Citations

Background Despite advances in cervical cancer screening, cervical cancer rates have been increasing in the last decade. Hispanic women have higher cervical cancer incidence and mortality rates compared to non-Hispanic women in the United States. These disparities are primarily due to language barriers experienced in this Spanish-preferred population. Our study aims to improve cervical cancer screening rates among Spanish-preferred patients through a Spanish-language multimedia presentation on cervical cancer screening. Methods In patients not adherent to U.S. cervical cancer screening guidelines, we conducted a non-randomized study comparing standard care in Family Medicine (FM) to standard care plus a multimedia presentation with Spanish voiceover intervention in Internal Medicine (IM). We evaluated whether baseline characteristics differed between the two study arms using the Wilcoxon rank sum test and either the Chi-Square test or Fisher’s exact test. For the primary goal, we examined whether there was a difference in screening scheduling rates between the intervention and standard care groups using the Chi-Square test. Using descriptive statistics, we investigated whether there was a difference in characteristics for those who scheduled screening and those who did not. Results We had 52 patients in IM and 58 in FM, differing in age and insurance status, with median ages of 45.5 and 40.0, and percent insured of 65.4% and 82.8%. Post-study, 25.0% (13/52) in IM and 15.5% (9/58) in FM scheduled cervical screening appointments, which was not significantly different, p=0.21. Patients who scheduled screening had higher rates of insurance coverage, at 95.5% compared to 69.3%. Conclusion No statistically significant difference in scheduling rates among Spanish-preferred patients was observed in this study. Further efforts should include larger samples and randomization.

Portal hypertension is a central driver of morbidity and mortality in advanced chronic liver disease, yet its contribution to death is frequently underestimated owing to underreporting on death certificates. Population-level data on portal hypertension-related mortality trends and disparities in the United States remain limited. We conducted a retrospective, population-based mortality study using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death database, identifying deaths with International Statistical Classification of Diseases and Related Health Problems, 10th Revision code K76.6 listed in any cause-of-death field from 1999 to 2023. Crude and age-adjusted mortality rates per 100,000 population were calculated and stratified by sex, U.S. Census region, race/ethnicity, and urban–rural status (the latter restricted to 1999–2020 due to data availability). Temporal trends were assessed using Joinpoint regression, with annual percent change (APC) reported as the primary trend metric and 95% confidence intervals presented for all estimates. A total of 34,551 portal hypertension-related deaths were identified. Overall age-adjusted mortality rates declined sharply from 1999 to 2002 (APC − 12.85%), plateaued for more than a decade, and rose thereafter. Mortality increased significantly in women after 2009 (APC + 6.69%) and in men after 2013 (APC + 6.18%). Among racial and ethnic groups, Hispanic or Latino individuals consistently demonstrated the highest mortality burden throughout the study period, followed by White individuals, whereas Black or African American individuals exhibited comparatively lower but significantly rising rates from 2006 onward. White individuals demonstrated the steepest recent acceleration, with a significant increase after 2014 (APC + 8.51%). Regionally, the South experienced the steepest post-2013 increase, while the Northeast retained the lowest absolute rates despite a significant rise after 2014. Urban populations showed early improvement through 2014 followed by rising mortality, whereas rural populations experienced a later but steeper rise beginning around 2013, with widening urban–rural disparities over time. Portal hypertension-related mortality has risen significantly since the mid-2010s across all demographic and geographic subgroups, with disproportionate burdens among Hispanic individuals, men, rural populations, and residents of the Southern United States. These findings highlight the urgent need for targeted prevention strategies, equitable access to hepatology care, and aggressive management of metabolic and alcohol-related risk factors to reverse this trajectory.

Background: Societal guidance recommends sequential noninvasive testing for metabolic dysfunction–associated steatotic liver disease (MASLD), using Fibrosis-4 (FIB-4) ≥1.3 as a gatekeeper before second-line assessment with the Enhanced Liver Fibrosis (ELF) score (<7.7 as a rule-out). The impact of this pathway design on the detection of fibrotic MASH remains uncertain. We aimed to evaluate the performance of guideline-endorsed sequential testing and to determine optimized ELF thresholds within alternative strategies. Methods: In this prospective study, patients with or at risk for MASLD underwent FIB-4, ELF testing, magnetic resonance elastography (MRE), and liver biopsy within 1 month. Fibrotic MASLD was defined as fibrosis stage ≥2 on histology or liver stiffness ≥3.1 kPa on MRE. Diagnostic performance of ELF was assessed, and sequential (ELF applied after FIB-4 ≥1.3) and concurrent (either test positive) testing strategies were compared. Results: Among 186 participants (median age 51 years; 69% women), fibrotic MASLD was present in 71 (38%). ELF demonstrated AUROC 0.77 (95% CI 0.70–0.84); the cohort-derived cutoff was 9.4 (80% sensitivity, 65% specificity). Lower cutoffs (8.7 and 7.7) increased sensitivity (≥90% and 100%) but low specificity (34% and 4%). FIB-4 ≥1.3 showed limited sensitivity (57%), resulting in 43% of fibrotic MASH cases being excluded from second-line testing. Sequential application of ELF, therefore, failed to overcome this sensitivity ceiling. A concurrent strategy using FIB-4 ≥1.3 or ELF ≥9.4 improved sensitivity to 87% with 64% specificity. Conclusions: Sequential FIB-4–based testing substantially limits the detection of fibrotic MASLD due to gatekeeping sensitivity constraints. Concurrent first-line testing with FIB-4 and ELF improves case identification, underscoring the importance of pathway design in optimizing noninvasive fibrosis assessment.

Abstract Background The potential risks and benefits of moderate‐intensity exercise in the management of fetal growth restriction (FGR) are controversial. Objective We sought to evaluate fetal responses to a 30‐min bout of moderate‐intensity exercise in pregnancies complicated by FGR. Study design This prospective study included 28 participants at a single academic institution. Pregnant individuals between 28w0d and 36w6d gestation with a diagnosis of FGR with normal Dopplers were enrolled. FGR was defined as total estimated fetal weight less than 10th percentile for estimated gestational age or abdominal circumference less than 10th percentile. Participants were excluded for body mass index (BMI) > 40, tobacco or substance use, hypertension on medications, or other contraindications to exercise. Participants exercised on a treadmill at a moderate intensity monitored using rate of perceived exertion (Borg scale) for 30 min. Fetal umbilical artery (UA), middle cerebral artery (MCA), aortic Dopplers, and maternal uterine artery Dopplers were sampled immediately before and after exercise. Biophysical profile and non‐stress tests were also performed. Maternal vital signs and rate of perceived exertion were monitored throughout exercise. Cerebro‐placental ratios (CPRs) were calculated after sampling. We hypothesized that there is no significant difference in fetal well‐being or Doppler flow in fetuses with FGR immediately after a 30‐min bout of moderate‐intensity maternal exercise compared to pre‐exercise. Results Biophysical profiles and non‐stress tests were reassuring before and after exercise. The primary outcome of UA Doppler values did not differ from pre‐ to post‐exercise. There was no difference in MCA, aortic Dopplers, or CPR. There was an increase in fetal heart rate ( p < 0.05) post‐exercise, which returned to baseline within several minutes. There was a decrease in uterine artery Dopplers ( p < 0.05) post‐exercise, which was driven by a non‐significant decrease in systolic flow and an increase in diastolic flow. Conclusions In this cohort, there were no acute adverse changes in fetal status after a single bout of moderate‐intensity maternal exercise with fetuses with FGR. These findings add to the limited available data in pregnancies complicated by FGR with normal Dopplers. Additional studies are needed to investigate the fetal and maternal effects of vigorous‐intensity and chronic exercise in this population or in populations with more evidence of placental dysfunction. Clinical trial registration NCT06039319.

Scientific evidence regarding AKI and acute kidney care has advanced in recent years. However, a knowledge gap remains on the implementation of these evidence-based practices (EBPs) into clinical care. Implementation science (IS) is focused on ensuring that this knowledge is translated in an effective, efficient and sustainable fashion. Objectives: 1) Define the current status of IS; 2) Define a roadmap for accelerating IS with a focus on patient/care partner advocacy, digital tool application, social determinants of health, and resource-limited settings; and 3) Develop a robust and broad research agenda incorporating IS methodology into the programs. Evidence Review: ADQI XXXV was conducted through a modified Delphi process with virtual meetings preceding an in-person meeting. Five workgroups were determined a priori to focus on 1) IS definitions and methods applicable to AKI and acute kidney care; 2) IS literature in AKI and acute kidney care; 3) Innovations in IS to accelerate the adoption, adherence to, and sustainment of EBPs in AKI and acute kidney care; 4) IS methods in resource-limited settings; and 5) Recommendations to identify and evaluate EBPs that are ready for implementation or de-implementation. Prior to the in-person meeting, each workgroup met virtually to review the literature and develop framework questions to address their objectives. During the two-day in person meeting, through iterative discussions, questions and supporting statements were finalized. These questions and statements were agreed upon through voting to achieve consensus, defined as agreement of ≥80%. Conclusions and Relevance: We report a structured multidisciplinary consensus for defining the role of IS in AKI and acute kidney care. Future programs should address these consensus questions and apply these statements along with IS methodology in the translation of science into clinical practice and the implementation/de-implementation of EBPs in clinical care.

ABSTRACT Genetic counselors describe their professional identity as who they are (personal characteristics and attributes), what they do (actions and skills), and what they possess (training and knowledge). A shared multidimensional perspective highlights the transferability of their skills across diverse roles and settings. This qualitative study aimed to identify factors that influence genetic counselors' perceptions and formation of their professional identities. Using Social Identity Theory as a theoretical framework, semi‐structured recorded interviews were conducted with 50 genetic counselors who were purposefully sampled to ensure diversity of personal demographics (gender, race/ethnicity, sexual orientation, disability, and caregiver status), as well as years, settings, and roles in genetic counseling practice. Transcripts were coded and subjected to codebook thematic analysis using NVivo. Professional identity was influenced by internal validation (sense of purpose in work, pride, and confidence), external validation (from other colleagues, work system, degree of autonomy, and patients), one's personal identities (demographics, life experiences, and persona), and connections with others (professional network, peer support, role models, and giving back). Alignment and misalignment of these factors and the perceived collective identity of the profession impacted genetic counselors' sense of belonging to the profession both positively and negatively, respectively. Continued efforts to diversify the profession, as well as expanded opportunities for genetic counselors to work in new settings and roles, require critical reflection and discussion about the collective identity of the genetic counseling profession. The findings of this study can inform the recruitment, training, credentialing, continuing education, and retention of genetic counselors to ensure that genetic counselors, regardless of their personal identities or their work roles or settings, develop and maintain a sense of belonging and commitment to the profession and its values. In turn, the support of professional identity formation can positively impact genetic counselors' job satisfaction, competency, and delivery of healthcare to their patients and the populations they serve.

Abstract Objectives Embedded pragmatic clinical trials (ePCTs) are conducted as part of routine clinical care and therefore use data collected from real-world data sources, such as electronic health record systems and administrative claims. A common approach for using these types of data across all phases of trial conduct is to create a computable phenotype (an explicitly defined data query data, including specified data types, data codes, and logical parameters) to capture patients with a clinical condition, exposure, symptom, characteristic, treatment, or outcome of interest. Materials and Methods The Electronic Health Record (EHR) Core Working Group of the NIH Pragmatic Trials Collaboratory captured the experiences of investigators in developing, adapting, and applying computable phenotype definitions in their studies. Results Four case studies describe different approaches to developing and using computable phenotypes in pragmatic trials. Discussion We recommend: (1) developing computable phenotypes as part of a team with multiple areas of expertise; (2) appropriate validation; (3) dissemination of salient details regarding phenotype creation; and (4) capturing and reporting any modifications made to phenotypes during the conduct of the trial. Conclusion A range of issues and decisions influence how computable phenotypes are developed and used in pragmatic clinical trials. Multidisciplinary teams that understand the context of the data, including the reason the data are collected and potential sources of bias, are best suited for the development and validation of phenotypes for ePCTs.

Background: Shared Decision Making in palliative care encompassing patient-clinician collaboration has shown potential for improved patient outcomes. However, the impact of decision aids intended to support palliative care decision making discussions across clinical care settings remains uncertain. Aim: To assess the impact of shared of decision aids on decision making, clinical outcomes, and quality of life for patients with palliative care needs and their caregivers. Design: Systematic review and meta-analysis of randomized controlled trials, reported according to PRISMA, with overall evidence quality assessed using GRADE. Data sources: Ovid MEDLINE (all segments), EMBASE, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and Scopus, from inception through September 20, 2024, without restrictions on publication date, sample size, or language. Eligible studies were randomized controlled trials that included adult patients with palliative care needs or their caregivers, using any form of decision aids. Outcomes encompassed decision-related, clinical, and quality of life measures. Results: Sixteen randomized controlled trials were included. Participant ages ranged from 44 to 85 years. Predominant decision aids were videos or printed materials addressing goals of care and treatment options, with aims that included improving understanding of prognosis and supporting values clarification. Decision aids significantly improved decision-related knowledge (SMD: 0.40, 95% CI: 0.14–0.67, p = 0.003) and lowered preference for cardiopulmonary resuscitation (OR: 0.28, 95% CI: 0.20–0.40, p < 0.001). They showed no significant impact on decisional conflict, satisfaction, or regret. Conclusion: Evidence regarding the effectiveness of decision aids in palliative care decision making is limited and of low overall quality, with observed improvements primarily in patient knowledge and changes in stated treatment preferences rather than established improvements in decision quality or values-concordant care. Future research should prioritize integration into comprehensive shared decision making frameworks, cultural adaptations, and larger-scale studies to enhance patient-centered outcomes.

Background Traumatic injury is the fourth leading cause of death nationally; rural residents are twice as likely to die from injury as urban counterparts. On-scene mortality coverage gaps across regional trauma systems remain poorly characterized. Objective To identify geographic blind spots and time-critical, spatially advantageous on-scene deaths (2019-2023) that fall outside modeled 10-minute drive-time service areas across seven North Central state trauma regions. Methods This retrospective analysis geocoded death certificate records to ZIP Code Tabulation Areas and modeled 10-minute drive-time service areas in ArcGIS Online. EMS agency headquarters and staffing classification (volunteer, mixed, paid) were obtained from the DHS EMS Service Map. Candidate sites were identified by maximizing coverage of weighted, uncovered death centroids per region. Results Of 11,868 decedents (60.7% male; mean age 64.4 years [SD 25.6]; 49.9% fall, 26.4% firearm), 7815 had geocodable addresses. Coverage ranged from 53.5% (Western) to 87.0% (North Central); 5492 (70.3%) fell within a 10-minute service area. One candidate site per region could extend modeled coverage to 4-321 additional death locations (480 combined). Volunteer-dominant regions, where 63% of agencies reported scheduling gaps, had the lowest coverage, suggesting headquarters presence overstates availability. Conclusion Geospatial analysis identified actionable blind spots where one additional EMS resource per region could extend modeled coverage to hundreds of death locations. Because these are modeled coverage gains, not demonstrated mortality reductions, and depend in volunteer-dominant regions on staffing reliability that placement alone cannot resolve, the identified locations warrant further evaluation, not presumed survival benefit.