes and outcomes. DESIGN/METHODS:Randomized quality improvement trial. PARTICIPANTS/METHODS:We identified patients receiving primary care at a large academic medical center with diagnosed HTN and uncontrolled BP (> 140 mmHg systolic or > 90 mmHg diastolic) at both of their last 2 visits. INTERVENTIONS/METHODS:Participants were randomized into three groups. The BP Activate Letter group received a letter containing algorithm-generated BP medication adjustment suggestions, and a recommendation to discuss these suggestions with their provider; the Control Letter group received a letter that recommended they talk to their provider about their HTN, without specific medication suggestions; and the No Letter group received no mailed outreach. MAIN MEASURES/METHODS:The primary outcome was time to occurrence of either a BP medication intensification or documented achievement of BP control to < 140/< 90 mmHg using EHR data extracted 6 months after letters were mailed. KEY RESULTS/RESULTS:The primary outcome, which was time to medication intensification or achievement of BP control, did not occur more frequently in the BP Activate Letter group (hazard ratio = 0.86; 95% confidence interval [CI]: 0.65 to 1.14), or in the Control Letter group (0.78; 0.59 to 1.03) compared to the No Letter group, and we saw no evidence of significant improvement in any secondary outcome or subgroup. Time to medication intensification appeared to be significantly longer in the Control Letter compared to the No Letter group (0.50; 0.30 to 0.85). CONCLUSIONS:Mailing patients one letter with computerized BP medication adjustment suggestions to consider did not lead to effective patient activation.

PURPOSE/OBJECTIVE:To report on the presentation, treatment, and visual outcome of stromal keratitis (SK) in the Zoster Eye Disease Study (ZEDS). DESIGN/METHODS:Secondary analysis of SK endpoint of randomized clinical trial. SUBJECTS/METHODS:Herpes Zoster Ophthalmicus (HZO) patients were randomized in a double-masked clinical trial of oral valacyclovir 1g daily or placebo for 1 year. They were followed prospectively every 3 months for 18 months for endpoints of SK, iritis (IR), endothelial keratitis (EK), or dendritiform epithelial keratitis (DEK). METHODS:Presentation of recurrent, new, or worsening SK was evaluated retrospectively by treatment assignment, randomization strata, and use of topical steroids. Investigators had been allowed discretionary treatment of endpoints including open label valacyclovir and topical steroids. Visual outcome and treatment with open label oral valacyclovir and topical steroids were evaluated. MAIN OUTCOME MEASURES/METHODS:Use of open label valacyclovir and topical steroid treatment of recurrent, new, or worsening SK, and visual acuity at 12 months. RESULTS:Recurrent, new, or worsening SK occurred in 105/527(20%) participants. Randomization group was not associated with this complication. Mean best corrected visual acuity at enrollment was logMAR 0.10±0.14 with no difference at 1 year, logMAR 0.13±0.2, and no difference between valacyclovir and placebo groups at enrollment or at 1 year. Among the 105 instances of SK, 79(75%) were recognized at scheduled study visits rather than at episodic visits. In only 11/105(10%) of recurrent, new, or worsening SK, did masked investigators opt to treat with open label oral antiviral. At the time of SK complication, 52/105(50%) were on topical steroid, but 47/52(90%) on topical steroids were using 1x daily or less, 21/47(45%) high potency and 26/47(55%) low potency (p=0.47). Of 48/105(47%) on no topical steroids at recurrent, new, or worsening SK, 18/48(38%) had discontinued steroids in the prior 3 months. 38/48(75%) on no topical steroids at complication SK were subsequently treated with high potency steroids 2x daily or more. Of 26/52(50%) on low potency steroids at complication SK, 23/26(88%) were treated with increase in frequency only. CONCLUSIONS:Individuals with ocular complications of HZO who develop SK generally maintain very good vision without use of oral antiviral therapy when monitored closely and SK is recognized and treated. Low potency topical steroids should be considered for treatment and ongoing suppression of SK in HZO.

BACKGROUND/UNASSIGNED:Histotripsy is a novel, non-invasive, non-ionising, non-thermal method of mechanical tumour disruption that received US FDA approval in October 2023 for the treatment of liver tumours. This study aims to summarise and evaluate the safety and outcomes data following histotripsy of primary and secondary liver tumours. METHODS/UNASSIGNED:statistic and Cochran's Q test. Publication bias was assessed using funnel plot visual inspection and Egger's regression test. Finally, the histotripsy technology was assessed using the IDEAL framework to inform the design of future trials. This work was registered with PROSPERO (CRD420261299804). FINDINGS/UNASSIGNED:= 6.6%). No significant publication bias was detected for mortality and safety outcomes; however, formal assessment of publication bias was limited by the small number of studies for these and all outcomes. All radiological control outcomes showed substantial heterogeneity across studies. INTERPRETATION/UNASSIGNED:Although there is notable heterogeneity across studies, pooled results indicate that histotripsy has high rates of technical feasibility and local control with a favourable side effect profile. Interpretation of these findings is limited by the small number of available studies, variability in outcome definitions and imaging assessment methods, and short follow-up durations. These results underscore the need for larger, prospectively designed studies with standardised reporting frameworks and longer follow-up to more precisely characterise the clinical, radiologic, and quantitative imaging outcomes following histotripsy. FUNDING/UNASSIGNED:None.

BACKGROUND/UNASSIGNED:As life expectancy rises, identifying causes and risk factors for incident acute ischemic stroke (AIS) among the oldest-old (≥80 years) is increasingly important. We examined whether the effect of age at stroke on AIS subtype is mediated by embolic risk factors and whether these factors improve AIS prediction. METHODS/UNASSIGNED:-VASc) and compared preinclusion and postinclusion of embolic risk factors. RESULTS/UNASSIGNED:-VASc: C statistics, 0.63 [95% CI, 0.59-0.67]). CONCLUSIONS/UNASSIGNED:These findings suggest that identification and control of embolic risk factors are critical to reduce stroke risk as people age, and better stroke-specific prediction tools are needed.

IMPORTANCE/UNASSIGNED:Artificial intelligence (AI)-enabled scribes have been proposed to reduce electronic health record (EHR) burden and improve clinician satisfaction. There is limited evidence about their associated results across multiple sites and relative benefits for different clinician groups. OBJECTIVE/UNASSIGNED:To assess the association of AI scribe adoption with changes in EHR time expenditure and visit volume and how associations vary by clinician characteristics. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Multisite, longitudinal cohort study of AI scribe adoption conducted at 5 US academic health care institutions that introduced AI scribes to their clinicians between June 2023 and August 2025. Participants were ambulatory clinicians. EXPOSURES/UNASSIGNED:AI scribe adoption, defined as receiving access to an AI scribe. This was determined by opt-in decisions by eligible physicians at 4 of the 5 sites. MAIN OUTCOME AND MEASURES/UNASSIGNED:Total time spent on the EHR, time spent on documentation, and time spent on the EHR outside scheduled hours or on unscheduled days, all normalized to 8 scheduled patient hours; weekly visit volume. RESULTS/UNASSIGNED:The sample comprised 8581 clinicians, including 1809 AI scribe adopters. Participants were 57.1% female and were split between primary care (24.4%), medical (62.4%), and surgical (13.2%) specialties. Most (74.1%) were attending physicians, with 18.1% advanced practice clinicians and 7.8% resident physicians. In a difference-in-differences analysis, AI scribe adoption was associated with 13.4 (95% CI, 9.1-17.7) fewer minutes of EHR time, 16.0 (95% CI, 13.7-18.3) fewer minutes of documentation time, and 0.49 (95% CI, 0.17-0.81) additional weekly visits delivered. Electronic health record time outside work hours did not change significantly. Changes associated with AI scribe adoption were greatest for primary care specialists, advanced practice clinicians, female clinicians, and clinicians who used AI scribes in 50% or more of visits. CONCLUSIONS AND RELEVANCE/UNASSIGNED:AI scribe adoption was associated with modest decreases in total EHR time and documentation time and with a modest increase in weekly visit volume.

BACKGROUND/UNASSIGNED:Precision oncology (PO) improves and extends the lives of patients living with cancer, but multiple studies have documented its underuse in practice. Specifically, studies note a significant lack of PO use within the Veterans Affairs (VA) medical system. A paucity of implementation of PO in oncologic practice poses a significant barrier to providing the most up-to-date guideline-based care. OBJECTIVE/UNASSIGNED:While several studies have explored determinants of PO use, we sought to contribute to the body of knowledge by additionally focusing on the unique perspectives of patients, as well as conducting a comprehensive study within the VA medical system, the United States' largest single-payer health care system. We conducted interviews with both patients and providers at multiple VA sites to identify and characterize barriers and facilitators of PO use in clinical care. METHODS/UNASSIGNED:Using a qualitative descriptive approach, we conducted semistructured interviews with 17 patients with cancer and 16 oncology providers recruited from multiple VA sites. Cancer types included prostate, gastrointestinal, and lung. Data were analyzed via a team-based coding approach using directed content analysis. Data were coded and then aggregated into themes and mapped to the Theoretical Domains Framework (TDF) and Behavior Change Wheel sources of behavior (Capability, Opportunity, and Motivation) based on the consensus of the study team. RESULTS/UNASSIGNED:The patient sample consisted of 17 all-male veterans seen at VA oncology clinics in 2022. Participants predominantly self-identified as White (n=9, 52.9%) or Black (n=6, 35.3%), and the majority (n=11, 64.7%) held a high school degree or a higher level of education. The provider sample consisted of 16 physicians, all of whom held MD degrees and practiced oncology. The provider sample represented 6 states, was 50% (8/16) female, and participants averaged 14 years in their current position. The overarching theme was the "Precision Oncology Feedback Loop," which captured the essence of the complex processes involved in facilitating PO care in the VA system. The TDF and Behavior Change Wheel helped categorize findings to identify where issues in the feedback loop could facilitate or generate barriers to care. CONCLUSIONS/UNASSIGNED:Our findings expand on the current literature by highlighting both patient and provider experiences across key TDF domains (Environmental Context and Resources, Knowledge, Memory, and Attention). The conceptual model produced by the analysis illustrates the complexities associated with the implementation. Our findings support the design of multilevel interventions that target increased knowledge or education, improved workflow, and ease of communication to enhance PO delivery.