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Built Environment Implementation Strategies to Promote Physical Activity: Expert Consensus for Local Implementation of Physical Activity Policy, Systems, and Environment (ECLIPPSE)
No full textContext: Despite evidence supporting the role of the built environment in promoting physical activity, there is limited guidance on how to implement recommended built environment changes at the local level.
Objectives: The objective of this project was to develop a compilation of implementation strategies that hold promise for aiding communities in implementing built environment changes that support active transportation and leisure-time physical activity, titled "Expert Consensus for Local Implementation of Physical Activity Policy, Systems, and Environment (ECLIPPSE)."
Design: A modified Delphi Technique using 3 web-based survey rounds was conducted from 2024 to 2025.
Setting: A multidisciplinary national expert panel was recruited to participate in this online panel.
Participants: The panel consisted of 23 professionals with expertise in the implementation of built environment changes to support physical activity at the local level.
Main outcome measure: The Round 1 and 2 surveys utilized a rating process to establish a compilation of potentially promising strategies for aiding communities in implementing physical activity-supportive built environment changes. The Round 3 survey involved rating these strategies on potential feasibility and impact and endorsing the final compilation.
Results: Fifty-five strategies emerged in 2 broad domains. The first domain, "Get Ready," included 4 categories: (1) Partnerships and collaboration (5 strategies); (2) staffing (5 strategies); (3) training and education (4 strategies), and (4) interactive assistance (2 strategies). The second domain, "Take Action," included 6 categories: (1) Data and community informed prioritization (6 strategies); (2) evaluative (8 strategies); (3) community awareness and demand (8 strategies); (4) engagement with decision-making processes (5 strategies); (5) funding (7 strategies); and (6) pilots or demonstration projects (5 strategies). The final compilation was endorsed by 95% of respondents.
Conclusions: The ECLIPPSE strategies can be used to aid implementation of built environment changes at the local level to support physical activity.No embarg
Smoking Cessation Among Patients with Chronic Pain in a Comparative Effectiveness Trial
Full text linkBACKGROUND: Many patients with chronic pain smoke cigarettes; they report lacking skills to cope with pain, a smoking trigger.
OBJECTIVE: Test the effectiveness of a telephone-delivered, cognitive-behavioral intervention (CBI) incorporating pain self-management to promote smoking cessation among people with chronic pain compared to a smoking cessation counseling control (Standard).
DESIGN: Randomized trial.
PARTICIPANTS: Current cigarette smoking, willingness to make a quit attempt, pain for ≥ 3 months with worst past week pain intensity of ≥ 4 on the 0-10 pain numerical rating scale.
INTERVENTIONS: CBI included 5 telephone sessions integrating smoking cessation and pain self-management, and combination nicotine replacement therapy (NRT). Standard included 5 telephone sessions and NRT.
MAIN MEASURES: Primary outcome used for power analysis was 14-day prolonged abstinence at 6 months. Other smoking outcomes included 7-day and 30-day point prevalence abstinence and 7-day prolonged abstinence at 6 and 12 months and 14-day prolonged abstinence at 12 months. Secondary outcomes included change in pain intensity and interference at 6 and 12 months.
KEY RESULTS: Patients were randomly assigned to CBI (n = 189) and Standard (n = 182), stratified by sex. Patients (88% men, median age = 60 years) smoked a median of 15 cigarettes per day with moderate pain intensity (5.2 (SD = 1.6)) and pain interference (5.5 (SD = 2.2)). Participation in all 5 counseling calls was higher in CBI (38% vs. 29%), and there was no difference in NRT use (47% vs. 45%). There were no differences by arm in smoking or pain outcomes.
CONCLUSIONS: Our study did not detect a difference in smoking cessation between standard counseling and counseling with enhanced content around pain self-management.
TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT02971137 Registered 2016-11-16.No embarg
Fazekas score predicts cognitive decline & frailty in older adults: insights from the SAGE-AF cohort study
Full text linkBackground: Atrial fibrillation (AF) is a common condition in older adults, often associated with increased risks of cognitive decline and frailty. White matter hyperintensities (WMH), visible on neuroimaging and quantified by the Fazekas score, have been linked to both cognitive and physical impairments. However, the relationship between WMH, cognitive decline, and frailty in older adults with AF remains relatively underexplored.
Methods: This study analyzed data from 86 participants in the SAGE-AF cohort, a two-year prospective multicenter cohort study of older adults with AF, who also had neuroimaging performed for clinical indications. WMH severity was assessed by independent reviewers using Fazekas scores from brain imaging. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA), and frailty was assessed at baseline as well as 1- and 2-year follow-up visits by trained examiners as part of the SAGE-AF study protocol. Participants were characterized based on the severity of their white matter hyperintensities and compared to baseline and two-year cognitive and physical functional status. Longitudinal regression models were used to adjust for demographic, clinical, and geriatric covariates.
Results: Participants with higher Fazekas scores (grades 2-3) demonstrated significantly lower baseline and follow-up MoCA scores and were more likely to meet frailty criteria over a two-year follow-up period. After adjusting for multiple factors known to influence cognitive decline, greater white matter hyperintensity (Fazekas grades 2-3) remained associated with a 2.6-fold increased risk of cognitive impairment at (p = 0.04) and a 2.7-fold increased risk of frailty at (p = 0.02).
Conclusion: Higher Fazekas scores are related to cognitive decline and frailty in older adults with AF, emphasizing WMH as a critical biomarker for aging-related impairments. Neuroimaging tools like Fazekas scoring could enhance risk stratification and inform targeted interventions for this vulnerable population.No embarg
Evolution of KoRV-A transcriptional silencing in wild koalas
No full textKoala retrovirus-A (KoRV-A) is spreading through wild koalas in a north-to-south wave while transducing the germ line, modifying the inherited genome as it transitions to an endogenous retrovirus. Previously, we found that KoRV-A is expressed in the germ line, but unspliced genomic transcripts are processed into sense-strand PIWI-interacting RNAs (piRNAs), which may provide an initial "innate" form of post-transcriptional silencing. Here, we show that this initial post-transcriptional response is prevalent south of the Brisbane River, whereas KoRV-A expression is suppressed, promoters are methylated, and sense and antisense piRNAs are equally abundant in a subpopulation of animals north of the river. These animals share a KoRV-A provirus in the MAP4K4 gene's 3' UTR that is spreading through northern koalas and produces hybrid transcripts that are processed into antisense piRNAs, which guide transcriptional silencing. We speculate that this provirus triggers adaptive transcriptional silencing of KoRV-A and is sweeping to fixation.No embarg
Physician Perception of Trust and Communication with Asian Patients with Serious Illness and Their Families in the United States: An Exploratory Qualitative Study
No full textBACKGROUND: Asians in the United States receive less palliative care and enter hospice less than Whites, disproportionately receive more invasive mechanical ventilation, and report less involvement in decision-making with physicians than they would like. Despite the growing literature addressing serious illness in diverse patient populations, communication with Asians is understudied. This study aimed to explore U.S. physician perceptions of clinical interactions with Asian patients with serious illness and barriers and facilitators to physician-patient communication.
METHODS: This is an exploratory qualitative descriptive study using semistructured interviews with U.S. physicians who cared for Asian patients with serious illness. We used an inductive content analysis approach to identify themes related to facilitators and barriers to communication between Asian patients, their families, and physicians.
RESULTS: We conducted 10 physician interviews between February and April 2024. Of participants, 50% were White and 50% were Asian, the majority were male, and 50% specialized in palliative care. Three major themes arose: (1) trust cannot be assumed; (2) understanding and honoring the role of family are key; and (3) honoring the patient's preferences for communication can build trust.
CONCLUSION: This study is a step in illustrating how a cross-cultural approach to communication needs to align physicians, patients, and families on the process of communication and shared decision-making and not only on the goals for care. Moving toward a cultural adaptive approach can empower clinicians to engage in a trust-building process of inquiry, observation, and understanding of how sociocultural factors impact patient preferences for health care.No embarg
Adverse cardiometabolic impacts of sleep fragmentation and estradiol suppression: An experimental model of menopause
No full textContext: Risk of cardiometabolic disease increases in women transitioning to postmenopause, during which estradiol declines universally. Most of these women experience fragmentation of sleep due to nocturnal hot flashes, without a reduction in total sleep time.
Objective: We examined the independent impact of estradiol suppression, sleep, and their combination on cardiometabolic outcomes categorized as satiety and hunger, lipid profile, cardiac vital signs, and glucoregulation.
Design: Participants completed 5-night inpatient studies under eucaloric conditions, once during mid-follicular phase/estrogenized and again under estrogen suppressed conditions, using the same experimental protocol both times. For all participants, sleep was unfragmented the first two nights and then experimentally fragmented without reducing total sleep time the next three nights.
Setting: Inpatient Intensive Physiological Monitoring research facility.
Participants: 38 healthy premenopausal women.
Intervention(s): Clinical experimental induced menopause model including gonadotropin-releasing hormone agonist-induced hypoestrogenism and sleep fragmentation.
Main outcome measure(s): Leptin and satiety.
Results: Estradiol suppression significantly decreased leptin and increased lipid profiles (FDR-adjusted p≤0.05). Sleep fragmentation significantly increased heart rate (FDR-adjusted p=0.002) and trended to increase fasting glucose (FDR-adjusted p=0.08). Estradiol suppression and sleep fragmentation worsened individual cardiometabolic outcomes by (median, IQR) 4.0% (1.5%, 6.3%) from normalized baseline values. Sleep fragmentation worsened a composite cardiometabolic index derived from individual clinical cardiometabolic measures by an additional 103% over estradiol suppression alone.
Conclusions: Independent of aging, there are significant adverse changes in cardiometabolic health induced by core components of the transition to postmenopause, including novel effects of sleep fragmentation, a modifiable target.1 year2026-11-0
Cost and activity analysis for a citywide patient navigation intervention to engage underserved patients in breast cancer treatment: Findings from the Translating Research Into Practice study
Full text linkBackground: Patient navigation is an evidence-based intervention for reducing delays in cancer care for underserved populations. There are limited economic evaluations of patient navigation in the US health care system and few have considered costs at various phases along the implementation spectrum. Having economic data, including costs and cost savings, can support sustainability of patient navigation programs. This study presents findings from a cost and activity analysis of a citywide hospital-based patient navigation program to engage women in timely breast cancer treatment post-diagnosis.
Methods: This study was conducted as part of Translating Research Into Practice (TRIP), a citywide patient navigation hybrid effectiveness-implementation research study conducted at five cancer care hospitals in Boston, Massachusetts. The authors surveyed participating patient navigators and supervisors about their tasks and level of effort over consecutive 10-day periods from 2019 to 2021. Patient navigators documented the time spent on activities in accordance with an 11-step protocol across five sites. Cost data were collected from annual fiscal year end expenditure hospital administrative databases at concurrent time frames. Descriptive analyses were used to calculate average time on tasks, cost per activity and cost per outcome. Cost savings were estimated by calculating the additional persons engaged in timely entry to treatment compared to a matched control group with respect to hospitalization and emergency room costs averted.
Results: Average time spent per day on TRIP-specific navigation activities was approximately 3 hours (range, 0-8 hours) and the average time per patient per day was 25 minutes (n = 7 navigators). Total costs for clinical site interventions were 392,407 for maintenance costs over the study period. A total of 223 patients were served during the intervention period with an average cost per patient of 1759 for maintenance. Potential costs savings with the TRIP navigation program from averted hospitalization and emergency room visits for 63 additional patients who received timely treatment is estimated at 30,429 and 5692 per patient, respectively, compared to treatment as usual.
Conclusions: The economic evaluation in this study provides insight into startup and implementation costs for uptake and scalability of navigation programs across a citywide system. The information may be useful for payors in reimbursing navigation activities and health systems in planning for high quality navigation programs to ensure patient-centered and timely treatment for women diagnosed with breast cancer.No embarg
Machine Learning-Enhanced Surveillance for Surgical Site Infections in Patients Undergoing Colon Surgery: Model Development and Evaluation Study
Full text linkBackground: Surgical site infections (SSIs) are one of the most common health care-associated infections, accounting for nearly 20% of all health care-associated infections in hospitalized patients. SSIs are associated with longer hospital stays, increased readmission rates, higher health care costs, and a mortality rate twice that of patients without infections.
Objective: This study aimed to develop and evaluate machine learning (ML) models for augmenting SSI surveillance after colon surgery with the goal of improving the efficiency of infection control practices by prioritizing patients at high risk.
Methods: We conducted a retrospective study using data from 1508 patients undergoing colon surgery treated between 2018 and 2023 at a single academic medical center. Of these 1508 patients, 66 (4.4%) developed SSIs as adjudicated by infection control practitioners following Centers for Disease Control and Prevention National Healthcare Safety Network criteria. Data included 78 structured variables (eg, demographics, comorbidities, vital signs, laboratory tests, medications, and operative details) and 2 features derived from unstructured clinical notes using natural language processing. ML models-logistic regression, random forest, and Extreme Gradient Boosting (XGBoost)-were trained using stratified 80/20 train-test splits. Class imbalance was addressed using cost-sensitive learning and the synthetic minority oversampling technique. Model performance was evaluated using precision, recall, F1-score, area under the receiver operating characteristic curve, and Brier scores for calibration.
Results: Of the 1508 patients, those who developed SSIs had longer hospital stays (mean 8.1, SD 6.8 days vs mean 6.3, SD 10.5 days; P<.001), higher rates of an American Society of Anesthesiologists score of 3 (52/66, 79% vs 653/1442, 45.3%; P<.001), and elevated white blood cell counts (51/66, 77% vs 734/1442, 50.9%; P<.001). XGBoost achieved the best overall performance with an area under the receiver operating characteristic curve of 0.788, precision of 50%, recall of 38%, and Brier score of 0.035. Random forest yielded perfect precision (100%) but lower recall (23%), with a Brier score of 0.034. Logistic regression showed the highest recall (46%) but the lowest precision (10%), with a Brier score of 0.139. Feature importance analysis using Shapley additive explanations (SHAP) values revealed that the top predictors included recovery duration (SHAP=1.18), SSI keyword frequency (SHAP=1.12), patient age (SHAP=1.12), and American Society of Anesthesiologists score (SHAP=0.94), with natural language processing-derived features ranking among the top 10.
Conclusions: ML models can augment traditional SSI surveillance by improving early identification of patients at high risk. The XGBoost model offered the best trade-off between discrimination and calibration, suggesting its utility in clinical workflows. Incorporating structured and unstructured electronic health record data enhances model accuracy and clinical relevance, supporting scalable and efficient infection control practices.No embarg
Risk Factors for Underutilization of Bone Mineral Density Screening in Patients with Inflammatory Bowel Disease Meeting Age and Comorbidity Criteria
No full textIntroduction
The complex interplay of chronic inflammation, malnutrition, and corticosteroid exposure places patients with inflammatory bowel disease (IBD) at higher risk for low bone mineral density (BMD) compared to the general population. As part of evidence-based health maintenance, BMD screening via dual-energy X-ray absorptiometry (DXA) is recommended for older adults and should be considered for individuals with high-risk comorbidities including chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, diabetes, and obesity. Despite these guidelines, studies have consistently demonstrated underutilization of DXA screening within the higher risk IBD populations. This study aims to quantify DXA screening rates among these patients and identify risk factors contributing to screening underutilization.
Methods
In this single-center retrospective cohort study, electronic medical record (EMR) data were used to identify IBD patients aged ≥50 years or with ≥1 chronic comorbidity via International Classification of Diseases-10 (ICD-10) codes K50 (Crohn’s) and K51 (ulcerative colitis) from gastroenterology visits between 1/1/2018 and 12/31/2024. The primary outcomes were DXA scans ordered but not completed (DXA ordered) or completed during the study (DXR resulted). Logistic regression analysis was carried out to examine possible differences in groups with DXA ordered and DXA resulted, while controlling for demographics, comorbidities, and disease duration.
Results
A total of 1,161 patients met the age or comorbidity criteria (mean age 58.1 years, range 20–95; 48.7% male; 88.6% non-Hispanic white; 52.7% Crohn’s disease, 47.3% ulcerative colitis; 44.2% current/former smokers; 37.2% Medicare; 12.5% Medicaid/other). Comorbidities included autoimmune (19.7%), cardiopulmonary (17.3%), and metabolic disorders (57.7%). Among those with available data from EMR reports (n=257), the average disease duration was 22.8 years. Overall DXA order and completion rates were 31.2% and 27.2%, respectively. Regression analyses showed decreased odds of DXA orders in younger age groups (≤49 and 50–59 years) and males, with an increased odds of DXA orders in patients on Medicare and in those with metabolic disorders. Similar patterns were observed for completed DXA scans. In a sub-study (n=250) of those with disease-time available, a higher disease time-to-age ratio was linked to increased odds of DXA resulted.
Conclusion
DXA screening was lower in younger age groups, men, and among those with Medicaid insurance, while higher in Medicare patients and patients with metabolic comorbidities. These findings highlight important considerations for groups at greater risk for underutilization of DXA screening.Master of Science in Clinical InvestigationNo embarg
Adapting an Anxiety Sensitivity Intervention for Perinatal Mental Health: Development of a Digital Intervention
No full textIntroduction: The goal of this study was to adapt an anxiety sensitivity intervention for mobile health delivery to perinatal populations experiencing economic marginalization.
Methods: A community-engaged and user-centered design approach informed the prototype of Reaching Calm. We conducted "think-aloud" interviews with perinatal individuals (n=15) experiencing elevated anxiety and economic stressors. Acceptability and usability were assessed with the Treatment Evaluation Inventory Short Form (TEI-SF) and System Usability Scale (SUS), respectively. We used rapid qualitative analysis to analyze interviews and the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize adaptations.
Results: Mean TEI-SF and SUS scores were 4.3 and 88.0, respectively. Participants reported the content was helpful, values consistent, addressed cultural norms, and elicited feelings of reassurance. Recommendations included additions to content and options for customization. Adaptations included modifications to context and content.
Conclusions: Findings suggest high acceptability and usability. Community-engaged, user-centered design may enhance digital intervention acceptability for perinatal individuals.No embarg