Mount Sinai Health System

To investigate longitudinal trends in the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE) performance, identify statistically significant inflection points in pass rates, and determine factors associated with the recent decline observed in 2022. This was a retrospective, observational study conducted in 2 phases. Phase 1 analyzed all QE attempts from 1980 to 2024 (n = 83,254) to identify changepoints using segmented regression and Bayes factor comparisons. Phase 2 focused on QE attempts surrounding the most recent changepoint from 2016 to 2024 (n = 23,784) and used multilevel nonlinear piecewise growth models to examine the association between physician characteristics and QE pass rates before and after the 2022 changepoint. Three statistically significant changepoints were identified: 1988, 2003, and 2022. Although increases in pass rates were noted in 1988 and 2003, 2022 was marked by a decline in pass rates with a steeper drop post-2022 (slope from 2016 to 2022 = -0.17 vs slope 2022 to 2024 = -0.67). From 2016 to 2022, MD graduates had a lesser decline in performance compared with non-MD peers. After 2022, those trained during the COVID pandemic also experienced a lesser decline. ABEM QE pass rates experienced 3 major inflection points since 1980, with the most recent occurring in 2022 and representing a meaningful decline. Physician-level characteristics, particularly medical school degree type and COVID-era training, were significantly associated with this trend.

Inclusion of youth (10–24 years) living with HIV (YLWH) in clinical research is critical to addressing their unique vulnerabilities and improving care outcomes. Examining the role of trust and relationship building in research decision-making is critical to designing ethical recruitment and engagement strategies. We conducted in-depth, semi-structured interviews with YLWH (10–24 years, enrolled in HIV care at Academic Model Providing Access to Healthcare (AMPATH) in western Kenya), caregivers (parents and guardians) of YLWH, and other subject matter experts (SMEs). Interviews focused on barriers, facilitators, and strategies to improve participant-researcher trust and relationship building, with a particular focus on recruitment and engagement strategies. Interviews were conducted with 99 participants (53% male): 40 YLWH [median age 17.5, (range 11–24), 50% female], 20 caregivers of enrolled YLWH (70% female), and 39 SMEs (33% female; 46% community leaders, 26% healthcare providers, 15% clinical researchers, 8% social scientists, 3% international research experts, 2% laboratory experts). All groups indicated trust could be built and broken through research processes. YLWH and SMEs viewed participant identification and study recruitment through medical records as a violation of trust, indicating that their HIV status and health information should remain confidential between themselves and their clinical team. All groups preferred recruitment through existing clinician-YLWH relationships, emphasizing the importance of privacy and confidentially; this strategy was viewed as stronger and more ethical. Losses of confidentiality and mistakes in sample collection that require participants to attend additional, unnecessary research visits or provide additional samples were identified by all groups as additional barriers to relationship-building. YLWH and caregivers discussed researcher characteristics that support relationship-building, emphasizing the importance of positive demeanors and non-stigmatizing behaviors by research personnel. YLWH and SMEs discussed operational needs that foster relationship-building, including proper communication about study procedures, reliably reporting results to participants, and receiving future benefits. Trusting participant-researcher relationships plays an important role in YLWH research decision making and greatly influence the development of ethical recruitment strategies. Study participants highlighted more appropriate and ethical recruitment strategies, stemming from strong participant-researcher relationships.

Approximately half of Nigerian women with non-metastatic breast cancer undergo surgery, yet psychosocial factors influencing mastectomy receipt are poorly understood. This study aimed to understand barriers, facilitators, and patient attitudes toward mastectomy for breast cancer in Nigeria. Using a prospective, convergent mixed-methods study design, we disseminated a structured questionnaire (N=225) and conducted in-depth interviews (N=18) among women with non-metastatic breast cancer recommended for mastectomy at 3 academic Nigerian institutions. Logistic regression identified factors associated with mastectomy within 1year of diagnosis; interviews were analyzed using the framework method. Qualitative and quantitative themes were triangulated using a joint display. Median age was 48years (IQR 40,57); median tumor size was 6.6cm (IQR 4.4,10.1). One hundred patients (44%) underwent mastectomy, 97 within 1 year of diagnosis. Nineteen percent (n=42/224) had not heard of breast cancer before diagnosis; 37% (n=82/223) had not heard of mastectomy. Interview participants expressed negative emotions toward mastectomy. Of those who did not receive surgery, the most common reasons were cost (n=41/125, 33%), loss to follow-up (n=20/125, 16%), traditional medicine (n=13/125, 10%), death (n=12/125, 9.6%), and disease progression (n=9/125, 7.2%). In multivariable analysis, awareness of mastectomy (OR 4.10, 95% CI 1.64,10.7, p-value=0.003) was significantly associated with surgery receipt within 1year. This study identified patient factors related to mastectomy receipt, including education and awareness, financial burden, fear of surgery, anticipated body image changes, and concern about adverse social impacts. Public health education about breast cancer surgery, pre-mastectomy counseling/peer-support, and financial may facilitate mastectomy receipt.

Digital biomarkers use sensors and analytics, to offer continuous monitoring and personalized medicine. In this Perspective, we describe real-world use cases, such as glucose tracking to optimise insulin dosing and wearables to measure heart rhythms to de-risk cardiovascular trials. We also discuss the issues preventing most candidate biomarkers from reaching clinical practice. Evidence generation is costly, regulatory reviews can be redundant, commercial incentives fall short, and data silos can be biased and/or nonrepresentative. By combining harmonized qualification pathways, value-based reimbursement, modular extensions for single-trial biomarkers, and adaptive post-market evidence loops, we propose a path from experimental signal to standard of care.