Faculty Bibliography

BACKGROUND/UNASSIGNED:With rising patient volumes and a focus on quality, our health system had the objective to create a more efficient way to ensure accurate documentation of colorectal cancer (CRC) screening intervals from inbound colonoscopy reports to ensure timely follow-up. We developed an integrated end-to-end workflow solution using machine learning (ML) and robotic process automation (RPA) to extract and update electronic health record (EHR) follow-up dates from unstructured data. OBJECTIVE/UNASSIGNED:This study aimed to automate data extraction from external, free-text colonoscopy reports to identify and document recommended follow-up dates for CRC screening in structured EHR fields. METHODS/UNASSIGNED:As proof of concept, we outline the process development, validity, and implementation of an approach that integrates available tools to automate data retrieval and entry within the EHR of a large academic health system. The health system uses Epic Systems as its EHR platform, and the ML model used was trained on health system patient colonoscopy reports. This proof-of-concept process study consisted of six stages: (1) identification of gaps in documenting recommendations for follow-up CRC screening from external colonoscopy reports, (2) defining process objectives, (3) identification of technologies, (4) creation of process architecture, (5) process validation, and (6) health system-wide implementation. A chart review was performed to validate process outcomes and estimate impact. RESULTS/UNASSIGNED:We developed an automated process with 3 primary steps leveraging ML and RPA to create a fully orchestrated workflow to update CRC screening recall dates based on colonoscopy reports received from external sources. Process validity was assessed with 690 scanned colonoscopy reports. During process validation, the overall automated process achieved an accuracy of 80.7% (557/690, 95% CI 77.8%-83.7%) for correctly identifying the presence or absence of a valid follow-up date and a follow-up date false negative identification rate of 32.9% (130/395, 95% CI 29.4%-36.4%). From the organization-wide implementation to go-live until December 31, 2024, the system processed 16,563 external colonoscopy reports. Of these, 35.3% (5841/16,563) had a follow-up date meeting the relevant ML model threshold and thus were identified as ready for RPA processing. CONCLUSIONS/UNASSIGNED:Implementation of an automated workflow to extract and update CRC screening follow-up dates from colonoscopy reports is feasible and has the potential to improve accuracy in patient recall while reducing documentation burden. By standardizing data ingestion, extending this approach to various unstructured data types can address deficiencies in structured EHR documentation and solve for a lack of data integration and reporting for quality measures. Automated workflows leveraging ML and RPA offer practical solutions to overcome interoperability challenges and the use of unstructured data within health care systems.

BACKGROUND:Nonadherence to antihypertensive medications is common. Mobile health (mHealth)-based behavioral economic interventions may improve adherence, but remain largely untested, especially in vulnerable populations. OBJECTIVE:The study sought to test whether an mHealth incentive lottery would lower systolic blood pressure (SBP) and improve adherence. METHODS:BETTER-BP (Behavioral Economics Trial To Enhance Regulation of Blood Pressure) was a randomized trial conducted in 3 safety-net clinics in New York City. Eligible participants were adults with hypertension prescribed at least 1 antihypertensive medication, with SBP >140 mm Hg, and poor self-reported adherence. In the intervention arm, an incentive lottery was administered via SMS messaging. All participants received passive adherence monitoring. The intervention lasted 6 months, with continued monitoring until 12 months. The primary clinical endpoint was change in SBP at 6 months. The primary process endpoint was adequate antihypertensive medication adherence (≥80% days adherent) from baseline to 6 months. RESULTS:Four-hundred participants (265 intervention:135 control) were enrolled with median age 57 years, 60.5% women, 61.5% Hispanic, and 20.3% non-Hispanic Black. Over 70% had Medicaid or no insurance. At 6 months, intervention arm participants were twice as likely to achieve adequate adherence (71% vs 34%; adjusted risk ratio: 2.04; 95% CI: 1.58-2.63), but there was no significant change in mean SBP (-6.7 mm Hg intervention vs -5.8 mm Hg control; P = 0.62). From 6 to 12 months, adherence was similar (31% intervention vs 26% control; adjusted risk ratio: 1.17; 95% CI: 0.83-1.65). CONCLUSIONS:In a diverse safety-net population, the BETTER-BP intervention doubled the rate of adequate antihypertensive medication adherence but did not reduce SBP at 6 months.

Iron plays a vital role in early brain development, supporting critical processes such as myelination, dendritogenesis, and neurotransmitter synthesis. The perinatal period marks a crucial transition from the intrauterine to the extrauterine environment, requiring significant brain adaptation to new stimuli and metabolic demands. However, tight spatiotemporal resolution capturing the timing and sequence of brain iron changes surrounding this critical transition has yet to be achieved. Leveraging a longitudinal perinatal cohort with 147 multi-echo MRI scans spanning from 25 to 60 post-conceptual gestational weeks, we mapped brain iron growth trajectories with R2* estimation across fetal, newborn and neonatal periods. We also examined whether sex, gestational age at birth, and birth weight influence R2* developmental trajectories. We found that parietal and superior temporal regions predominately show linear growth trajectories throughout the perinatal period across birth, while the occipital cortex, the temporal pole, inferior temporal regions and a subset of frontal regions exhibit non-linear trends. For most of the non-linear trajectories, growth rates peak around 40 weeks, highlighting the critical window of birth transition for brain R2* change. These results provide the first longitudinal insights into R2* development across birth, uncovering distinct regional growth patterns that may align with different phases of neurodevelopment.

Adolescent mental health remains a critical yet under-prioritized issue in low- and middle-income countries (LMICs) like Kenya, where resource limitations, stigma, and systemic barriers hinder access to care. While policies and strategies such as Kenya's Mental Health Action Plan (2021-2025) exist on paper, their implementation is constrained by limited resources and a weak mental health service delivery infrastructure. This qualitative descriptive study examines the perspectives of mental health actors and youth advocates on the development and implementation of adolescent mental health policy in Kenya. Using a political economy analysis, we conducted 15 key informant interviews (KIIs) and analyzed observational field notes from a Google Jam board exercise to explore factors that enable or impede the prioritization of adolescent mental health policy and care. Thematic analysis was guided by Shiffman and Smith's policy framework, focusing on four domains: actor power, ideas, political context, and issue characteristics. Findings reveal significant barriers, including the exclusion of adolescents from decision-making, limited family involvement, weak policy formulation, and the destabilizing effects of government transitions. Stigma, poverty, and chronic underfunding further hinder progress, despite ongoing strategic efforts. Comparisons with other LMICs indicate that these challenges are widespread, underscoring the need for localized, inclusive, and well-coordinated approaches. Addressing these issues will require strong political commitment, increased youth-led advocacy, and sustained investment in mental health services. By prioritizing adolescent mental health, Kenya can move toward a more equitable and effective mental health system that supports the wellbeing of its youth.

BACKGROUND:Adolescents in low- and middle-income countries (LMICs) face significant mental health challenges, yet their perspectives are often underrepresented in the design of preventive strategies. Co-design approaches, such as human-centered design (HCD), offer a promising way to tailor interventions and implementation strategies to adolescents’ needs and local context. In LMICs, these methods require careful adaptation to address resource constraints, limited design literacy, and cultural norms. This study documents how HCD was adapted to engage adolescents in northern Ghana as co-designers of school-based mental health preventive strategies. METHODS:Guided by the first two phases of HCD, we conducted two workshops with 24 students from 12 public senior high schools in Tamale, Ghana. Workshop 1 (Inspiration) used structured, case-based discussions informed by the Consolidated Framework for Implementation Research (CFIR) to explore adolescents’ perspectives on mental health. Workshop 2 (Ideation) used interactive choice-based activities to elicit youth-generated strategies. To align with cognitive and sociocultural factors, we incorporated scaffolded facilitation, hands-on activities, and peer-led engagement. Qualitative data from facilitator notes, artifacts, and audio-confirmed summaries were synthesized using structured rapid qualitative analysis. RESULTS:Adolescents identified key mental health concerns, including stigma, peer and family influences, and fears about confidentiality. Gender-specific discussions revealed culturally rooted concerns, such as peer pressure and substance use among boys and limited support-seeking among girls. Adolescents prioritized five school strategies: teacher training, curricular integration, mentorship programs, activities that promote positive thinking and mindfulness, and entertainment-based mental health education. Youth demonstrated a conceptual shift from viewing mental health as an individual problem to a shared responsibility across schools and communities. Formation of an Adolescent Advisory Board reflected youth interest in sustained leadership and co-design. CONCLUSIONS:Contextualized co-design methods can meaningfully engage adolescents in LMIC settings and support the development of culturally grounded, feasible, and youth-prioritized mental health strategies. Structured facilitation enhances both the inclusivity and authenticity of adolescent engagement. This study contributes to implementation science by presenting a replicable co-design framework with policy relevance and providing a foundation for multilevel intervention development in resource-constrained educational systems. SUPPLEMENTARY INFORMATION:The online version contains supplementary material available at 10.1186/s12889-025-25012-0.

OBJECTIVE:To examine associations between oxidative stress and fetal weight across pregnancy. STUDY DESIGN/METHODS:Cohort study of pregnant participants from 2016-2021 in New York City with urinary lipid, protein, and DNA oxidative stress biomarkers (<18, 18-25, >25 weeks) and estimated fetal weight from ultrasound fetal biometry with the HadlockIII formula (20, 30, 36 weeks). RESULT/RESULTS:percentile. Oxidative stress biomarkers of protein damage were associated with larger estimated fetal weight at 20 (3.4 [95% CI: 1.2, 5.7]) and 36 weeks (16.5 [95% CI: 5.2, 27.8]). CONCLUSION/CONCLUSIONS:These findings advance our understanding of different oxidative stress pathways and their potential role in fetal growth.

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts (RHI). In CTE, hyperphosphorylated tau (p-tau) aggregates are found in neurons at the depth of cortical sulci close to the gray matter/white matter (GM/WM) boundary. To date, CTE can only be diagnosed postmortem by neuropathological examination. Traumatic encephalopathy syndrome (TES) is the clinical syndrome purported to be associated with CTE pathology. The aim of this study is to investigate microstructural properties at the GM/WM boundary in individuals with a history of exposure to RHI and clinical features of CTE (i.e., TES). Diffusion magnetic resonance imaging (dMRI), TES diagnoses, and cerebrospinal fluid (CSF) biomarkers were acquired from 165 male former American football players (age: 57.29 ± 8.23 years) from the DIAGNOSE CTE Research Project, a multicenter, observational cohort study. Fractional anisotropy (FA) was measured at the GM/WM boundary of the whole brain. In addition, a widely used method (tract-based spatial statistics [TBSS]) was applied to measure FA of central WM. We used analyses of covariance to test associations between FA and TES. Furthermore, we used linear regressions to test associations between FA and nine CSF biomarkers (i.e., p-tau-181, -217, -231, total tau, amyloid β [Aβ]_1-40, Aβ_1-42, glial fibrillary acidic protein [GFAP], neurofilament light [NfL], and soluble triggering receptor expressed on myeloid cells-2 [sTREM2]). We report an association between higher FA at the GM/WM boundary and higher levels of certainty for CTE pathology (F(1, 147) = 5.781, 95% confidence interval (CI) = 0.0003-0.003, p = 0.035) as well as neurobehavioral dysregulation (F(1, 148) = 7.559, 95% CI = 0.001-0.009, p = 0.020), and functional dependence/dementia (F(1, 148) = 5.046, 95% CI = 0.0004-0.006, p = 0.039). In addition, we report an association between higher FA at the GM/WM boundary and higher CSF p-tau-181 (β = 0.272, 95% CI = 0.078-0.466, p = 0.029) and p-tau-217 (β = 0.295, 95% CI = 0.102-0.488, p = 0.027). FA of the central WM was not associated with TES diagnoses. Taken together, these findings suggest that dMRI at the GM/WM boundary could be used to investigate microstructural alterations suggestive of tau pathology-associated neurodegeneration in individuals with TES, the clinical presentation of CTE. Future studies are needed to validate this approach and to identify clinically useful cutoff values for dMRI metrics.

BACKGROUND:Infliximab (IFX) is commonly used in the management of acute severe ulcerative colitis (ASUC), yet up to 30% of individuals still require colectomy within 1 year. Clinical data characterizing these patients, however, are limited. AIMS/OBJECTIVE:We aimed to determine risk factors for colectomy among patients with ASUC who received in-hospital IFX treatment. METHODS:We performed a retrospective analysis of patients with ASUC who were treated with at least one dose of IFX while admitted between 2014 and 2022. Cox proportional hazards (PH) models were used to assess demographic, clinical, and laboratory risk factors for colectomy within 30 days and 1 year of IFX initiation. RESULTS:Overall, 36/170 (21.2%) patients underwent colectomy within 1 year of IFX initiation, with 22 (12.9%) individuals requiring colectomy within 30 days. On univariable analysis, concomitant Clostridioides difficile infection during admission, a ≤50% decrease in C-reactive protein (CRP) and experiencing 3 or more bowel movements per day within 48 hours after an initial IFX dose were significantly associated with 1-year colectomy. On multivariable Cox PH analysis, C. difficile infection during admission (aHR=2.92, 95% CI: 1.12-7.58) and a higher CRP/albumin ratio on admission (aHR=1.13, 95% CI: 1.01-1.27) were associated with increased colectomy risk within 1 year of IFX initiation. CONCLUSIONS:C. difficile infection and a higher CRP/albumin ratio on admission are associated with decreased time to colectomy within 1 year of IFX among patients presenting with ASUC. These factors may aid in early risk stratification to minimize delays in JAK-inhibitor initiation or surgical referral.