Publications by Year: 2026

BACKGROUND: Racial inequities in hospital-based care for Black adults are well-documented, yet the mechanisms by which interpersonal and institutional racism contribute to these inequities remain poorly understood. Non-clinician hospital staff, such as patient care assistants, spend significant time with patients and are often members of minoritized communities, yet their perspectives on racism in the hospital are rarely studied.

OBJECTIVE: To investigate non-clinician staff members' perspectives on how interpersonal and institutional racism affect hospital-based care for Black adult patients.

DESIGN: Qualitative study using in-depth, semi-structured interviews and community-based participatory research principles.

PARTICIPANTS: Fifteen hospital staff members (patient care assistants, custodians, transporters, and ward clerks) from a large, urban, academic medical center on the West Coast. Participants self-identified as Black (27%), Hispanic (20%), and/or Asian (53%).

APPROACH: Semi-structured interviews explored respondents' perspectives on racism in the hospital. Interviews were analyzed using thematic analysis. A Community Advisory Board of eight Black individuals provided feedback and member checking.

KEY RESULTS: Five themes emerged from the data: (1) staff members experienced workplace racism; (2) racial stereotypes appeared to contribute to inequitable care for Black patients; (3) institutional factors, such as inadequate staffing, were felt to contribute to inequitable care; (4) individual factors, such as going "above-and-beyond" job responsibilities, helped mitigate inequitable care; and (5) institutional diversity, equity, and inclusion (DEI) interventions received mixed appraisals, with staff often excluded from initiatives.

CONCLUSIONS: Inequities in hospital-based care for Black patients may have roots in complex interactions between individual biases, workplace discrimination, institutional factors, and systemic underinvestment in non-clinician staff. Respondents perceived that institutional factors, such as inadequate staffing and demanding workloads, amplified racist beliefs, resulting in inequitable care for Black patients. Hospitals should invest in non-clinician hospital staff and address structural factors impeding staff members' ability to provide equitable care to all patients.

IMPORTANCE: International medical graduates (IMGs-physicians who graduated from a medical school outside the US) hold a significant role in the US healthcare system. Research suggests that clinicians' attitudes towards end-of-life (EOL) care may vary across countries.

OBJECTIVE: To compare EOL care processes and outcomes for older adults treated by IMGs vs. US medical graduates (USMGs).

DESIGN: Cross-sectional study.

PARTICIPANTS: A 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older who died in 2016-2019.

MAIN MEASURES: Seven EOL care-related measures: (i) palliative care counseling or hospice enrollment in the last 180 days of life; (ii) emergency department visits, (iii) hospital admissions, (iv) intensive care unit admissions, (v) use of mechanical ventilation or cardiopulmonary resuscitation, or (vi) feeding tube placement in the last 30 days of life; and (vii) death in an acute care hospital. We adjusted for beneficiary- and physician-level confounders; P-values were adjusted using the Bonferroni-Holm method for multiple comparisons.

RESULTS: Among 391,425 beneficiaries, 117,754 (30.1%) were attributed to IMGs and 273,671 (69.9%) to USMGs. We found no evidence that six of the seven measured EOL care processes and outcomes differ between IMGs and USMGs. Beneficiaries treated by IMGs were slightly less likely to have emergency department visits in the last 30 days of life (57.1% vs. 57.6%; adjusted difference, -0.5 pp; 95% CI, -0.9 to -0.2; P = 0.04) compared with those treated by USMGs. Subgroup analyses by beneficiaries with cancer or chronic heart failure showed no evidence that EOL care processes and outcomes differ by physician's country of medical school after adjustment for multiple comparisons.

CONCLUSIONS: EOL care processes and outcomes were similar for older adults treated by IMG and USMG physicians, despite potential differences in medical training during medical school.

BACKGROUND: Gestational diabetes mellitus is becoming increasingly prevalent and has been associated with adverse outcomes for both mothers and their children. Prenatal exposure to maternal obesity and hyperglycemia has been associated with higher risks of macrosomia, neonatal hypoglycemia and later metabolic disorders. However, because diagnostic fasting glucose thresholds vary internationally, it remains unclear how different cut-offs, as well as fasting glucose as a continuous measure, relate to offspring growth and metabolism. This study investigated whether maternal fasting glucose predicts offspring body composition, anthropometry and metabolic outcomes at birth and at 3 years.

METHODS: The analysis used data from the Lifestyle in Pregnancy (LiP) study and its 3-year follow-up, the LiPO study. Of 301 women in LiP, 157 participated in LiPO, and 75 children had DXA assessments. Maternal fasting plasma glucose at 28 weeks was analyzed continuously and across thresholds from 4.6 to 5.8 mmol/L using regression models adjusted for maternal age and pre-pregnancy BMI. Offspring outcomes included birth weight, birth weight z-score, BMI z-score, fat and fat-free mass, lipids and blood pressure.

RESULTS: Higher maternal fasting glucose was associated with a higher birth weight z-score. At 3 years, no significant associations were found for BMI z-score or metabolic markers, although small, non-significant trends toward higher fat and fat-free mass were observed. Threshold analyses showed that glucose ≥ 5.6 mmol/L predicted higher birth weight and increased large-for-gestational-age risk, and glucose ≥ 5.3 mmol/L predicted higher cord c-peptide. No threshold was linked to metabolic differences at 3 years.

CONCLUSION: Maternal hyperglycemia was associated with adverse neonatal outcomes but not with offspring adiposity at 3 years. Longer-term follow-up, including the ongoing 15-year LiP data, is needed to determine whether mild maternal hyperglycemia has later metabolic consequences.

TRIAL REGISTRATION: Both the LiP and LiPO studies received approval from the Regional Ethics Committee of Southern Denmark (S-20070058) and were registered with the Danish Data Protection Agency. The LiP study was registered at www.

CLINICALTRIALS: gov (NCT00530439) with a registration date of September 13, 2007. The LiPO follow-up, initiated in 2010 while the LiP study was still ongoing, was registered at www.

CLINICALTRIALS: gov (NCT01918319) to compare offspring of LiP participants.

INTRODUCTION: Globally, an estimated 56.8 million people require palliative care each year, with half in their final year of life. However, access appears to be scarce in the most impoverished settings, like rural sub-Saharan Africa. Africa is expected to experience a sharp rise in severe health-related suffering, underscoring the need to increase access to palliative care.

METHODS: A convergent parallel mixed-methods design was conducted to assess factors affecting palliative care access and utilisation in rural Malawi. Interviews using a question guide were conducted with patients, caregivers, and service providers to examine experiences in palliative care access and service utilisation, and the analysis used thematic content analysis. Electronic medical data were extracted, de-identified, and analysed using STATA software version 18.0 from nine palliative care implementing facilities using descriptive statistics.

RESULTS: Electronic medical records were analysed with 204 patients enrolled in the program. The mean age was 58.6 years, and 47% (n = 96) were aged 65+. Females predominated, comprising 65% (n = 132) of the enrollees. 72% (n = 139) of the patients lived more than five kilometres from the nearest clinic. Analysis of forty-four key informants’ interviews highlighted the importance of health system and facility management, structural and contextual determinants of healthcare access, and community-based care and household health determinants, which play a central role in program management and coordination, community health worker (CHW) engagement, and availability of essential supplies plays a central role in service accessibility and utilisation.

CONCLUSION: The findings from the study highlight the importance of addressing social determinants of health, supporting community-based health workers, and strengthening local leadership to improve palliative care access. Provider support and locally adapted strategies can facilitate the delivery of palliative care services in hard-to-reach settings. While these insights are drawn from a single district and may not be broadly generalizable, they provide context-specific guidance for program managers and policymakers aiming to enhance palliative care access and utilisation in similar low-resource settings.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12904-026-02003-5.

BACKGROUND: Adolescents and young adults (AYAs) with cancer experience deficits in social connection that persist into survivorship; currently, few interventions target this unmet need. The current article describes the protocol for a pilot, parallel-group randomized controlled trial of a psychosocial intervention [Promoting Resilience in Stress Management (PRISM)] that includes a new skill-based module targeting AYA social needs (SN). The aims are to (1) establish the feasibility and acceptability of the PRISM-SN-adapted program; and (2) demonstrate proof-of-concept via clinically meaningful improvements in patient-reported outcomes (PROs).

METHODS: We anticipate 70 AYAs will enroll and complete data collection at two sites: Seattle Children's Hospital and UPMC Children's Hospital of Pittsburgh. Eligible AYAs are ages 12-25 years old; diagnosed with a new malignancy < 6 months; treatment plan includes chemotherapy and/or radiation; and are English-speaking. Enrolled AYAs are randomized 1:1 to receive PRISM-SN or usual care and complete surveys at baseline and 12-week follow-up. PRISM-SN includes 5 sessions (4 standard PRISM modules + new SN module) teaching behavioral skills associated with psychosocial wellbeing. Sessions are delivered 1:1 by a trained coach, in person or virtually, 1-2 weeks apart. Feasibility will be defined based on uptake, retention, and patient-reported intervention acceptability. Proof-of-concept will be defined based on clinically meaningful change and detectable differences in PROs at 12 weeks, including social relationship coping efficacy (primary PRO of interest), social support, quality of life, resilience, anxiety, depression, and hope. Descriptive statistics and covariate-adjusted regression models will be used to assess feasibility outcomes and examine trends and between-group differences in PROs across study arms.

DISCUSSION: This pilot trial will determine feasibility of PRISM-SN in the context of a multi-site trial; provide proof-of-concept via effects of PRISM-SN on social connection outcomes; and represent an important step toward addressing an unmet need in AYA cancer care. Future directions include testing efficacy and effectiveness via larger multicenter trials.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT06242964.

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts (RHIs), characterized by tau tangles around small blood vessels at the depths of the sulci. Currently, CTE can be diagnosed only postmortem, but can present with an array of cognitive, behavioral, mood, and motor symptoms. However, traumatic brain injury is also associated with increased risk of Alzheimer's disease (AD) and may lead to comorbid neuropathology. Characterization of the in vivo biomarkers of CTE is a necessary next step to facilitate accurate diagnoses. We examined the profile of cerebrospinal fluid (CSF) biomarkers of amyloid-β, total tau (tTau), and phospho-tau (pTau) in a cohort of former professional (PRO, n = 100) and college (COL, n = 40) football players at high risk of CTE compared to asymptomatic unexposed controls (UE, n = 43). CSF was collected under controlled conditions using collection, processing, and cryostorage kits provided by the DIAGNOSE CTE Research Project Biomarker Core, and concentrations of Aβ40, Aβ42, tTau, and pTau (pTau181, pTau217, pTau231) were measured at the University of Gothenburg, Sweden, using immunoassays. Associations between CSF biomarker levels with football history, and diagnosis of traumatic encephalopathy syndrome (TES) were examined using linear regression, and corrected for age, education, APOE-ε4 allele status, race, and body mass index. Our analysis revealed that football exposure affected both CSF Aβ40 (p = 0.039) and Aβ42 (p = 0.038), particularly among those under 60 years of age in the PRO compared to the UE exposure group. Among former football players, estimates of RHI exposure were not generally associated with CSF Aβ, tTau, and pTau biomarker levels. CSF Aβ40 (p = 0.0041) and Aβ42 (p = 0.011) were lower in former football players with TES diagnosis compared to unexposed participants, although CSF Aβ, tTau, and pTau biomarker levels did not differ between former players with and without a TES diagnosis. Among former football players, reduced CSF Aβ40 (p = 0.011) and Aβ42 (p = 6e-04) were observed in those with cognitive impairment compared to those with neurobehavioral dysregulation. The findings of significant associations of reduced CSF Aβ levels with RHI in elite football players are in line with recent postmortem studies; however, the lack of relationship with CSF tTau and pTau species observed to be altered in the setting of AD suggests that the pathological features of CTE reflected in fluid biomarkers are complex and require further study. The overlapping comorbid age-dependent features of neurodegeneration that occur in those at risk for CTE suggest that tau pathology in CTE is not reliably reflected by currently available fluid biomarkers and that the use of multiple biomarkers related to the compound characteristics of CTE may be required for early detection.

BACKGROUND: Muscle atrophy is a common complication of ageing, and many chronic conditions, lacks defined therapeutic interventions. It is still mostly unknown how circular RNAs contribute to muscle atrophy.

METHODS: circRNA sequencing and quantitative real-time PCR were performed to detect the changed circRNAs in muscle atrophy models and aged muscle. Then the gain-of-function and loss-of-function experiments were used to investigate the function of circSnd1 in muscle atrophy and muscle ageing. Furthermore, we used RIP-MS and RIP assay to determine the downstream and upstream mechanism of circSnd1 in muscle atrophy.

RESULTS: Here, we characterized the function and mechanism of highly species-conserved circRNA derived from staphylococcal nuclease and Tudor domain containing 1 gene (named circSnd1) in muscle atrophy. CircSnd1 is upregulated in many types of muscle atrophy models in both in vivo and in vitro (all p < 0.01). Meanwhile, circSnd1 is also higher expressed in aged muscle in humans (+2.2-fold, n = 5, p < 0.05), mice (+43.96%, n = 6, p < 0.05) and myotubes (+42.21%, n = 6, p < 0.05). Functional analyses show that circSnd1 promotes muscle atrophy and muscle ageing at the cellular level and mouse level while repressing it ameliorates multiple types of muscle atrophy (all p < 0.05). Mechanistically, the RNA binding protein eukaryotic translation initiation factor 4A3 (EIF4A3) can bind to the intron flanking sequence of circSnd1 to induce circSnd1 cyclization and increase circSnd1 expression in muscle atrophy. In addition, circSnd1 promotes the binding between human HLA-F adjacent transcript 10 (FAT10) and eukaryotic translation elongation factor 1 alpha 1 (EEF1A1). FAT10 competes with ubiquitin for binding with EEF1A1, which decreases the ubiquitination of EEF1A1 and stabilizes the protein level of EEF1A1 in muscle cells to promote atrophy.

CONCLUSIONS: We have identified circSnd1 as a novel circRNA that promotes muscle atrophy and highlighted its potential as a novel therapeutic target.

BACKGROUND: Antiphospholipid syndrome (APS) is associated with venous thromboembolism, which can lead to chronic thromboembolic pulmonary hypertension (CTEPH). Despite treatment with pulmonary endarterectomy (PEA), some patients continue to experience pulmonary hypertension (PH), which is potentially caused by APS-related distal vasculopathy. The aim of this study was to assess persistent PH after surgery and to investigate post PEA outcomes, including immediate postoperative complications, hospitalizations within 1 year of surgery, and mortality.

METHODS: We performed a retrospective analysis of adult patients with CTEPH who underwent PEA. We included patients with and without APS. Data were obtained from the Saudi Pulmonary Hypertension Registry (2011-2022). We assessed immediate postoperative complications, rehospitalizations within 1 year, and mortality. Additionally, we evaluated patients with right heart catheterization 1 year before and after PEA for persistent PH.

RESULTS: The study included 37 patients with APS-CTEPH and 41 patients without APS. Persistent PH was observed in 43% of patients, with no significant difference between the groups. Notably, patients in the APS-CTEPH group who received pulmonary vasodilator therapy before PEA had a reduced risk of developing persistent PH. Postoperative complications were significantly higher in the APS-CTEPH group (p = 0.002). Despite these risks, the 5-year survival rate was 98.3%, with no significant difference between the groups.

CONCLUSION: APS is associated with a higher incidence of immediate postoperative complications and rehospitalizations within the 1st year after surgery. However, APS does not appear to increase the risk of persistent PH or affect long-term mortality in this cohort.

INTRODUCTION: Routine screening for health-related social needs (HRSNs) is inconsistent, creating disparities in who gets identified and supported. Transgender patients, already facing structural stigma, may be especially affected.

METHODS: We analyzed electronic health records from a large urban safety-net system (2018-2023). We identified 2639 transgender patients with at least one outpatient visit and created a ∼11:1 comparison cohort of 23 944 cisgender patients. Overall, 7.5% (n = 1997) completed a Social Needs Questionnaire (SNQ), including 1840 cisgender and 157 transgender patients. We compared screening rates using chi-square tests and assessed adjusted odds for HRSN with logistic regression.

RESULTS: Transgender patients were screened less often than cisgender patients (5.9% vs 7.7%, P = 0.001). Among those screened, they had more than twice the odds of housing instability, poor-quality housing, and healthcare costs. Odds for interpersonal violence were th3ree times higher. Findings were consistent in sensitivity analyses adjusting for age, insurance, and neighborhood.

CONCLUSION: Transgender patients were underscreened yet faced greater HRSNs. Standardized screening and expanded supports are critical to support transgender communities.