Faculty Bibliography

RATIONALE & OBJECTIVE/UNASSIGNED:(ICD)-coded AKI as well as their clinical and molecular characteristics and evaluate their associations with clinical outcomes. STUDY DESIGN/UNASSIGNED:Prospective cohort study. SETTING & PARTICIPANTS/UNASSIGNED:A total of 5,692 adults with proteomic and metabolomic profiling from the Atherosclerosis Risk in Communities study, excluding individuals with end-stage kidney disease at baseline (2011-2013). EXPOSURES/UNASSIGNED:AKI, defined as either ICD-coded or undiagnosed based on 3 abstracted levels of serum creatinine measured during hospitalizations. OUTCOMES/UNASSIGNED:Incident coronary heart disease, heart failure, stroke, and all-cause mortality. ANALYTICAL APPROACH/UNASSIGNED:ICD-coded AKI was compared with undiagnosed AKI across all hospitalizations. Risk factors for ICD-coded and undiagnosed AKI were assessed separately using Cox proportional hazards models from study visit to the first AKI encounter. Time-varying Cox models were used to evaluate the associations of ICD-coded and undiagnosed AKI with adverse outcomes. RESULTS/UNASSIGNED:ICD codes identified 51.4% of AKI defined based on changes in serum creatinine, with higher sensitivity for more severe stages and a specificity of 87.0%. Undiagnosed AKI was more common in women; otherwise, clinical risk factors for undiagnosed AKI were similar to those for ICD-coded AKI, as were proteomic and metabolomic risk factors. Both AKI groups were strongly associated with coronary heart disease, heart failure, stroke, and mortality. LIMITATIONS/UNASSIGNED:AKI was estimated using 3 values of serum creatinine only and not urinary output. Diagnosed AKI was identified using billing codes, which may underestimate clinical diagnosis of AKI. CONCLUSIONS/UNASSIGNED:Undiagnosed AKI is prevalent, especially among women, and is biologically and prognostically similar to ICD-coded AKI, motivating efforts to improve AKI recognition and diagnosis.

OBJECTIVE/UNASSIGNED:To examine clinicians' experiences using ambient documentation technology (ADT) in ambulatory practice, with a focus on impacts on documentation workflows, perceived cognitive burden, and clinical reasoning. MATERIALS AND METHODS/UNASSIGNED:This survey study included clinicians participating in an ADT pilot at NYU Langone Health between March and December 2024. Clinicians completed a baseline survey before receiving access to ADT and a posttrial survey after use. Outcomes included self-reported changes in documentation time, workflow, communication, cognitive load, and clinical and diagnostic reasoning. RESULTS/UNASSIGNED:Eighty-four clinicians across multiple specialties participated. Most reported reduced documentation time (75 [89%]) and preferred editing ambient notes (65 [77%]). Many reported reduced cognitive load (49 [58%]), while fewer reported improvements in clinical (22 [26%]) or diagnostic reasoning (20 [24%]). Clinicians who viewed note writing as part of their reasoning process reported heterogeneous cognitive effects, whereas those who did not reported no perceived benefit. A subset reported workflow changes (26 [31%]) or changes in patient communication (22 [26%]) to integrate ADT. Concern about reliance on ADT was reported by 26 clinicians (31%). DISCUSSION/UNASSIGNED:Clinicians using ADT commonly reported efficiency gains and reduced cognitive burden, although reported cognitive effects varied across clinicians and practice contexts. CONCLUSION/UNASSIGNED:Clinicians reported reductions in documentation burden and changes in documentation workflows following ADT adoption, with heterogeneous perceived effects on clinical reasoning. Implementation should address both efficiency and changes to clinicians' cognitive and workflow practices.

BACKGROUND:A large body of evidence has documented the effects of ortho-phthalates, additives to soft plastic used in food packaging, on premature birth. Ortho-phthalates are increasingly replaced with alternatives including tere-phthalates and di(isononyl) cyclohexane-1,2-dicarboxylate (DINCH). A limited toxicological literature suggests that DINCH metabolites disrupt sex hormones and promote oxidant stress known to contribute to adverse birth outcomes, and epidemiologic studies have also been limited in sample size, inclusivity of different populations and measurements at different time points in pregnancy. METHODS:We leveraged a large American cohort comprised of mother-child dyads from twenty-two cohorts to assess associations of trimester-specific and pregnancy-wide DINCH metabolites with birth weight (BW) and gestational age (GA). FINDINGS/RESULTS:Average prenatal urinary DINCH was inversely associated with birth length, birthweight, and birthweight for gestational age z-scores, but not GA. A tenfold increase in the pregnancy-averaged DINCH metabolite cyclohexane-1,2-dicarboxylic acid-monocarboxy isooctyl ester (MCOCH) was associated with a decrease of 27.43 g (95%CI: -54.81, -0.04) in birthweight. Trimester-specific analyses revealed stronger associations for third trimester DINCH exposure with birth outcomes. INTERPRETATION/CONCLUSIONS:In a large American cohort representing a broad range of backgrounds, we identified an inverse association of DINCH with standardized measures of birth size, but not gestational age. Further studies should examine joint exposures to DINCH, tere- and orthophthalates, and repeated measures across pregnancy.

BACKGROUND:Suicide rates among middle-aged and older adults in the US remain disproportionately high, yet recent national trends in suicidal ideation, suicide planning, and suicide attempts and their clinical correlates remain poorly characterized. METHODS:This serial cross-sectional study analyzed data from the 2021-2024 National Survey on Drug Use and Health, a nationally representative survey of 42,440 US adults aged ≥50 years. Logistic regression estimated temporal trends in suicidality; interaction terms tested differential trends by sociodemographic characteristics, past-year major depressive episode (MDE), serious psychological distress (SPD), substance use, prescription medication misuse, and chronic medical conditions for suicidal ideation and planning. RESULTS:From 2021 through 2024, suicidal ideation increased from 2.0% to 2.9% (p = 0.049), suicide planning from 0.3% to 1.1% (p < 0.001), and suicide attempts from 0.2% to 0.6% (p = 0.02). Significant increases in ideation and planning were concentrated among those without MDE, while increases in ideation were also observed among those without SPD, alcohol use, and prescription medication misuse. Suicide planning increased more steeply among those with cannabis use than those without (449.9% vs. 188.3% increase; interaction p = 0.04). CONCLUSIONS:Suicidality increased significantly among US adults aged ≥50 years from 2021 through 2024. While individuals with MDE and other traditional risk factors had elevated absolute risk, increases in ideation were concentrated among those without these factors, and planning increased broadly across most subgroups. These findings highlight potential gaps in prevention frameworks that rely exclusively on traditional risk factor screening and underscore the need for broader risk assessment in this population.

Neurobehavioral dysregulation (NBD) is a core clinical feature of traumatic encephalopathy syndrome (TES), but its relationships with repetitive head impact (RHI) exposure, cognitive performance, and depressive symptoms remain unclear. This study examined clinical factors associated with NBD among former American football players with substantial RHI exposure. Cross-sectional baseline data were analyzed from 179 former American football players enrolled in the DIAGNOSE CTE Research Project, including 119 former professional and 60 former college players. NBD was assessed using measures of impulsivity, behavioral regulation, hostility, and emotional lability. Multivariate regression models evaluated associations of continuous NBD scores with depressive symptom dimensions, cognitive performance, playing level, and years of football participation, adjusting for demographic and clinical covariates. Secondary analyses evaluated dichotomized NBD outcomes using study-specific thresholds. Bonferroni-adjusted p-values were reported for multiple comparisons. Depressive symptoms demonstrated the most consistent associations with NBD. Greater neurovegetative depressive symptom burden was associated with greater impulsivity (estimate = 6.84; 95% CI = 4.45, 9.23; p-value < 0.0001), behavioral dysregulation (estimate = 11.63; 95% CI = 8.50, 14.76; p-value < 0.0001), hostility (estimate = 5.07; 95% CI = 2.32, 7.81; p-value = 0.0004), and emotional lability (estimate = 1.16; 95% CI = 0.12, 2.20; p-value = 0.0284). Greater agitated/reactive depressive symptom burden was associated with greater impulsivity (estimate = 3.42; 95% CI = 1.44, 5.41; p-value = 0.0008) and hostility (estimate = 5.11; 95% CI = 2.89, 7.32; p-value < 0.0001), while greater affective depressive symptom burden was associated with greater behavioral dysregulation (estimate = 3.09; 95% CI = 0.01, 6.18; p-value = 0.0494). Better verbal memory was associated with lower impulsivity (estimate = -2.02; 95% CI = -3.65, -0.40; p-value = 0.0149) and behavioral dysregulation (estimate = -2.64; 95% CI = -4.76, -0.52; p-value = 0.0150), while better executive speed was associated with lower behavioral dysregulation (estimate = -3.10; 95% CI = -5.11, -1.09; p-value = 0.0027). Years of football exposure was not independently associated with NBD outcomes. Among former American football players with substantial RHI exposure, depressive symptom burden was more consistently associated with NBD than football participation characteristics or cognitive performance. These findings support a heterogeneous clinical phenotype and underscore the importance of evaluating depressive symptoms when interpreting NBD in the context of TES.

OBJECTIVE:Type 2 diabetes mellitus (T2DM) affects millions of Americans, and prediabetes significantly increases progression to T2DM. Community Health Workers (CHWs) may help prevent diabetes through behavioral interventions, but their effectiveness in real-world settings remains uncertain. We evaluated whether a CHW intervention prevents incident T2DM among adults with prediabetes. RESEARCH DESIGN AND METHODS/METHODS:Pragmatic, cluster-randomized controlled trial in primary care clinics at the Veterans Affairs NY Harbor Healthcare System (Manhattan) and Bellevue Hospital, New York City. The study included adults aged 18-75 years with HbA1c 5.7-6.4% and no prior diabetes or use of diabetes medications other than metformin. Primary care teams were cluster-randomized to a 12-month CHW program-health action plans, motivational interviewing, health education, and community referrals-versus usual care. The primary outcome was incident diabetes during up to 6 months' follow-up after the 12-month intervention. Secondary outcomes were changes in HbA1c, weight, blood pressure, lipids, and health care utilization. RESULTS:Incident diabetes occurred in 5.9% of intervention patients versus 4.3% of controls (risk difference 1.6%; 95% CI -3.68% to 4.10%). No significant differences were observed in HbA1c, weight, blood pressure, or lipids. The intervention group had more primary care encounters (77.6% vs 62.5%) and emergency department encounters (35.0% vs 29.1%). CONCLUSIONS:In this pragmatic trial, a 12-month CHW program did not reduce incident diabetes among adults with prediabetes but was associated with greater health care engagement (more primary care visits). More intensive or standardized CHW models should be tested to determine whether increased engagement translates into long-term metabolic benefit. TRIAL REGISTRATION/BACKGROUND:The study protocol was registered at ClinicalTrials.gov (NCT03006666, 12/27/2016). https://clinicaltrials.gov/study/NCT03006666.

PURPOSE/OBJECTIVE:This work reports on the proof-of-concept testing for a suite of educational modules designed to improve oncology clinician sexual health (SH) communication with adolescent and young adult (AYA) patients. METHODS:Pediatric oncology clinicians completed four interactive SH education modules. Intervention feasibility was evaluated through rates of intervention completion and study retention, with benchmarks of 60% and 70%, respectively. Acceptability and perceived usefulness were assessed through standardized self-report measures, using a benchmark of 70% of participants rating the intervention favorably. Pre- and postsurveys evaluated knowledge, attitudes and beliefs, SH communication practices, and perceived self-efficacy. Open-ended feedback and key takeaways from each module were analyzed qualitatively. RESULTS:A total of 45 clinicians enrolled, with 39 completing the intervention and study surveys. Completion and retention rates (86.6% and 100%, respectively) exceeded the preset feasibility benchmarks. Positive endorsement of self-report measures demonstrated acceptability (100%) and perceived usefulness (94.9%). Pre- and postintervention surveys signaled increases in clinician knowledge, beliefs, and self-efficacy. Key qualitative insights from participants were received pertaining to AYA concerns, needs, and preferences and clinician responsibilities. CONCLUSION/CONCLUSIONS:This innovative approach to clinician education on SH demonstrates potential to improve clinician knowledge and engagement in SH conversations with AYAs, a key first step in improving AYA SH during and after cancer. Next steps must focus on a larger trial to assess intervention effectiveness.

BACKGROUND/UNASSIGNED:Pregnancy requires finely tuned immune changes that support implantation, placental development, maternal-fetal tolerance, and preparation for labor, yet the normative trajectories of circulating inflammatory proteins across gestation remain poorly defined. This cross-sectional study investigates how circulating inflammatory proteins vary with gestational age in pregnancy and examines the impacts of fundamental biological characteristics, such as gravidity and fetal sex. METHODS/UNASSIGNED:Data were drawn from 1154 pregnant individuals from six study sites of the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) Cohort. We used Olink high-throughput proteomic profiling to map cross-sectional associations between protein expression levels and gestational age at blood draw using linear, spline-based, and generalized additive modeling approaches. RESULTS/UNASSIGNED:Generalized additive models provided the best fit, revealing that immune changes across pregnancy were predominantly nonlinear. Sixty-one proteins showed significant associations with gestational age, with many exhibiting shared inflection points that aligned with major physiological transitions. A small subset of proteins also showed evidence of modification by fetal and maternal characteristics. CD244 displayed different gestational patterns by fetal sex, while CST5 and SIRT2 showed varied gestational associations by maternal gravidity. CONCLUSION/UNASSIGNED:The findings highlight pregnancy as a sequence of coordinated immune transitions rather than a simple linear shift and provide one of the most detailed characterizations to date of circulating inflammatory protein dynamics across human gestation. Establishing these normative trajectories offers a crucial reference for detecting early deviations that may signal risk for pregnancy complications and for identifying biomarkers in maternal and fetal health research.

INTRODUCTION/BACKGROUND:The National Heart, Lung and Blood Institute (NHLBI), in 2020, funded six implementation research trials in Africa (Botswana, Mozambique, Nigeria, South Africa, Uganda and Zambia) to test implementation strategies for integrating evidence-based cardiovascular disease (CVD) care into primary care for people living with HIV. We identified cross-site implementation strategies used by the six trials to integrate CVD care for people living with HIV in these diverse settings. METHODS:Between December 2022 and September 2023, we reviewed protocols for each trial and followed up with study teams from the six studies to identify implementation strategies targeting the individual (healthcare worker [HCW] and patient), facility and system levels. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy of implementation strategies, we grouped and defined strategies used for each study. We then specified each strategy (i.e. actor, the action, action targets, temporality, dose, implementation outcomes addressed and theoretical justification) to understand similarities and differences in how cross-cutting implementation strategies were operationalized. RESULTS:Ten implementation strategies were identified across the six trials for integrating hypertension (six studies) and diabetes (one study) care into existing HIV primary healthcare platforms. Three strategies, HCW training, audit and feedback, and practice facilitation or coaching, were implemented in all trials. Function and form synthesis showed that while these strategies shared the common goal of improving provider capacity and quality of care, their delivery varied across settings. HCW training was adapted in duration, frequency and trainer type; audit and feedback processes differed in how data were used and integrated with district quality improvement structures; and practice facilitation approaches ranged from study-led to health system-led models. These adaptations reflected contextual differences in health system capacity and available resources while maintaining a shared focus on strengthening HIV-CVD service integration. CONCLUSIONS:With the increasing burden of CVD among people living with HIV, identifying implementation strategies for integrating CVD care into HIV primary healthcare is critical. Our study provides contextually relevant information on cross-site implementation strategies aimed at achieving this in six African countries. The findings underscore the necessity of strategies that extend beyond conventional training, highlighting coaching, facilitation and developing data systems as central to approaches to improve integrated CVD care for people living with HIV in low-resource settings.