Faculty Bibliography

As the technology for ectogenesis continues to advance, the ethical implications of such developments should be thoroughly and proactively explored. The possibility of full ectogenesis remains hypothetical at present, and myriad concerns regarding the safety and efficacy of the technology must be evaluated and addressed, while pressing moral considerations should be fully deliberated. However, it is conceivable that the technology may become sufficiently well established in the future and that eventually full ectogenesis might be deemed ethically acceptable as a reproductive alternative to gestation within a human womb under certain circumstances. If the safety and efficacy of full ectogenesis are established, if ethical dilemmas are sufficiently well addressed, and if the technology is offered as a reproductive option to cisgender heterosexual individuals or couples desiring to become parents, there is a moral obligation grounded in social justice to ensure that full ectogenesis be made available to individuals or couples identifying as members of sexual- or gender-minority groups who likewise seek to pursue parenthood. We examine the history of access to current family-building options, including assisted reproductive technology, surrogacy and adoption, for these populations and conclude that in the absence of robust empirical evidence suggesting an increased risk of harm to children of individuals and couples who identify as members of sexual- or gender-minority groups, equitable access to ectogenesis as a pathway to parenthood for sexual and gender minorities must be assured as a matter of reproductive justice.

Background: Primary care clinics often struggle to choose the approach to alcohol and drug screening that is best suited to their resources, workflows, and patient populations. We are conducting a multi-site study to inform the implementation and feasibility of electronic health record (EHR)-integrated screening.
Method(s): In two urban academic health systems, researchers worked with stakeholders from 6 clinics to define and implement their optimal screening approach. All clinics used single-item screening questions for alcohol/drugs followed by AUDIT-C/DAST-10. Clinics chose between: (a) screening at routine vs. annual visits; and (b) staff-administered vs computer self-administered screening. Results were recorded in the EHR, and data was extracted quarterly to describe implementation outcomes including screening rate and detected prevalence of unhealthy (moderate-high risk) use among those screened. Findings are from the first 3 to 12 months post-implementation at each clinic.
Result(s): Across sites, of 84 311 patients with primary care visits, 58 492 (69%) were screened. In the four clinics with mature (9-12 months) implementation, screening rates ranged from 42% to 95%. Rates were lower (10%-22%) in the two clinics that recently launched. Screening at routine encounters, in comparison to annual visits, achieved higher screening rates for alcohol (90%-95% vs 42%-62%) and drugs (90%-94% vs 38%-60%). Staff-administered screening, in comparison to patient self-administered screening, had lower rates of detection of unhealthy alcohol use (2% vs 15-37%). Detection of unhealthy drug use was low, ranging from 0.3% to 1.5%.
Conclusion(s): EHR-integrated screening was feasible to implement in at least four of the six clinics; 1-year results (available Fall 2019) will determine feasibility at all sites. Self-administered screening at routine primary care visits achieved the highest rates of screening and detection of unhealthy alcohol use. Although limited by differences among clinics and their patient populations, this study provides insight into outcomes that may be expected with commonly used screening strategies in primary care.
Summary: This multi-site study conducted in the NIDA Clinical Trials Network seeks to inform the implementation and feasibility of EHR-integrated screening for substance use in primary care. This study will provide insight into outcomes that may be expected with commonly used screening strategies in primary care and may assist in fine-tuning the most appropriate approach to alcohol and drug screening best suited for primary care clinics, based on their individual resources, workflows, and patient populations

PURPOSE:Cohort participants usually have lower mortality rates than nonparticipants, but it is unclear if this survival advantage decreases or increases as cohort studies age. METHODS:We used a 1975 private census of Washington County, Maryland, to compare mortality among cohort participants to nonparticipants for three cohorts, Campaign Against Cancer and Stroke (CLUE I), Campaign Against Cancer and Heart Disease (CLUE II), and Atherosclerosis Risk In Communities (ARIC) initiated in 1974, 1989, and 1986, respectively. We analyzed mortality risk using time-truncated Cox regression models. RESULTS:Participants had lower mortality risk in the first 10 years of follow-up compared with nonparticipants (fully adjusted average hazard ratio [95% confidence intervals] were 0.72 [0.68, 0.77] in CLUE I, 0.69 [0.65, 0.73] in CLUE II, and 0.74 [0.63, 0.86] in ARIC), which persisted over 20 years of follow-up (0.81 [0.78, 0.84] in CLUE I, 0.87 [0.84, 0.91] in CLUE II, and 0.90 [0.83, 0.97] in ARIC). This lower average hazard for mortality among participants compared with nonparticipants attenuated with longer follow-up (0.99 [0.96, 1.01] after 30+ years in CLUE I, 1.02 [0.99, 1.05] after 30 years in CLUE II, and 0.95 [0.89, 1.00] after 30+ years in ARIC). In ARIC, participants who did not attend visits had higher mortality, but those who did attend visits had similar mortality to the community. CONCLUSIONS:Our results suggest the volunteer selection for mortality in long-standing epidemiologic cohort studies often diminishes as the cohort ages.

Background and Objectives: To rapidly develop, implement, and evaluate emergency department (ED) clinical protocols for initiation of buprenorphine (E

OBJECTIVE:To explore the impact of an adapted goals-of-care communications skills workshop created for ED physicians from the physicians' perspective. METHODS:Semi-structured, one-on-one audio-recorded interviews lasting 30-60 min were conducted with twelve physicians who had completed the training workshop. Interviews explored the experience of undertaking the workshop, its impact on their clinical practice and their ability to teach new skills to other clinicians using learnt techniques. Descriptive content analysis was performed on interview transcripts. RESULTS:Participants reported positive experiences of the workshop. The analysis identified four main themes and ten subthemes dealing with workshop content and its impact on subsequent ED-based clinical practice. There were: 1) value and future improvements for the course; 2) value of the course to practice; 3) value of the course for teaching residents and 4) barriers to application of learning. Specifically recommended components include the use of mnemonics, mechanisms to introduce difficult conversations and a positive feedback environment. Participant-recommended refinements to the workshop included emphasising urgency, replicating the chaotic ED environment and expanding content to include more ED-focused goals-of-care discussions. CONCLUSION/CONCLUSIONS:A short, focused training workshop directed at improving palliative care communication skills among ED clinicians appears to be welcomed and useful.

OBJECTIVES/OBJECTIVE:To assess relations of prepregnancy maternal and paternal obesity with offspring behavioral problems and psychiatric symptoms at 7-8 years in the Upstate KIDS study, a prospective cohort study. STUDY DESIGN/METHODS:Maternal body mass index (BMI) was calculated from prepregnancy height and weight provided in vital records or self-report at 4 months postpartum. Mothers reported paternal height and weight. At 7-8 years, mothers indicated if their children had been diagnosed with ADHD or anxiety (n = 1915). Additionally, children's behavior was measured with the Strengths and Difficulties Questionnaire at 7 years of age (n = 1386) and the Vanderbilt ADHD Diagnostic Parent Rating Scale at 8 years of age (n = 1484). Based on Strengths and Difficulties Questionnaire scores, we identified children with borderline behavioral problems. Adjusted risk ratios (aRR) and 95% CIs were estimated with robust multivariable Poisson regression. RESULTS:had higher risks of reported ADHD (aRR, 1.14, 95% CI, 0.78-1.69; aRR, 1.96, 95% CI, 1.29-2.98; and aRR, 1.82, 95% CI,1.21-2.74, respectively). Risks of hyperactivity problems identified by the Strengths and Difficulties Questionnaire and a positive screen for inattentive or hyperactive/impulsive behavior with the Vanderbilt ADHD Diagnostic Parent Rating Scale were also higher with increasing maternal prepregnancy BMI. Paternal BMI was not associated with child outcomes. CONCLUSIONS:Our findings suggest that maternal, rather than paternal, obesity is associated with maternal report of child ADHD diagnosis and inattentive or hyperactivity problems. Further research is needed to understand how maternal obesity might influence these behavioral changes during or after pregnancy.

Primary aldosteronism is a frequent cause of resistant hypertension and is associated with an increased risk of developing diabetes mellitus. Aldosterone impairs insulin secretion in isolated islets, and insulin secretion is increased in aldosterone synthase-deficient mice. We hypothesized that treatment for primary aldosteronism increases insulin secretion and insulin sensitivity in humans. We conducted a prospective cohort study in patients with primary aldosteronism, with assessment of glucose metabolism before and 3 to 12 months after treatment. Participants underwent treatment for primary aldosteronism with adrenalectomy or a mineralocorticoid receptor antagonist at the discretion of their treating physician. We assessed insulin secretion and insulin sensitivity by hyperglycemic and hyperinsulinemic-euglycemic clamps, respectively, on 2 study days after a 5-day standardized diet. After treatment, the C-peptide and insulin response during the hyperglycemic clamp increased compared with pretreatment (ΔC-peptide at 90-120 minutes +530.5±384.1 pmol/L, P=0.004; Δinsulin 90-120 minutes +183.0±122.6, P=0.004). During hyperinsulinemic-euglycemic clamps, insulin sensitivity decreased after treatment (insulin sensitivity index 30.7±6.2 versus 18.5±4.7 nmol·kg^-1·min^-1·pmol^-1·L; P=0.02). Insulin clearance decreased after treatment (872.8±207.6 versus 632.3±178.6 mL/min; P=0.03), and disposition index was unchanged. We conclude that the insulin response to glucose increases and insulin clearance decreases after treatment for primary aldosteronism, and these effects were not due to alterations in creatinine clearance or plasma cortisol. These studies may provide further insight into the mechanism of increased diabetes mellitus risk in primary aldosteronism.

Beta amyloid (Aβ) accumulation is the earliest pathological marker of Alzheimer's disease (AD), but early AD pathology also affects white matter (WM) integrity. We performed a cross-sectional study including 44 subjects (23 healthy controls and 21 mild cognitive impairment or early AD patients) who underwent simultaneous PET-MR using 18F-Florbetapir, and were categorized into 3 groups based on Aβ burden: Aβ- [mean mSUVr ≤1.00], Aβi [1.00 < mSUVr <1.17], Aβ+ [mSUVr ≥1.17]. Intergroup comparisons of diffusion MRI metrics revealed significant differences across multiple WM tracts. Aβi group displayed more restricted diffusion (higher fractional anisotropy, radial kurtosis, axonal water fraction, and lower radial diffusivity) than both Aβ- and Aβ+ groups. This nonmonotonic trend was confirmed by significant continuous correlations between mSUVr and diffusion metrics going in opposite direction for 2 cohorts: pooled Aβ-/Aβi and pooled Aβi/Aβ+. The transient period of increased diffusion restriction may be due to inflammation that accompanies rising Aβ burden. In the later stages of Aβ accumulation, neurodegeneration is the predominant factor affecting diffusion.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally ac-cepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospital received multiple injured patients within minutes; lessons learned included the need for a formal-ized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for multiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in orga-nizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.