Faculty Bibliography

BACKGROUND:The design and integration of technology within inpatient hospital rooms has a critical role in supporting nursing workflows, enhancing provider experience, and improving patient care. As health care technology evolves, there is a need to design "future-proofed" physical environments that integrate technology in ways that support workflows and maintain clinical performance. Assessing how current technologies affect nursing workflows can help inform the development of these future environments. OBJECTIVE:We assessed the current challenges nursing staff face in inpatient rooms, gather insights on technology, and build environment interactions to envision the design of a technology-integrated "Inpatient Room of the Future." METHODS:A qualitative study was conducted involving semistructured interviews, shadowing, and focus groups among nursing staff in the inpatient setting. Methods including horizon scanning, scenario analysis, technology assessment, and backcasting facilitated a comprehensive qualitative analysis of current technology use and needs in inpatient nursing workflows to inform exploratory design considerations for technology-integrated envisioned futures solutions. RESULTS:In total, 26 nursing staff across 4 inpatient hospital units participated in this study. Analysis identified four major themes considered central to designing a technology-integrated inpatient room that enhances nursing workflow and experience: (1) the need for seamless integration of technologies advocating for a unified system that minimizes fragmented technology use and enhances efficiency; (2) the potential for technology to reduce cognitive load, alleviate mental strain, and streamline complex workflows; (3) a focus on enhancing interpersonal communication with specific emphasis on tools that facilitate clear and efficient communication among clinicians and with patients; and (4) the importance of improved staff well-being with design considerations aimed at promoting both physical and mental health for health care workers in the inpatient setting. Envisioned future solutions included enhanced patient monitoring with automated measurements and actions through computer vision and data triangulation, a smart electronic health record-integrated supply management system using computer vision to detect supply shortages and auto-delivery of needed supplies, and a personal tech smart assistant capable of real-time patient monitoring and escalation, task prioritization, and hands-free clinical documentation and communication. CONCLUSIONS:While current technologies address specific tasks, there are significant opportunities for better technology integration, reducing cognitive load, enhancing communication, and promoting the physical and mental well-being of nursing staff. Future research should focus on seamless technology integration aligned with clinical workflows and implementing supportive technologies that do not interfere with clinician judgment and critical thinking. Policy recommendations include oversight mechanisms for evaluating artificial intelligence-enabled devices, safeguarding patient information, and ensuring nurses are actively involved at every stage of technology development and implementation. Future inpatient unit designs should actively engage input from both nursing professionals and technologists in developing future-proofed clinical spaces to ensure the creation of integrated systems that foster a cohesive and harmonious user experience.

BACKGROUND:Sarcopenia has been associated with adverse postoperative outcomes in older age cohorts, but has not been assessed in older adults with inflammatory bowel disease (IBD). Further, current assessments of sarcopenia among all aged individuals with IBD have used various measures of muscle mass as well as cutoffs to define its presence, leading to heterogeneous findings. METHODS:In this single-institution, multihospital retrospective study, we identified all patients aged 60 years and older with IBD who underwent disease-related intestinal resection between 2012 and 2022. Skeletal Muscle Index (SMI) and Total Psoas Index (TPI) were measured at the superior L3 endplate on preoperative computed tomography scans and compared through receiver operating characteristic curve. We then performed multivariable logistic regression to assess risk factors associated with an adverse 30-day postoperative outcome. Our primary outcome included a 30-day composite of postoperative mortality and complications, including infection, bleeding, cardiac event, cerebrovascular accident, acute kidney injury, venous thromboembolism, reoperation, all-cause rehospitalization, and need for intensive care unit-level care. RESULTS:A total of 120 individuals were included. Overall, 52% were female, 40% had ulcerative colitis, 60% had Crohn's disease, and median age at time of surgery was 70 years (interquartile range: 65-75). Forty percent of older adults had an adverse 30-day postoperative outcome, including infection (23%), readmission (17%), acute kidney injury (13%), bleeding (13%), intensive care unit admission (10%), cardiac event (8%), venous thromboembolism (7%), reoperation (6%), mortality (5%), and cerebrovascular accident (2%). When evaluating the predictive performance of SMI vs TPI for an adverse 30-day postoperative event, SMI had a significantly higher area under the curve of 0.66 (95% CI, 0.56-0.76) as compared to 0.58 (95% CI, 0.48-0.69) for TPI (P = .02). On multivariable logistic regression, prior IBD-related surgery (adjusted odds ratio [adjOR] 6.46, 95% CI, 1.85-22.51) and preoperative sepsis (adjOR 5.74, 95% CI, 1.36-24.17) significantly increased the odds of adverse postoperative outcomes, whereas increasing SMI was associated with a decreased risk of an adverse postoperative outcome (adjOR 0.88, 95% CI, 0.82-0.94). CONCLUSIONS:Sarcopenia, as measured by SMI, is associated with an increased risk of postoperative complications among older adults with IBD. Measurement of SMI from preoperative imaging can help risk stratify older adults with IBD undergoing intestinal resection.

BACKGROUND/UNASSIGNED:Organophosphate ester flame retardants and plasticizers (OPEs) have myriad uses in industry and consumer products. Increasing human exposure to OPEs has raised concerns about their potential effects on child neurodevelopment during pregnancy. OBJECTIVE/UNASSIGNED:We investigated whether OPE urinary concentrations during pregnancy were associated with child autism-related outcomes. METHODS/UNASSIGNED:We included 4159 mother-child pairs from 15 cohorts in the NIH Environmental influences on Child Health Outcomes (ECHO) Consortium, with children born from 2006-2020 (median age [interquartile range]: 6 [4,10] years). Nine OPE biomarkers were measured in urine samples collected mid- to late pregnancy. Dilution-adjusted biomarkers were modeled continuously, categorically (high [> median], moderate [≤ median], non-detect), or as detect/non-detect depending on their detection frequency. We assessed child autism-related traits via a) parent report on the Social Responsiveness Scale (SRS) and b) clinical autism diagnosis. We examined associations of OPEs with child outcomes, including modification by child sex, using generalized estimating equations to account for clustering by ECHO cohort. RESULTS/UNASSIGNED:Compared with non-detectable concentrations, high exposure to bis(butoxyethyl) phosphate (BBOEP) was associated with higher autistic trait scores (adj-β 0.97, 95% confidence interval [CI]: 0.42, 1.52) and greater odds of autism diagnosis (adjusted odds ratio [adj-OR]: 1.27, 95% CI: 1.07, 1.50). Bis(1-chloro-2-propyl) phosphate (BCPP) showed associations with autistic trait scores (BCPP adj-β for high exposure vs. non-detect: 0.34, 95% CI: -0.46, 1.13; BCPP adj-β for moderate exposure vs. non-detect: 0.72, 95% CI: 0.24, 1.20). High exposure to bis(2-chloroethyl) phosphate (BCETP) was associated with lower odds of autism diagnosis (adj-OR: 0.76, 95% CI: 0.60, 0.95). Other OPEs showed no associations in adjusted models. Associations between BBOEP and higher autistic trait scores were stronger in males than females. DISCUSSION/UNASSIGNED:Prenatal exposure to OPEs, specifically BCPP and BBOEP, may be associated with higher risk of autism diagnosis and related traits in childhood. https://doi.org/10.1289/EHP16177.

BACKGROUND/UNASSIGNED:The relationship between prenatal exposure to low-level air pollution and child autism spectrum disorder (ASD) is unclear. OBJECTIVE/UNASSIGNED:To examine associations of prenatal air pollution exposure with autism. METHODS/UNASSIGNED:quantiles) using quantile regression and with ASD diagnosis using logistic regression. Models were run within census divisions, and coefficients were pooled in a meta-analysis. RESULTS/UNASSIGNED:also was associated with ASD. DISCUSSION/UNASSIGNED:Associations with ASD outcomes were present even at low levels of air pollutants. https://doi.org/10.1289/EHP16675.

Effective mild cognitive impairment (MCI) screening requires accessible testing. This study compared two tests for distinguishing MCI patients from controls: Rapid Automatized Naming (RAN) for naming speed and Low Contrast Letter Acuity (LCLA) for sensitivity to low contrast letters. Two RAN tasks were used: the Mobile Universal Lexicon Evaluation System (MULES, picture naming) and Staggered Uneven Number test (SUN, number naming). Both RAN tasks were administered on a tablet and in a paper/pencil format. The tablet format was administered using the Mobile Integrated Cognitive Kit (MICK) application. LCLA was tested at 2.5% and 1.25% contrast. Sixty-four participants (31 MCI, 34 controls; mean age 73.2 ± 6.8 years) were included. MCI patients were slower than controls for paper/pencil (75.0 vs. 53.6 sec, p < 0.001), and tablet MULES (69.0 sec vs. 50.2 sec, p = 0.01). The paper/pencil SUN showed no significant difference (MCI: 59.5 sec vs. controls: 59.9 sec, p = 0.07), nor did tablet SUN (MCI: 59.3 sec vs. controls: 55.7 sec, p = 0.36). MCI patients had worse performance on LCLA testing at 2.5% contrast (33 letters vs. 36, p = 0.04*) and 1.25% (0 letters vs. 14. letters, p < 0.001). Receiver operating characteristic (ROC) analysis showed similar performance of paper/pencil and tablet MULES in distinguishing MCI from controls (AUC = 0.77), outperforming both SUN (AUC = 0.63 paper, 0.59 tablet) and LCLA (2.5% contrast: AUC = 0.65, 1.25% contrast: AUC = 0.72). The MULES, in both formats, may be a valuable screening tool for MCI.

PurposeTo evaluate the association between demographic characteristics and weight-loss in response to financial incentives designed using behavioral economics.DesignRetrospective analysis of randomized clinical trial (RCT).SettingFIReWoRk RCT (NCT03157713), which found that financial incentives were more effective than provision of weight-management resources only for weight-loss.Subjects668 adults with obesity (221 in resources-only group, 447 in incentive groups) living in low-income neighborhoods.MeasuresDemographic characteristics and weight-loss.AnalysisLinear mixed-effects models with interaction terms to examine effect of incentives on weight-loss in different demographic groups.ResultsMean age of participants was 47.69 years, 81.0% were women, 72.6% were Hispanic, and mean BMI was 37.95 kg/m². Financial incentives increased percent weight loss at 6 months (difference in percent weight loss between financial incentive and resources-only group = -2.41%; 95% CI -3.23% to -1.58%). In fully adjusted models, participants who were Black lost less weight than participants who were White (difference in percent weight loss = 2.12%; 95% CI 0.25% to 3.99%). Differences in percent weight loss by sex, age, education and neighborhood income were absent. Models that tested for interactions between group assignment and percent weight loss did not demonstrate evidence of a heterogenous effect of incentives in sociodemographic subgroups.ConclusionBlack participants in the FIReWoRk intervention lost less weight than White participants, but effectiveness of financial incentives generally did not vary significantly by sociodemographic characteristics. However, it remains important to evaluate potential impacts of financial incentive programs on health disparities.

INTRODUCTION/BACKGROUND:Fentanyl-related deaths involving stimulants have increased in the US, but little is known about nonfatal overdoses involving use. We examined national trends in nonfatal fentanyl-related exposures involving co-use of cocaine or methamphetamine. METHODS:In this cross-sectional analysis, data from US poison centers were used to estimate annual trends in reported exposures involving fentanyl and stimulant use from 2015 to 2023. Cases included patients aged ≥13 with exposures involving intentional misuse or "abuse" of fentanyl where nonfatal adverse effects occurred (n=13,173). Co-exposure trends were examined, and multivariable logistic regression models were used to estimate how region and medical outcome severity were associated with (1) fentanyl-cocaine use (vs. fentanyl, no cocaine use) and (2) fentanyl-methamphetamine use (vs. fentanyl, no methamphetamine use). RESULTS:Between 2015 and 2023, among fentanyl-related exposures, cocaine use increased from 1.3% to 10.0% (669.2% increase, p<.001) and methamphetamine use increased from 1.5% to 10.8% (620.0% increase, p<.001). Exposures in the Northeast were associated with higher odds of cocaine co-use, while exposures in the Midwest, South, and West were associated with higher odds of methamphetamine co-use. Compared to those with less severe effects, those with a major (life-threatening) effect had higher odds of cocaine co-use, but lower odds of methamphetamine co-use. CONCLUSIONS:Similar to drug-related mortality trends, nonfatal fentanyl poisonings involving co-use of cocaine or methamphetamine increased in recent years and became increasingly widespread. Differences in experience of life-threatening adverse effects linked to different stimulants suggests varying risk according to which stimulant is involved.

IMPORTANCE/UNASSIGNED:In the context of the US opioid crisis, factors associated with the prevalence of opioid use disorder (OUD) must be identified to aid prevention and treatment. State medical cannabis laws (MCL) and recreational cannabis laws (RCL) are potential factors associated with OUD prevalence. OBJECTIVE/UNASSIGNED:To examine changes in OUD prevalence associated with MCL and RCL enactment among veterans treated at the Veterans Health Administration (VHA) and whether associations differed by age or chronic pain. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Using VHA electronic health records from January 2005 to December 2022, adjusted yearly prevalences of OUD were calculated, controlling for sociodemographic characteristics, receipt of prescription opioids, other substance use disorders, and time-varying state covariates. Staggered-adoption difference-in-difference analyses were used for estimates and 95% CIs for the relationship between MCL and RCL enactment and OUD prevalence. The study included VHA patients aged 18 to 75 years. The data were analyzed in December 2023. MAIN OUTCOME AND MEASURES/UNASSIGNED:International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) OUD diagnoses. RESULTS/UNASSIGNED:From 2005 to 2022, most patients were male (86.7.%-95.0%) and non-Hispanic White (70.3%-78.7%); the yearly mean age was 61.9 to 63.6 years (approximately 3.2 to 4.5 million patients per year). During the study period, OUD decreased from 1.12% to 1.06% in states without cannabis laws, increased from 1.13% to 1.19% in states that enacted MCL, and remained stable in states that also enacted RCL. OUD prevalence increased significantly by 0.06% (95% CI, 0.05%-0.06%) following MCL enactment and 0.07% (95% CI, 0.06%-0.08%) after RCL enactment. In patients aged 35 to 64 years and 65 to 75 years, MCL and RCL enactment was associated with increased OUD, with the greatest increase after RCL enactment among older adults (0.12%; 95% CI, 0.11%-0.13%). Patients with chronic pain had even larger increases in OUD following MCL (0.08%; 95% CI, 0.07%-0.09%) and RCL enactment (0.13%; 95% CI, 0.12%-0.15%). Consistent with overall findings, the largest increases in OUD occurred among patients with chronic pain aged 35 to 64 years following the enactment of MCL and RCL (0.09%; 95% CI, 0.07%-0.11%) and adults aged 65 to 75 years following RCL enactment (0.23%; 95% CI, 0.21%-0.25%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:The results of this cohort study suggest that MCL and RCL enactment was associated with greater OUD prevalence in VHA patients over time, with the greatest increases among middle-aged and older patients and those with chronic pain. The findings did not support state cannabis legalization as a means of reducing the burden of OUD during the ongoing opioid epidemic.

BACKGROUND/UNASSIGNED:Maternal sustained smoking during pregnancy is associated with thousands of differentially methylated CpGs in newborns, but impacts of other prenatal tobacco smoking exposures remain unclear. OBJECTIVE/UNASSIGNED:To identify differential DNA methylation in newborns from maternal sustained smoking and less studied prenatal smoking exposures (i.e., maternal exposure to secondhand smoke [SHS] exposure during pregnancy, maternal quitting before pregnancy, paternal smoking around conception, paternal quitting before pregnancy). METHODS/UNASSIGNED:We conducted a large meta-analysis of prenatal tobacco smoking exposures and epigenome-wide newborn blood DNA methylation through the Pregnancy And Childhood Epigenetics Consortium (PACE). Across 19 cohorts, 11,175 parent-newborn pairs contributed information on at least one prenatal smoking exposure, mostly from questionnaires. Maternal blood or urine cotinine measurements, available in a few studies, provided objective data on maternal SHS and smoking during pregnancy. Primary analyses used Illumina450K methylation data; secondary analyses in 5 cohorts examined CpGs unique to the EPIC array. RESULTS/UNASSIGNED:) was associated with paternal former smoking. Forty-one novel genes were identified using maternal cotinine measurements compared to questionnaire. In EPIC unique analyses (n=3,415), differential methylation was observed with maternal sustained smoking (211 CpGs), maternal SHS (5 CpGs), and paternal former smoking (4 CpGs). Smoking-associated CpGs in blood were strongly enriched for functional elements across multiple tissues. CONCLUSIONS/UNASSIGNED:Maternal sustained smoking has the largest impact on newborn DNA methylation, suggesting a strong influence of the intrauterine environment. We observed minimal impacts for less studied exposures including SHS, maternal former smoking and paternal smoking. https://doi.org/10.1289/EHP16303.

Algorithmic bias occurs when predictive model performance varies meaningfully across sociodemographic classes, exacerbating systemic healthcare disparities. NYC Health + Hospitals, an urban safety net system, assessed bias in two binary classification models in our electronic medical record: one predicting acute visits for asthma and one predicting unplanned readmissions. We evaluated differences in subgroup performance across race/ethnicity, sex, language, and insurance using equal opportunity difference (EOD), a metric comparing false negative rates. The most biased classes (race/ethnicity for asthma, insurance for readmission) were targeted for mitigation using threshold adjustment, which adjusts subgroup thresholds to minimize EOD, and reject option classification, which re-classifies scores near the threshold by subgroup. Successful mitigation was defined as 1) absolute subgroup EODs <5 percentage points, 2) accuracy reduction <10%, and 3) alert rate change <20%. Threshold adjustment met these criteria; reject option classification did not. We introduce a Supplementary Playbook outlining our approach for low-resource bias mitigation.