Faculty Bibliography

The rising global incidence of breast cancer and the persistent shortage of specialized radiologists have heightened the demand for innovative solutions in mammography screening. Artificial intelligence (AI) has emerged as a promising tool to bridge this demand-supply gap, with potential applications ranging from full automation to integrated AI-human decision-making. This study evaluates the economic feasibility of incorporating artificial intelligence (AI) into mammography screening within healthcare settings, considering full or partial integration. To evaluate the economic viability, we employ an optimization model specifically designed to minimize mammography screening costs. This model considers three distinct approaches when interpreting mammograms: automation strategy utilizing AI exclusively, delegation strategy involving the selective allocation of tasks between radiologists and AI, and the expert-alone strategy relying solely on radiologist decisions. Our findings underscore the significance of disease prevalence in relation to the trade-off between costs associated with false positives (e.g., follow-up expenses) and false negatives (e.g., litigation costs stemming from missed diagnoses) in shaping the AI strategy for healthcare organizations. We backtest our approach using data from an AI contest in which participants aimed to match or surpass radiologists' performance in assessing screening mammograms for women. The contest data supports the optimality of the delegation strategy, potentially leading to cost savings of 17.5% to 30.1% compared to relying solely on human experts. Our research provides guidance for healthcare organizations considering AI integration in mammography screening, with broader implications for work design and human-AI hybrid solutions in various fields.

IMPORTANCE/UNASSIGNED:Expectancy effects are significant confounding factors in psychiatric randomized clinical trials (RCTs), potentially affecting the interpretation of study results. This narrative review is the first, to our knowledge, to explore the relationship between expectancy effects, compromised blinding integrity, and the effects of active treatment/placebo in psychiatric RCTs. Additionally, we present statistical and experimental approaches that may help mitigate the confounding impact of expectancy effects. The review concludes with recommendations to enhance the reliability of RCTs in psychiatry. OBSERVATIONS/UNASSIGNED:The placebo response comprises both specific and nonspecific elements, with expectation being a key specific component. Evidence from experimental and clinical studies suggests that expectancy can influence treatment responses in RCTs. Blinding integrity may be compromised by perceived treatment efficacy and adverse effects, introducing bias into outcome assessments. Treatment expectations can lead to unblinding during RCTs, and meta-analytic data from studies in the fields of psychedelics and anxiety disorders indicate that this can influence effect sizes. Therefore, controlling for expectancy effects is essential when interpreting RCT results. Novel statistical methods, though still in need of further validation, offer strategies to address this issue. Another approach may involve experimental medicine models, which aim to develop objective improvement markers (readouts) less affected by expectancy effects. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Expectancy effects represent a significant confound in psychiatric RCTs. We recommend collecting data on treatment expectations alongside monitoring blinding integrity to more accurately interpret study results. Additionally, developing objective readouts that are less confounded by expectancy effects offers another promising avenue for mitigating these confounding influences in psychiatric RCTs.

Medical and surgical advancements of the past 70 years have resulted in a remarkable shift in the natural history of congenital heart disease (CHD) such that survival to adulthood is expected for >90% of children born with congenital heart defects, including those with complex CHD. There are now more adults than children living with CHD, a majority of them are female. As significant strides have been made in the management of adult patients with CHD, there has been an evolving understanding of the important role inherent sex-specific differences play in impacting long-term outcomes for females with CHD including differences in sexual and reproductive health, risk and incidence of acquired cardiovascular disease, and health surveillance. Notably, care for the female CHD patient is a continuum that is not isolated to discrete stages but cumulative of health exposures and experiences over a lifetime. This review aims to provide a brief overview of the current understanding of the unique health needs and considerations for females with CHD over their lifetime for both the pediatric and adult provider to help identify opportunities for care optimization, continue to raise awareness of the necessity of lifelong care and advocate for the critical need of research that prospectively evaluates pregnancy and other health-related exposures on long-term quality of life and survival for females with CHD.

STATEMENT OF THE CLINICAL PROBLEM ADDRESSED BY THE CASE/UNASSIGNED:We report an atypical clinical presentation of a rapidly progressive neurologic emergency that required prompt investigation and treatment of impending respiratory failure. We discuss the differential diagnosis, evaluation, emergency management, and treatment options of patients with atypical variants of this disorder. BRIEF DESCRIPTION OF CASE PRESENTATION/UNASSIGNED:A 56-year-old woman with a history of hypothyroidism, anxiety, and depression presented to the emergency department 3 weeks after an upper respiratory and ear infection with cough, pain with sinus palpation, tingling in her fingers bilaterally and right foot, hives, and an episode of blurry vision on awakening. She was discharged home with antibiotics. That evening, she developed rapidly progressing hoarseness and dysphagia and returned to the emergency department. An initial examination and laryngoscopy revealed complete left vocal cord paralysis, consistent with a left cranial nerve X palsy, which prompted a neurologic evaluation. Her examination progressively worsened over the next day requiring mechanical ventilation and ICU admission. SUMMARY OF THE KEY TEACHING POINT IN THE CASE/UNASSIGNED:New-onset bulbar cranial neuropathies should raise concern for neurologic disorders that can be rapidly progressive and result in respiratory failure. Urgent diagnosis and treatment are warranted.

BACKGROUND:Loneliness is a quality-of-life (QoL) concern for patients facing serious, life-limiting illnesses. Discerning risk factors of loneliness in palliative care patients allows providers to take preventative action and develop holistic treatment plans. METHODS:A planned sub-study of patients who completed the previously developed Three-Item Loneliness Scale upon enrollment into the multicenter, randomized clinical trial Emergency Medicine Palliative Care Access (EMPallA) with the objective of investigating the association of multimorbidity with loneliness in patients with late-stage illnesses. The EMPallA study included patients who were at least 50 years old and diagnosed with at least one end-stage illness (advanced cancer, advanced congestive heart failure (CHF), end-stage renal disease (ESRD), or advanced chronic obstructive pulmonary disease (COPD)). RESULTS:We analyzed 1,212 surveys using a mixed-effects logistic regression model. Our findings suggest those with a single illness are less likely to be lonely than those with multimorbidity (odds ratio [OR] = 0.5, 95% CI 0.3 to 0.8). Additionally, older age was associated with less loneliness (OR comparing age by 10-year increments is 0.7 [95% CI: 0.6 to 0.9]), after adjusting for disease type, education level, race, sex, immigrant status, having a caregiver, COVID-19 period, language, and site geographic location. CONCLUSIONS:Patients suffering from multimorbidity self-report being "very lonely" more often than patients with a single advanced illness; furthermore, advanced illness patients who were middle-aged (versus elderly) were 25% more likely to report being "very lonely." TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov identifier: NCT03325985. Registered October 30, 2017.

INTRODUCTION/UNASSIGNED:Cardiovascular disease (CVD) is a leading cause of mortality in the United States, disproportionately affecting marginalized populations such as Black and Latinx sexual minority men with HIV. These individuals face heightened CVD risk due to chronic inflammation related to HIV, side effects from treatment, and intersecting social disadvantages, including stigma and discrimination. Behavioral interventions specifically targeting these populations have been limited, with insufficient uptake in marginalized communities. METHODS/UNASSIGNED:This study used Intervention Mapping (IM) to develop a culturally tailored CVD prevention intervention for Black and Latinx sexual minority men with HIV. IM is a systematic, theory- and evidence-based framework for health promotion program planning. We focused on the first three of six steps in the IM process: (1) assessing community needs through literature review, framework development, and community-engaged research; (2) identifying program outcomes to develop a logic model of change; and (3) selecting theory-based methods and practical strategies for program design. RESULTS/UNASSIGNED:The needs assessment revealed significant barriers to cardiovascular health, including medical distrust, stigma, and lack of access to culturally appropriate healthcare. The logic model of change highlighted behavioral and environmental determinants influencing cardiovascular health, leading to specific performance objectives and change objectives. Strategies included leveraging eHealth technologies, such as avatar-led interactive videos, to provide private, culturally relevant health education and reduce barriers like medical distrust. Community-based participatory methods were integral to ensure the intervention was culturally resonant and acceptable. DISCUSSION/UNASSIGNED:This study demonstrated the use of IM to systematically develop a culturally tailored CVD prevention intervention for Black and Latinx sexual minority men with HIV. The findings highlight the importance of community-engaged and culturally appropriate approaches in developing interventions for historically marginalized populations. These strategies aimed to address health disparities and empower them to engage in cardiovascular health-promoting behaviors, ultimately improving cardiovascular health outcomes. Leveraging technology to foster engagement and providing culturally relevant support were crucial elements of the intervention. The insights gained may inform future cardiovascular health promotion efforts targeting similar populations.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate patient-reported outcomes (PROs) and survivorship in obese patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year follow-up. METHODS:A retrospective review was conducted of patients who underwent arthroscopy for FAIS from 2010-2013. Patients were assessed at baseline, 1 month, 6 months, 1-, 2-, 5-, and 10 years using the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS). Patients were categorized based on BMI into normal, overweight, and obese cohorts. Minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated for both PROs. Improvements from baseline were analyzed and differences between groups were evaluated while controlling for age. Survival to revision surgery was assessed with Kaplan-Meier survival curves. RESULTS:144 patients (65.2% female) with a mean age of 38.8 ± 13.0 years and an average follow-up of 11.6 (range 10.0-13.8) years were included, and categorized into normal weight (59.7%), overweight (26.4%), and obese (13.9%). All groups showed significant improvement in PROs at 10 years compared to baseline (p=0.007). Obese patients had lower postoperative scores (mHHS: 72.8 vs. 90.1, p=0.009; NAHS: 68.4 vs.. 88.6, p=0.003) and improvement in scores from baseline (mHHS: 23.4 vs. 37.7, p=0.013; NAHS: 18.4 vs. 40.0, p=0.004) at 10-year follow-up, as well as lower achievement of mHHS PASS (60.0% vs 87.2%, p=0.015), NAHS PASS (50.0% vs. 89.5%, p<.001) and NAHS MCID (70.0% vs. 93.0%, p=0.008). Obese patients also had a higher rate of conversion to THA (17.4% vs 3.3%, p=0.012). The overall complication rate was 4.2% compared to 10% in the obese group, with obese patients experiencing a superficial infection more frequently (p=0.002). CONCLUSION/CONCLUSIONS:Although obese patients still have significantly improved outcomes compared to baseline, at 10-year follow-up they have inferior outcomes compared to nonobese patients and higher rates of conversion to THA. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

BACKGROUND:We sought to estimate the prevalence of synthetic cannabinoid use and characteristics of people who use in the US general population. METHODS:We compared the prevalence of past-year synthetic cannabinoid use in 2023 to 2021 among individuals ages ≥ 12 surveyed via the National Survey on Drug Use and Health (N = 173,808). We also compared prevalence according to demographic and drug use characteristics and delineated correlates of past-year use. RESULTS:Synthetic cannabinoid use increased from 0.17 % in 2021 to 0.26 % in 2023, a 50.0 % increase (p = .042) (0.25 % prevalence in 2021-2023 overall). The largest increases were among those aged ≥ 35 (by 255.3 %), those with an annual family income of < $20,000 (by 242.1 %), and those who used methamphetamine in the past year (by 184.6 %) (Ps < .05). In our final multivariable model, those with less than a high school diploma (aOR=2.20, 95 % CI: 1.12-4.32) and those with past-year cannabis use (aOR=13.55, 95 % CI: 8.36-21.95) and use disorder (aOR=26.03, 95 % CI: 17.70-38.29) were at higher odds for synthetic cannabinoid use, as were people with methamphetamine use (aOR=3.08, 95 % CI: 1.18-8.01) and use disorder (aOR=4.74, 95 % CI: 2.17-10.37), and prescription opioid misuse (aOR=1.75, 95 % CI: 1.05-2.93) and use disorder (aOR=3.22, 95 % CI: 1.78-5.82). CONCLUSION/CONCLUSIONS:Survey data suggest that synthetic cannabinoid use is rare but increasing, particularly among people of lower socioeconomic status and people who use other drugs. Cannabis use disorder in particular is associated with higher odds for use. Research is needed to determine if overreporting is occurring due to confusion with emerging cannabis products.