Faculty Bibliography

BACKGROUND:Lack of sexual orientation and gender identity (SOGI) collection hinders the ability to identify cancer disparities, create opportunities for improvement, and reveal the burden of cancer among sexual and gender minority (SGM) populations. Our institution is one of the first NCI-Designated Comprehensive Cancer Centers to collect SOGI as standard-of-care demographics. METHODS:This analysis includes 118 320 patients who came to the H. Lee Moffitt Cancer Center & Research Institute ("Moffitt") between January 1, 2016 and December 31, 2023 and completed the institutional standard-of-care electronic patient questionnaire. Descriptive analyses were conducted to assessed overall and age-specific differences between SGM and non-SGM patients (ie, cisgender-heterosexual) for demographics, SOGI disclosure, clinical covariates, and psychosocial and quality-of-life needs. RESULTS:Compared with non-SGM patients, SGM patients were statistically significant younger, single, self-identified as racial and ethnic minorities, reported higher psychosocial and quality-of-life needs, and had higher-than-expected rates for several specific cancer sites. CONCLUSIONS:Revealing these real-world cancer disparities among SGM patients based on only 7 years of SOGI data collection highlights the fundamental importance of systematic collection of this demographic information for identifying and eventually mitigating health disparities.

IMPORTANCE/UNASSIGNED:Midlife vascular risk factors are associated with an elevated risk of dementia. However, the total contribution of vascular risk factors in midlife and late life with incident dementia is uncertain. OBJECTIVE/UNASSIGNED:To quantify the proportion of incident dementia attributable to modifiable vascular risk factors measured in midlife and late life and to examine differences by apolipoprotein ε4 genotype, self-reported race, and sex. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This was a prospective cohort analysis of the Atherosclerosis Risk in Communities (ARIC) study using 33 years of follow-up (1987-2020). The setting included ARIC field centers (Jackson, Mississippi; Forsyth County, North Carolina; Minneapolis suburbs, Minnesota; Washington County, Maryland). Study baseline in Black and White participants with complete exposure and covariate data was set by age at risk factor measurement (45-54 years, 55-64 years, and 65-74 years). Data were analyzed from August 2023 to December 2024. EXPOSURES/UNASSIGNED:Hypertension (systolic blood pressure [BP] ≥130 mm Hg, diastolic BP ≥80 mm Hg, or use of medication for BP), diabetes (fasting glucose ≥126 mg/dL, nonfasting glucose ≥200 mg/dL, self-reported physician's diagnosis, or use of any diabetes medication), and current smoking (self-reported). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Incident dementia. Population attributable fractions were estimated by age 80 years, and separately after 80 years, from having at least 1 vascular risk factor by age at risk factor measurement. RESULTS/UNASSIGNED:A total of 7731 participants were included in analysis of risk factors measured at age 45 to years (4494 female [58%]; 2207 Black [29%]; 5524 White [71%]), 12 274 contributed to analysis of risk factors measured at age 55 to 64 years (6698 female [55%]; 2886 Black [24%]; 9388 White [76%]), and 6787 contributed to analysis of risk factors measured at age 65 to 74 years (3764 female [56%], 1375 Black [20%]; 5412 White [80%]). There were 801, 995, and 422 dementia cases by 80 years, respectively. The fraction of dementia by 80 years attributable to at least 1 vascular factor at age 45 to 54 years was 21.8% (95% CI, 14.3%-29.3%), at 55 to 64 years was 26.4% (95% CI, 19.1%-33.6%), and at 65 to 74 years was 44.0% (95% CI, 30.9%-57.2%). Attributable fractions for these factors were higher in apolipoprotein ε4 noncarriers at age 55 years and older (range, 33.3%-61.4%), Black individuals at age 45 years and older (range, 25.5%-52.9%), and female individuals at age 55 years and older (range, 29.2%-51.3%). Only 2% to 8% of dementia cases after 80 years were attributable to these factors. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Results of this cohort study suggest that between 22% and 44% of incident dementia cases by 80 years in the ARIC study were attributed to midlife and late-life vascular risk factors. Assuming causal relationships, maintaining optimal vascular health across the life course could mitigate a sizeable proportion of dementia risk by 80 years.

IMPORTANCE:Artificial intelligence (AI)-assisted ambient documentation technologies that use audio from clinic visits to generate documentation are being deployed across hospital systems to optimize clinical note writing and reduce administrative burden. However, little is known about optimal approaches to engage patients in informed consent for these tools. OBJECTIVES:To explore clinician and patient experiences with consent processes and examine the association between the use of ambient documentation tools and the patient-clinician relationship. DESIGN, SETTING, AND PARTICIPANTS:This study was conducted from March 1 to December 31, 2024, in ambulatory practices across specialties in a large urban academic health center as part of an ongoing operational quality improvement initiative. Participants included clinicians and patients participating in an operational proof-of-concept exploration of ambient documentation technology. MAIN OUTCOMES AND MEASURES:A pragmatic, sequential, inductive-deductive qualitative evaluation was conducted of informed consent contexts, processes, and challenges among ambulatory clinicians and patients exposed to ambient documentation technology. Evaluation included site visits, clinical observations, clinician interviews, and patient surveys to explore perceptions and challenges related to consent. RESULTS:A total of 121 ambient documentation pilot users included 18 clinicians (mean [SD] years of practice, 18.6 [100]; 10 men [55.6%]) and 103 patients (mean [SD] age, 37 [12.5] years; 65 women [63.1%]). The most common consent approach was a verbal patient-clinician conversation prior to an individual encounter. Patients and clinicians had a spectrum of comfort with ambient technology; 77 patients (74.8%) reported being comfortable or very comfortable with their physician using ambient documentation. Patient trust, detail in the consent discussion, and intended tool use were associated with patient comfort and intent to consent. Technical understanding was associated with comfort with consent conversations: when provided basic information about the technology, 84 patients (81.6%) consented; this decreased to 57 patients (55.3%) when details about AI features, data storage, and corporate involvement were disclosed. Perceived benefits included reduced documentation burden, improved decision-making, and enhanced communication. Concerns included data security, legal liability, cognitive impacts, and equity. When asked about responsibility for medical errors linked to ambient documentation, 66 patients (64.1%) held physicians accountable; for data security breaches, 79 patients (76.7%) believed vendors should be responsible. Participants suggested a flexible consent model with digital touchpoints, education, nonclinical staff support, and opt-out options. CONCLUSIONS AND RELEVANCE:In this quality improvement study of 121 pilot users of AI-assisted ambient documentation technology, informed consent relied primarily on verbal conversations that varied based on time, knowledge, and the patient-clinician relationship. A flexible, multimodal approach-including education, time to discuss risks and benefits, digital resources, nonclinical staff involvement, and clear opt-out options-may improve consent processes and support broader acceptance of ambient documentation tools.

OBJECTIVES/OBJECTIVE:To study the impact of an educational intervention on obstetrician-gynecologist clinicians' knowledge of racial and ethnic disparities in the menopause experience. METHODS:Twenty-five obstetrician-gynecologist physicians (residents, fellows, and attendings) at an academic medical center in New York, NY, completed the Achieving Menopausal Health Equity Network course, a brief web-based intervention consisting of four modules delivered through narrated didactic videos and interactive tools, a 10-item pretest and posttest, and a course evaluation survey. The primary outcome was a change in knowledge scores after the completion of the educational intervention. Item analysis was also performed to assess item discrimination, item difficulty, and response frequency. Feedback on modules was obtained, and thematic analysis was performed. RESULTS:In this study, 25 participants completed the educational intervention. There was a statistically significant increase in mean test scores after participation (pretest mean score=7.1/10 vs. posttest mean score=8.1/10, P =0.0021). The following themes emerged in thematic analysis: knowledge building with potential for practical application for clinicians and non-clinicians, clarity and relevance, and opportunities for growth for future iterations of the modules. CONCLUSIONS:This brief, online educational curriculum focused on racial and ethnic disparities in menopause significantly improved the knowledge of obstetrician-gynecologist clinicians at various levels of training and provides a useful model for introducing more formal training on menopause medicine for obstetrician-gynecologist clinicians.

Fetal iron status has long-lasting effects on neurodevelopmental outcomes and risk of psychopathology. Although prenatal exposure to maternal psychological stress has been linked to offspring peripheral iron status at birth, it is unknown whether maternal prenatal stress is related to fetal brain iron during gestation. We utilized 86 multi-echo functional magnetic resonance imaging (fMRI) scans from 52 fetuses (23 females; gestational age [GA] 24-38 weeks) to estimate R2* relaxometry as a proxy for fetal brain iron levels. Our results showed that greater maternal anxiety symptoms were associated with higher estimated fetal iron levels in the left cerebellar vermis after controlling for fetal sex and GA. Our finding suggests that fetal brain iron levels may be sensitive to exposure to maternal stress in utero. In a subset of participants with available infant outcome data (n = 31), no significant associations were found between fetal brain iron levels and later cognitive, language, and motor development during infancy. Overall, this study presents the first evidence of associations between maternal prenatal stress and fetal brain iron, which lays the groundwork for future investigations of biological embedding of prenatal maternal stress on the fetal brain and later neurodevelopment through prenatal iron accumulation as a potential mechanism.

The COVID-19 pandemic catalyzed a rapid expansion of telemedicine across the United States, expanding access to video-based services but also raising concerns about equitable access, use, and experience among minority populations. This mixed-methods scoping review quantitatively describes patterns of video-based telemedicine utilization and qualitatively evaluates factors impacting utilization among racial/ethnic minorities in the United States during the COVID-19 pandemic. We conducted a comprehensive literature search across six databases for studies published between January 2020 and March 2023. Eligible studies reported on telehealth or telemedicine use, specifically video-based visit utilization among racial/ethnic minorities. Reviewers independently screened studies, extracted data, and synthesized findings using an integrated mixed-methods approach. Of 1801 studies, 77 studies met the inclusion criteria. Of these, a majority were published in metropolitan coastal areas, and most were heterogeneous in their definition of telemedicine and utilization. Quantitatively, 33 studies (42.9%) reported increased use of video-based telemedicine, 29 (37.7%) reported decreased use, and 15 (20%) reported variable use across racial/ethnic subgroups. Most studies assessed disparities among non-Hispanic Black and Hispanic/Latinx populations (73 and 66 studies, respectively), while fewer examined disparities among other minority populations (45 studies). Factors associated with telemedicine adoption included patient- and community-level digital access barriers, low organizational digital capacity and infrastructure, implicit bias, and inadequate provider education and training. Identified facilitators included trust and awareness of telemedicine, adequate provider training, cultural and linguistic adaptations, targeted internet subsidies, and telemedicine reimbursements. Video-based telemedicine utilization among racial/ethnic minorities during the COVID-19 pandemic was heterogeneous, influenced by individual, systemic, and implementation factors. Disparities were most pronounced among Asians and other minority populations. Despite increased attention and efforts to address access barriers, our findings highlight the need for more targeted, culturally and structurally tailored interventions to improve digital inclusion.

OBJECTIVE:Guatemala has one of the highest rates of maternal mortality in Central America. A total of 60% of births in Guatemala are attended by traditional Mayan birth attendants, or comadronas. Their prevalence in these communities makes them a valuable resource to bridge home births with safe prenatal care. The objective of this study was to evaluate a low-cost prenatal care training program for Guatemalan comadronas with the goal of improving maternal health outcomes in the region. METHODS:In this retrospective longitudinal cohort study, we examined the knowledge retention of comadronas enrolled in a 12-month prenatal care training program known as the School of PowHER (SOP). Recruited from the Lake Atitlán region of Guatemala by Saving Mothers, 501(c)(3) and the Guatemalan Ministry of Health, comadronas participated in a four-month didactic curriculum followed by a nine-month clinical curriculum. Pre- and post-tests were administered to assess learning outcomes over the study's duration (2014-2022), and test results were evaluated to assess the effectiveness of the SOP. RESULTS:A total of 123 women were recruited and enrolled in all eight graduating classes of the SOP from 2014, 2016-2019, and 2021-2022. An average, statistically significant improvement in didactic and clinical pre- and post-test scores was found across all years analyzed. CONCLUSION/CONCLUSIONS:The SOP is a low-cost, culturally appropriate, community-based model that empowers comadronas through knowledge and skill acquisition to improve local maternal health outcomes. This program proves effective at not only teaching comadronas prenatal health information and clinical skills, but also at promoting long-term retention of these skills.