Faculty Bibliography

BACKGROUND/UNASSIGNED:Clinical decision support (CDS) tools embedded in electronic health records in the form of integrated clinical prediction rules provide a potentially effective intervention to reduce inappropriate antibiotic prescribing for acute respiratory infections. However, their effectiveness has been limited by workflow barriers and low adoption by health care providers. Nurses are well positioned to implement evidence-based protocols using CDS tools. In a multicenter randomized controlled trial, a nurse-led implementation strategy for acute respiratory infection integrated clinical prediction rules was evaluated for use in primary care and urgent care settings. OBJECTIVE/UNASSIGNED:This study aimed to examine nurse and nurse leader perspectives on the sustainability of an electronic health record-integrated CDS tool for antibiotic stewardship and explored factors influencing its potential long-term integration into ambulatory nursing practice beyond the clinical trial. METHODS/UNASSIGNED:We interviewed 22 nurses and nurse leaders from 37 clinics across 3 academic medical centers that participated in the clinical trial. Two semistructured interview guides, one for nurses and one for nursing leadership, were developed to understand the barriers and facilitators to implementing a decision aid tool for nurses and to elicit challenges specific to nursing interactions with the CDS tool. Interviews were recorded and transcribed. Using thematic content analysis and iterative coding, our team collaboratively identified emerging themes related to sustainability and refined the results with consensus. RESULTS/UNASSIGNED:Five themes emerged: (1) importance of staffing stability and capacity, (2) impact of dedicated clinic resource availability, (3) variable nurse readiness with CDS-guided clinical care, (4) influence of openness to change and a nurse-supportive clinic culture, and (5) ongoing need for training and support. Specific recommendations for future actions were also noted. CONCLUSIONS/UNASSIGNED:Our findings revealed specific barriers and facilitators to the sustainability of a CDS tool from the nursing perspective that can inform further implementation of nurse-led delegation protocols in the ambulatory setting. Future solutions should consider mapping physical workflows, scheduling specific to nurse visits, continuing education, and treating cough and sore throat as 2 distinct processes.

BackgroundPersons living with dementia (PLWD) and their care partners face unique challenges in participating in research studies. Community Engagement Studios (CES) provide a framework for researchers to work directly with community members, considered as Community Experts, who experience conditions under study to enhance research design, implementation, and dissemination.ObjectiveWe describe our experience conducting CES with PLWD and their care partners and lessons learned.MethodsPLWD and their care partners participated in three CES between July and December 2022; one in New Hampshire in English and two in New York, one of which was in Spanish. We followed the CES Toolkit guidance, which involves 1) inviting experts/stakeholders (PLWD and their care partners) to a consultative meeting, 2) preparing a presentation (interview guide) and facilitating the meeting, and 3) receiving and analyzing feedback from participants.Results12 community members (6 PLWD and 6 care partners) participated in our three studios. Three study design factors were identified during the CES: recruitment process (trust and communication with the research team), participants' autonomy, and trust and communication with clinicians. Spanish language community members raised similar issues to those in the English-speaking CES. However, Spanish language participants also noted the potential impact of interpreters during clinic visits.ConclusionsCES were feasible, informative, and well-received by PLWD and led to changes in our study design. We describe strategies for engaging care partners and PLWD, Community Experts, to elicit valid and valuable recommendations for making research studies more relevant and impactful.

BACKGROUND:Implementation strategies are dynamic and multi-faceted, and may require adaptations to fit implementation contexts, especially in lower-and-middle income countries. We report the adaptations for an ongoing late-stage implementation science trial (R01HL147811) that integrates hypertension management into HIV care in Lagos, Nigeria - a country with a high dual-disease burden - through the Task Strengthening Strategy for Hypertension (TASSH) intervention and Practice Facilitation implementation strategy. METHODS:FRAME (Framework for Reporting Adaptations and Modifications-Enhanced) modules were used to record adaptations to the intervention (i.e., TASSH) respectively, enhance participant recruitment and retention rates, and increase frequency of trainings. Data collection sources included (not limited to) patient records, nurses' logs, and minutes of implementation review meetings. Data across these sources was coded retrospectively by trained research staff and triangulated during virtual meeting discussions. Once consensus was reached, data was mapped onto the relevant framework modules using Microsoft Excel. RESULTS:We modified FRAME to include an additional component on 'what was originally planned' for the context of the adaptations. There were twelve adaptations identified during the implementation of the study. The adaptations characterized by using the frameworks included reordering recruitment start dates of study cohorts, providing patients incentives to attend follow-up visits, adding feeder sites to the study sites, and increasing the frequency of training to account for the high nurse turnover in the primary healthcare centers. Overall, 25% of the adaptations involved expanding the structure of the intervention and implementation strategies, and 33% involved adding new elements to the strategies. All adaptations occurred in the implementation phase of the trial. CONCLUSION/CONCLUSIONS:Based on our experiences, the characterization of the adaptations using FRAME demonstrates their combined applicability to an ongoing trial that can be tailored to fit the local context. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov ( NCT04704336). Registered on 11 January 2021.

OBJECTIVE:To examine associations between patient-reported health-related social needs (HRSNs) and clinical quality measure (CQM) performance in an urban federally qualified health center (FQHC) network. METHODS:This cross-sectional study included adult patients (≥18 years) screened for HRSNs at a general internal medicine clinic, Clinic-1, and a prenatal healthcare clinic, Clinic-2, within a FQHC network, between January 1, 2018, and July 31, 2022. HRSNs were assessed across 9 domains. Performance was assessed for 13 process and 2 outcome-based CQMs at Clinic-1 and 5 process-based CQMs at Clinic-2. Prevalence ratios (PR) were estimated using logistic regression to compare CQM performance by HRSN status, adjusted for relevant demographic, clinical, and clinician factors. RESULTS:At Clinic-1, reporting a HRSN was associated with lower hemoglobin A1c control (PR, 0.81; 95%CI, 0.69, 0.95). At Clinic-2, reporting a HRSN was associated with higher cervical cancer screening (PR, 1.07; 95%CI, 1.03, 1.11). No other CQMs differed significantly by HRSN status. CONCLUSIONS:HRSNs were not associated with differences in performance for most CQMs at this FQHC network. Exceptions were observed negative associations with diabetes A1c control and positive associations with cervical cancer screening. Further research is needed to elucidate mechanisms through which unmet HRSNs impact CQMs across care settings.

BACKGROUND:Pregnant women are widely exposed to organophosphate esters (OPEs). Few studies have examined how gestational OPE exposures may influence child growth rates, which are important predictors of subsequent cardiometabolic health. METHODS:Among 4566 mother-child dyads from 14 sites within the Environmental influences on Child Health Outcomes (ECHO) Cohort, we evaluated associations of gestational urinary concentrations of nine OPE metabolites with early and mid-childhood rates of change in age- and sex-standardized weight (WAZ), height (HAZ), and body mass index (BMIZ). Using linear mixed models, we estimated associations between each OPE metabolite and each growth measure separately in early childhood (2-5 years; n = 4321) and mid-childhood (6-10 years; n = 2504). We evaluated effect modification by child sex and maternal pre-pregnancy BMI. RESULTS:. DISCUSSION/CONCLUSIONS:In this large, diverse sample of U.S. children, gestational exposure to OPEs was associated with child growth rates, but the direction and magnitude differed by OPE biomarker and developmental period (early- or mid-childhood).

BACKGROUND AND AIMS/OBJECTIVE:Nitazenes are a novel subclass of synthetic opioids that have been increasingly implicated in the United States (US) overdose crisis. Despite their growing presence in the illicit drug supply, national trends have not been systematically evaluated. This study aimed to describe temporal and geographic patterns in nitazene detections and assess substances co-involved in nitazene-positive biospecimens. DESIGN/METHODS:Cross-sectional study using forensic data from two national sources: the US Drug Enforcement Administration's National Forensic Laboratory Information System (NFLIS) and the Center for Forensic Science Research & Education's (CFSRE) NPS Discovery Program. SETTING AND CASES/METHODS:Nitazene detections in all 50 US states and the District of Columbia between 2019 and 2024. MEASUREMENTS/METHODS:We quantified annual nitazene detections overall and by individual nitazene analog, US Census region and state. Temporal trends were modeled using piecewise linear regression with a Poisson distribution and log link, nationally and by region. NPS Discovery data were used to characterize substances co-involved with nitazene-positive biospecimens. FINDINGS/RESULTS:Between 2019 and 2024, 7117 nitazene analog reports were submitted to NFLIS, increasing from 43 in 2019 to 1905 in 2024. Counts rose sharply from 2019 to 2021 [count ratio = 7.32; 95% confidence interval (CI) = 2.22-24.20] but did not increase statistically significantly from 2021 to 2024 (count ratio = 1.08; 95% CI = 1.00-1.17). Early detections were predominated by isotonitazene (97.7% of NFLIS nitazene reports in 2019) but later shifted toward metonitazene and protonitazene (29.5% and 30.1%, respectively, in 2024). NPS Discovery identified 361 nitazene-positive biospecimens, increasing from 11 in 2019 to 113 in 2024, with counts increasing by approximately 45% per year (count ratio = 1.45; 95% CI = 1.23-1.71). Nearly all nitazene-positive biospecimens (98.3%) had at least one co-detected substance, most commonly fentanyl (54.6%). CONCLUSIONS:Nitazene detections increased sharply across the United States between 2019 and 2024, with shifting patterns in the prevalence of individual nitazenes and extensive polysubstance involvement. These findings highlight the need to strengthen drug testing capacity, expand epidemiological surveillance and implement targeted public health interventions to mitigate harms associated with this emerging class of synthetic opioids.

OBJECTIVE:Supporting early relational health (ERH) positively affects lifelong health. We investigated perspectives of low-income parents of preterm children regarding child factors and parenting behaviors (defined as responsive parenting, structure/routines, and warm parent-child relationship) associated with ERH and factors associated with these behaviors. METHODS:We conducted in-depth, semi-structured interviews with low-income parents of children born preterm between Neonatal Intensive Care Unit (NICU) discharge and age 3 years. We examined perceptions of ERH and used the PRECEDE framework to identify predisposing, enabling, and reinforcing factors affecting parenting behaviors associated with ERH. We developed codes and themes iteratively using a deductive qualitative approach. RESULTS:We interviewed 22 parents of children born 24 to 34 weeks' gestation at 1 to 35 months corrected age. Regarding perspectives on ERH, parents shared that the NICU hospitalization heightens attention to children after discharge and that they feel an intense, sometimes overwhelming, bond with children born preterm. Parents both make accommodations for their preterm children and treat them the same as children born full term. Medical vulnerability affects how they spend time with their children. Regarding predisposing, enabling, and reinforcing factors of parenting behaviors associated with ERH, parents noted that developmental professionals can support relationships, that perceptions of preterm birth affect parents' relationships with their children, and that prior experience parenting preterm and full-term children affects confidence and knowledge of how to form relationships. CONCLUSION/CONCLUSIONS:Adaptation of existing ERH interventions should incorporate ways that NICU hospitalization and views of prematurity inform low-income parents' perceptions and use of parenting behaviors associated with ERH.

Characterizing the relationship between DNA methylation and circulating proteins is critical to understanding the epigenetic regulation of the human plasma proteome. Here, we performed an epigenome-wide association study (EWAS) of 5,032 circulating proteins in 1,449 White and 315 Black participants from the Atherosclerosis Risk in Communities (ARIC) cohort. We identified 12,500 significant protein quantitative trait methylation (pQTM)-protein associations involving 1,647 proteins. Among 7,796 unique pQTMs, 14.7% were classified as cis-pQTMs, which were enriched for fundamental cellular processes, whereas trans-pQTMs were predominantly linked to immune-related functions. Trans-pQTMs also exhibited stronger associations with demographic, lifestyle, and clinical traits compared with cis-pQTMs. We identified proteins such as GM2A and EPHB6 whose expression appears to be strongly associated with DNA methylation, suggesting potential as targets for epigenetic-based therapeutic interventions. Together, these findings demonstrate the extensive impact of DNA methylation on the circulating proteome through cis- and trans-regulatory mechanisms and underscore the influence of population-level traits on epigenetic regulation. These findings highlight a broad impact of DNA methylation on circulating proteins through both cis- and trans-regulatory mechanisms and the roles of population-level phenotypes.