Faculty Bibliography

Background: Pregnancy is a crucial period to improve cardiovascular health (CVH) for mothers and their families. The current study emphasizes framework-guided factors that influence the adaptation of an evidence-based intervention (Parents as Teachers and Healthy Eating Active Living Taught at Home [PAT + HEALTH]) to support healthy gestational weight gain and postpartum weight management among pregnant women with obesity and their infants in Nigeria. Methods: From May to June 2023, 43 in-depth interviews were conducted with 11 parents, 15 community health extension workers (CHEWs)/health educators, and 17 policymakers/ healthcare supervisors in the Federal Capital Territory, Nigeria. Additionally, nine focus groups were conducted with 75 participants. Interviews were recorded, de-identified, and transcribed. The updated Consolidated Framework for Implementation Research (CFIR 2.0) informed the development of the interview guides and the thematic analysis. Transcripts were double-coded using Dedoose. Results: We identified assessing context, tailoring strategies, local attitudes, and sustainability as constructs to consider when adapting and implementing the PAT + HEALTH intervention successfully within the Nigerian primary care context. For example, policymakers and healthcare supervisors emphasized the feasibility of the intervention, including raising community awareness, planning for hard-to-reach areas, and ensuring supportive supervision of CHEWs delivering the intervention. Additional factors included customizing educational content and delivery methods to fit the cultural, socioeconomic, and environmental contexts of Nigerian families. CHEWs highlighted the importance of public education on locally available foods for better nutrition. Potential barriers to the PAT + HEALTH intervention included local attitudes influenced by sociocultural factors, such as food taboos, and structural factors, including limited financial support for the long-term sustainability of some components of the home visiting program. Conclusions: Building on these formative activities, the ENHANCE CVH trial will advance dissemination and implementation science by adapting, testing, and evaluating the effectiveness and implementation of the PAT + HEALTH intervention among pregnant women with obesity and their infants in Nigeria in a cluster randomized trial. Trial registration: ClinicalTrials.gov/NCT06773299, Registration Date: January 14, 2025.

BACKGROUND/UNASSIGNED:Effective management of alcohol withdrawal syndrome during hospitalization is paramount to patient safety and quality care. NYC Health + Hospitals initiated a quality improvement project to pilot an electronic health record (EHR) integrated, nurse-driven CIWA-Ar symptom-triggered protocol, including recommendations for medications for alcohol use disorder (MAUD), in medical and surgical units at 3 public hospitals. OBJECTIVE/UNASSIGNED:To describe implementation processes and to report related implementation outcomes (appropriateness, feasibility, and adoption) of the updated CIWA-Ar protocol in a safety net hospital setting. METHODS/UNASSIGNED:NYC Health + Hospitals implemented a standardized CIWA-Ar symptom-triggered, nurse-driven EHR protocol on March 15, 2022. The protocol included order sets, practice advisories, task lists, and reminders for assessments and orders. We measured nursing perspectives on feasibility and appropriateness at 6 months via a survey. We measured provider adoption as the proportion of admissions with a CIWA-Ar protocol ordered among admissions that triggered a recommendation, and MAUD use as the proportion of admissions with a MAUD order during hospitalization among all patients with a protocol ordered. RESULTS/UNASSIGNED:= .249). CONCLUSIONS/UNASSIGNED:The CIWA-Ar protocol was appropriate, feasible, and adopted at NYC public hospitals. Quality improvements to ensure protocol fidelity with benzodiazepine dosing and MAUD prescribing are needed.

BACKGROUND/UNASSIGNED:Weight bias is pervasive, occurs in a variety of contexts, and is associated with a range of suboptimal outcomes, including delays or avoidance in seeking health care, misdiagnosis, and denial of services. The aim of this study was to quantitatively describe the relationship between experiences of weight bias and eating behaviors of patients in a lifestyle medicine program and qualitatively describe healthcare providers' insights about weight bias. METHODS/UNASSIGNED:This study utilized an explanatory sequential design that drew on one-time survey data collected from 109 patients of a Plant-Based Lifestyle Medicine (PBLM) Program in New York City in 2019. Ordinary Least Squares and logistic regression models examined the association between weight bias and healthful plant-based eating and emotional eating after adjusting for sociodemographic characteristics. Qualitative data come from asynchronous interviews with five healthcare providers from the PBLM program completed in 2024 which were analyzed using rapid coding. RESULTS/UNASSIGNED:Survey participants were on average 53 years old, 67.0% female, 68.6% Black, Indigenous, and other people of color (BIPOC), and 56.2% reported experiencing weight bias. Weight bias was associated with 4.07 fewer points on the healthful plant-based eating measure (95%CI: 6.86, -1.27), and participants had 5.06 times the odds (95%CI: 1.76, 14.59) of emotional eating compared to those not reporting weight bias. Interview themes were: (1) Weight bias negatively influences patient lives, (2) Weight bias is negatively associated with patients' mental health, (3) Promising weight-inclusive approaches, and (4) Recommendations for providers to address weight bias. CONCLUSION/UNASSIGNED:Experiences of weight bias were associated with suboptimal eating behaviors and poor mental health. Providers observed their patients experience harm in connection with weight bias, suggested weight-inclusive approaches, and identified recommendations that would mitigate weight bias in healthcare environments including routinely screening for weight bias, training providers on weight inclusive care, incorporating mental health services into care teams, and creating size inclusive spaces. This study demonstrates that weight bias is linked to deleterious outcomes and the importance of weight-inclusive care delivery and environments.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Plasma biomarkers such as phospho-tau species are increasingly used in clinical practice for the diagnosis of Alzheimer disease (AD). Phosphorylated-tau at threonine 181 (p-tau181) values also provide prognostic information about incident dementia. Cognitive status similarly conveys prognostic information, but the relationship between plasma biomarkers for AD and cognitive status requires clarification. METHODS:Participants from the Atherosclerosis Risk in Communities (ARIC) study who were adjudicated as free of dementia in 2011-2013 had plasma samples analyzed for p-tau181 and other biomarkers. Participants were surveilled for incident dementia through December 31, 2022. Cumulative incidence curves, Cox models, and Fine-Gray models were used to evaluate the independent and combined discriminatory accuracy of cognitive status and plasma biomarkers for incident dementia. RESULTS:The sample comprised 1,577 ARIC participants (age 76.5 years, 60% women, 73% White, 27% Black). The risk of incident dementia was higher in persons with a baseline status of mild cognitive impairment (covariate-adjusted hazard ratio [HR] 2.94, 95% CI 2.61-3.33) compared with those who were cognitively unimpaired independent of biomarker status. The risk of dementia was also higher in persons with more abnormal concentrations of p-tau181 and other biomarkers independent of cognitive status. When age, cognitive status, and p-tau181 were included in the same models, the risk was attenuated relative to models where only cognitive status or plasma biomarkers were included. For continuous p-tau181 concentrations, the covariate-adjusted HR without cognitive status was 1.45 (95% CI 1.36-1.54), but when cognitive status was included, the HR decreased to 1.37 (95% CI 1.29-1.46). Models showed that when combined with age, p-tau181 alone, cognitive status alone, or the combination of p-tau181 and cognitive status had similar discriminatory accuracy. DISCUSSION/CONCLUSIONS:Cognitive status and plasma biomarker concentrations convey independent but overlapping information about the risk of incident dementia. Although cognitive status and plasma p-tau181 have similar discriminatory accuracies, the far lower incidence rate of dementia in persons who are initially cognitively unimpaired highlights the importance of an accurate clinical diagnosis.

Consumer wearable devices are commonly used by patients and consumers for several reasons with increasing application as new technologies are developed. Use of these devices is an emerging issue in Neurology because of increased adoption and the additional data reported to providers by patients. Understanding of possible functions, limitations, and effect on patients of non-US Food and Drug Administration (FDA)-cleared wearable technology to inform neurologic care is needed. A common theme in people with neurologic conditions regarding consumer wearables and associated tracking applications is that there is significant promise in these tools, but adherence (days per use/per week), continued engagement (attrition), and unintended consequences such as heightened anxiety remain important issues. Further understanding and validation of these devices is needed within the field of Neurology before full use and confidence can be achieved. Below, we provide examples of non-FDA-cleared wearable devices used in Neurology in the areas of epilepsy, headache, cardiac monitoring, and sleep.

BACKGROUND AND AIM/UNASSIGNED:Extended-release injectable naltrexone (XR-Naltrexone) is an effective treatment for opioid use disorder (OUD); however, initiation can be challenging as it requires an opioid-free period. This exploratory analysis examines patient characteristics associated with successful initiation of XR-Naltrexone in the National Drug Abuse Treatment Clinical Trials Network (CTN-0051) Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment (X:BOT) trial. METHODS/UNASSIGNED:Patient demographics and clinical variables associated with successful XR-Naltrexone initiation were examined among 283 participants with OUD randomized to XR-Naltrexone in the X:BOT trial. Variables included severity of opioid use, characteristics of opioid and other substance use, treatment history, psychiatric history, baseline depression, and pain. Logistic regression models were used to estimate the effect of variables on the odds of induction success. RESULTS/UNASSIGNED:204 (72%) of 283 participants randomized to receive XR-Naltrexone completed successful induction. Housing status and pain were significantly associated with XR-Naltrexone induction status. Reported homelessness was significantly associated with higher odds of successful XR-Naltrexone induction (OR: 2.31; 95% CI: 1.12, 4.76). Individuals that reported moderate or extreme pain on the EuroQoL had half the odds of successful induction compared to those without pain (OR: 0.49; 95% CI: 0.27, 0.89). CONCLUSIONS/UNASSIGNED:Among patients with OUD initiating treatment on inpatient units, homelessness was associated with greater likelihood of successfully initiating XR-Naltrexone, while chronic pain was associated with lower likelihood of XR-Naltrexone initiation. Future research on XR-Naltrexone initiation should consider tailoring treatment based on housing status and other social determinants, and evaluation and management of pain.

BACKGROUND:Cardiovascular disease is the most common cause of morbidity and mortality in kidney transplant recipients. Screening for coronary disease is frequently required prior to kidney transplantation, but coronary intervention has not been shown to be beneficial except in complex coronary artery disease. The likelihood of finding significant coronary artery disease and the benefits of routine pre-transplant screening are uncertain. METHODS:We performed a systematic review and meta-analysis. Medline & Embase were searched to identify manuscripts published between 1998 and 2024 reporting the results of pre-transplant screening. The primary endpoints were the frequency of detecting significant coronary lesions for which there are AHA class 1 indications for revascularization: a) >50% left main stenosis; or b) multi-vessel disease with ejection fraction < 35% during pre-kidney transplant screening. Secondary endpoints included frequency of detecting multivessel disease, proximal left anterior descending artery (LAD) disease, and number of patients who underwent invasive coronary angiography. Meta-regression was used to explore outcome heterogeneity according to the presence of hypertension, diabetes, and age. RESULTS:We identified 1273 studies out of which 44 met eligibility criteria. The mean prevalence of class 1 indications was 2%, although the heterogeneity was high with estimates ranging from 0% to 17%. Estimated prevalence of proximal LAD disease was 2% and left main stenosis was 1%, whereas 10% of patients had multi-vessel coronary artery disease, and 35% were referred for invasive angiography. There was no evidence of significant heterogeneity according to sex of the population or prevalence of diabetes or hypertension. CONCLUSIONS:Identification of class I indications for revascularization during pre-transplant coronary screening was rare.

IMPORTANCE/UNASSIGNED:Artificial intelligence (AI)-enabled scribes have been proposed to reduce electronic health record (EHR) burden and improve clinician satisfaction. There is limited evidence about their associated results across multiple sites and relative benefits for different clinician groups. OBJECTIVE/UNASSIGNED:To assess the association of AI scribe adoption with changes in EHR time expenditure and visit volume and how associations vary by clinician characteristics. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Multisite, longitudinal cohort study of AI scribe adoption conducted at 5 US academic health care institutions that introduced AI scribes to their clinicians between June 2023 and August 2025. Participants were ambulatory clinicians. EXPOSURES/UNASSIGNED:AI scribe adoption, defined as receiving access to an AI scribe. This was determined by opt-in decisions by eligible physicians at 4 of the 5 sites. MAIN OUTCOME AND MEASURES/UNASSIGNED:Total time spent on the EHR, time spent on documentation, and time spent on the EHR outside scheduled hours or on unscheduled days, all normalized to 8 scheduled patient hours; weekly visit volume. RESULTS/UNASSIGNED:The sample comprised 8581 clinicians, including 1809 AI scribe adopters. Participants were 57.1% female and were split between primary care (24.4%), medical (62.4%), and surgical (13.2%) specialties. Most (74.1%) were attending physicians, with 18.1% advanced practice clinicians and 7.8% resident physicians. In a difference-in-differences analysis, AI scribe adoption was associated with 13.4 (95% CI, 9.1-17.7) fewer minutes of EHR time, 16.0 (95% CI, 13.7-18.3) fewer minutes of documentation time, and 0.49 (95% CI, 0.17-0.81) additional weekly visits delivered. Electronic health record time outside work hours did not change significantly. Changes associated with AI scribe adoption were greatest for primary care specialists, advanced practice clinicians, female clinicians, and clinicians who used AI scribes in 50% or more of visits. CONCLUSIONS AND RELEVANCE/UNASSIGNED:AI scribe adoption was associated with modest decreases in total EHR time and documentation time and with a modest increase in weekly visit volume.

BACKGROUND:Sugary drink taxes have been implemented in several U.S. jurisdictions, but we know little about the impact of taxes on calories purchased in restaurants. The impact may differ in restaurant (vs. non-restaurant) settings because restaurant consumers may be less likely to travel to other jurisdictions for a single meal, choose no beverage or non-taxed beverages, decrease their beverage size, or order combo meals where the drink is bundled with other items at a single price. METHODS AND FINDINGS/RESULTS:We used six years of transaction-level sales data (2015-2020) from 7,341 Taco Bell restaurant locations to estimate the association of sugary drink policies with beverage calories purchased in the drive-through setting of fast food restaurants over time. Taco Bell restaurants represents a large sample size of data from several U.S. jurisdictions across a long follow-up period, which is unique in the literature. We defined the treatment group as restaurants in five jurisdictions where taxes were ever implemented (Albany, CA; Cook County, IL; Oakland, CA; Philadelphia, PA; Seattle, WA) (n = 60 restaurants). We identified a group of comparison restaurants where taxes were never implemented using synthetic control methods (n = 60 restaurants). We used a difference-in-differences design with calendar month and restaurant fixed effects to compare changes in outcomes between groups between the baseline (3-14 months prior to tax implementation) and 3- to 24-month follow-up periods, overall and by jurisdiction. Our primary outcome measure was beverage calories per transaction, from individually-purchased beverages and combo meals (separately). In the baseline period, average beverage calories per transaction were 51.1 (SD = 8.6) in the tax group and 42.3 (SD = 7.4) in the comparison group; and 119.5 (SD = 15.3) and 115.0 (SD = 23.0) beverage calories per transaction in combo meals. Overall, we observed no association between taxes and changes in beverage calories per transaction between groups during the follow-up period, including from individual beverage items (difference-in-differences = -0.3 (95% CI [-0.8, 1.2]) and combo meals (difference-in-differences = -4.3 (95% CI [-13.5, 5.0]). We observed similar results by location, except in Oakland, CA, where customers purchased 16.8 (95% CI 19.6, 14.1) fewer beverage calories per transaction from combo meals; the association was null after conditioning on the purchase of a beverage (difference-in-differences = -1.01 [-4.93, 2.92)]). The main limitations of our study methodology include the exclusion of beverage calorie data from in-store transactions and that the majority of the restaurants in our sample were located in Cook County. CONCLUSIONS:Though we observed differences in certain jurisdictions, overall our findings suggest that sugary drink taxes may not be effective in reducing beverage calorie consumption in fast food restaurants.