Digital Commons Network^™

Improving Compliance With Preoperative Antibiotic Protocols For Cardiac Implanted Electronic Devices: A Quality Improvement Project, James Kaup

DNP Projects

Abstract

Background

Cardiac implantable electronic device infections remain a serious complication of permanent pacemaker implantation despite evidence-based infection prevention guidelines.

Local Problem

An academic electrophysiology laboratory identified inconsistent guideline-concordant antibiotic selection despite consistently high compliance with recommended antibiotic timing.

Methods

A nurse-led, quasi-experimental pre-post quality improvement project evaluated implementation of a standardized preoperative antibiotic prophylaxis protocol. Data from 36 permanent pacemaker implantations (16 pre-intervention, 20 postintervention) were analyzed.

Interventions

The intervention included a standardized antibiotic protocol, multidisciplinary staff education, and performance feedback.

Results

Guideline-concordant antibiotic selection improved from 37.5% to 95.0% (χ² = 11.27, P = .001). Antibiotic timing remained …

The Performance Of Machine Learning Algorithms In Predicting Under-Five Anaemia In Tanzania, Henry Ofori Duah, Derrick Nyantakyi Owusu, Godwin G. Duah, Paul Shidende

College of Nursing Faculty Research and Publications

Aim

Anaemia in children under five remains a major public health concern, contributing significantly to global child morbidity and mortality. With the rise of machine learning (ML), novel opportunities exist to model and predict anaemia more effectively. This study aimed to evaluate and compare the performance of five ML algorithms in predicting anaemia among under-five children in Tanzania.

Methods

We conducted a secondary data analysis using the 2017 Tanzania Malaria Indicator Survey (TMICS). The dataset (n = 5906) was randomly split into training (70%) and test (30%) sets. Five ML algorithms, Linear Discriminant Analysis (LDA), Logistic Regression, Random Forest (RF), …

Improving Effective Completion Of Catheter Care Using A Reminder System To Minimize Incidence Of Catheter-Associated Urinary Tract Infections: A Quality Improvement Project, Morgan K. Leonard

Master's Theses and Capstones

BACKGROUND: CAUTI rates can be decreased by implementing a care cluster for RNs for CAUTI care into morning assessments and medication administration to ensure it is being done regularly with reminders through cards at the computers in patient rooms. LOCAL PROBLEM: The local problem in the microsystem were the catheter-associated urinary tract infection (CAUTI) rates at 1.199, while the national benchmark is 1.000 (Medicare, n.d.).

METHODS: Reminder cards were placed in patient rooms on the computers which are highly utilized by staY while providing patient care to serve as a reminder to complete catheter care in a high task burden …

Incorporating Structured Safety Huddles To Improve Nursing Communication And Reduce Medical-Surgical Inpatient Fall Rates: A Quality Improvement Project, Alexia K. Leonard

Master's Theses and Capstones

BACKGROUND: Patient falls are a significant concern for patient safety in the acute care setting and are typically connected to inadequate communication during shift transitions. Bedside shift report is considered the standard of care, however, barriers are still present when shifting patient care responsibilities among nursing staff. A literature review identified standardized safety huddles as an evidence-based practice to improve areas of communication, teamwork, situational awareness, and patient safety. This quality improvement (QI) project concentrated on the implementation of a standardized evening safety huddle in order to improve nursing communication and reduce patient falls on an inpatient medical-surgical/telemetry unit. METHODS: …

Using Text Messages To Reduce Pediatric No-Show Rates In Primary Pediatric Care, Kelly A. Rexford-Hudson

West Chester University Graduate Theses, Dissertations, and Final Projects

Pediatric appointment no-show rates lead to fragmented care, missed preventative services, delayed immunizations, and reduced clinic efficiency. Children who miss well-child and follow-up visits are at increased risk for unmanaged chronic conditions and gaps in developmental surveillance. The purpose of this Doctor of Nursing Practice quality improvement project was to evaluate whether bilingual text message reminders would decrease no-show rates in a pediatric primary care clinic. Led by the Plan-Do-Study-Act framework and Bronfenbrenner's Ecological Model, this intervention consisted of two manual text message reminders, delivered in English and Spanish, at 7 days and 2 days before scheduled appointments during a …

Attitudes And Expectations Towards Acupuncture For Primary Dysmenorrhoea: Findings From A Cross-Sectional Survey In Australia, Weiting Liu, Amanda Towell-Barnard, Khui Hung Lee, Timothy Leen Kang

Research outputs 2022 to 2026

Objective: To describe attitudes towards acupuncture and expectations regarding potential treatment outcomes among women with self-reported primary dysmenorrhoea (PD) residing in Australia. Methods: A cross-sectional, descriptive online survey was conducted to assess attitudes and treatment expectancy using an adapted version of previously published complementary and alternative medicine (CAM) attitude scale and a validated acupuncture expectancy scale (AES). Data were analysed descriptively, with exploratory analysis conducted to support the interpretation of response patterns. Ethical approval was obtained from the Edith Cowan University Human Research Ethics Committee (2023-04471-LIU) and participants provided electronic informed consent. Results: A total of 247 responses were received. …

Optimising Vaginal Microbiome Profiling For Clinical Translation: A Comparative Assessment Of Sample Storage Methods And A Vagina-Specific 16s Rrna Gene Database, Alishum Ali, Jeffrey A. Keelan, Blagica Penova-Veselinovic, Morten E. Allentoft, Michael Bunce, Claus T. Christophersen

Research outputs 2022 to 2026

Vaginal microbiome composition has been linked to risk of preterm birth (PTB), a persistent global health challenge. 16S rRNA microbial profiling has identified specific vaginal community state types (CSTs) that have been associated with PTB risk. Diagnostic profiling requires standardised pre-analytical protocols. We evaluated two storage methods and validated a curated, vagina-specific 16S rRNA gene database (VagDB) to enhance annotation. Paired Copan FLOQ swabs from 22 women at high PTB risk were processed for either (a) dry/immediate freezing or (b) Amies-stabilisation/refrigeration. Amplicon sequence variants were generated via 16S rRNA gene (V4) PCR and Illumina sequencing. We assessed diversity, composition, and …

Proof-Of-Concept Development And Preclinical Evaluation Of A Microarray Patch Platform For Codelivery Of Multiple Broadly Neutralizing Antibodies For Hiv Prevention, M. Melissa Peet, Vivek Agrahari, Parbeen Singh, Lam Luong Hoai Nguyen, Louise A. Ouattara, Eun Sung Yang, Carolina Herrera, Amarendra Pegu, Theodore C. Pierson, Thanh D. Nguyen, Gustavo F. Doncel

CONRAD Publications

Broadly neutralizing antibodies (bnAbs) are advancing as a preventative or treatment option for HIV infection, but currently must be administered parenterally, typically as a large injection or infusion, an invasive method of delivery, especially for the pediatric population. Here, we present proof-of-concept data on a minimally invasive microneedle (MN) patch platform codelivering three bnAbs, PGT121, VRC07-523LS, and PGDM1400LS, from separate MN patch units or pixels. Each 1 cm² patch pixel, fabricated via solvent casting, contained ∼2 mg of one bnAb. In ex vivo porcine skin tests, the MNs effectively penetrated the skin. When tested in vitro in PBS buffer, MNs …

Proof-Of-Concept Development And Preclinical Evaluation Of A Microarray Patch Platform For Codelivery Of Multiple Broadly Neutralizing Antibodies For Hiv Prevention, M. Melissa Peet, Vivek Agrahari, Parbeen Singh, Lam Luong Hoai Nguyen, Louise A. Ouattara, Eun Sung Yang, Carolina Herrera, Amarendra Pegu, Theodore C. Pierson, Thanh D. Nguyen, Gustavo F. Doncel

CONRAD Publications

Broadly neutralizing antibodies (bnAbs) are advancing as a preventative or treatment option for HIV infection, but currently must be administered parenterally, typically as a large injection or infusion, an invasive method of delivery, especially for the pediatric population. Here, we present proof-of-concept data on a minimally invasive microneedle (MN) patch platform codelivering three bnAbs, PGT121, VRC07-523LS, and PGDM1400LS, from separate MN patch units or pixels. Each 1 cm² patch pixel, fabricated via solvent casting, contained similar to 2 mg of one bnAb. In ex vivo porcine skin tests, the MNs effectively penetrated the skin. When tested in vitro in PBS …

Implementation Of A Ventilator-Associated Pneumonia Bundle To Reduce The Incidence Of Ventilator-Associated-Pneumonia And Improve Patient Care, Taylor Ryan Rice

Graduate Theses, Dissertations, and Problem Reports (ETD)

Introduction: Ventilator-associated pneumonia (VAP) is a concerning complication that can

develop from complications when a patient is placed on a mechanical ventilator. Endotracheal

intubation puts patients at risk for micro aspiration, which can lead to VAP.

Evidence Review: Nine articles were selected for review; after critical appraisal, seven were

kept for further review. Evidence in these articles shows that using evidence-based methods in a

VAP bundle can decrease the length of stay, mechanical ventilator days, and the incidence of

VAP.

Purpose: The purpose of this project was to improve oral care for intubated patients and keep

the incidence of VAP …

The Therapeutic And Physiological Effects Of Citrus Peel Extraction On Helicobacter Pylori Bacteria, Sara Saeb Rasheed, Rawnaq Z. Fadhil, Marwah Amer Qamandar, Salah M.M. Al-Chalabi

Al-Esraa University College Journal for Medical Sciences

The antibiotic resistance has emerged as a growing international concern affecting not only human health but also the environment, animal population, and global economy. The increasing prevalence of antibiotic resistance poses a serious and escalating threat to public health. This problem is further exacerbated by the limited development of new antibiotic, high production costs, and risks about its side effects. Identifying novel antibiotic agents is crucial for managing fungal and bacterial infection. Consequently, numerous natural compound have been investigated as potential alternative therapies. Plant extracts are valuable source of bioactive compounds and represent a promising strategy to control pathogenic microorganisms. …

Mental Health First Aid Certification's Impact On Filipino Nurses' Ability To Increase Personal Help-Seeking Behaviors, Self-Awareness Of Health Changes, And Improved Self-Connection, Maria Elena Holguin, Brenda Marshall, Faith Atte, Katherine J. Roberts

School of Nursing Faculty Scholarship and Creative Works

Background

Post COVID-19, almost 50% of nurses reported severe depression, and over 30% moderate to severe anxiety. Nurses from minority racial and ethnic backgrounds, including Filipino nurses, accounted for more than 54% of COVID-related deaths, despite comprising only 24.1% of the nursing workforce. Filipino nurses, making up only 1% of the U.S. population, comprise 4.5 % of the nursing workforce and face significant barriers to seeking mental health services, including stigma, a sense of shame, and adherence to cultural values that view mental illness as unacceptable.

Aim 

To assess the impact of Mental Health First Aid (MHFA) certification among Filipino …

Adapter Changes Of Central Line Patients On Total Parenteral Nutrition, Courtney Erin Schappell

Walden Dissertations and Doctoral Studies

Central line-associated bloodstream infections (CLABSIs) remain a significant and preventable patient safety issue, especially among hospitalized patients receiving total parenteral nutrition (TPN). Patients on TPN face a higher risk of infection due to the high glucose content of the solution and the frequent access required for central line therapy. The Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality have recognized CLABSI prevention as a national priority. In addition, there is emphasis on high-risk groups like patients receiving TPN. The Infusion Therapy Standards of Practice, an evidence-based guideline, recommends catheter care, including timely adapter (i.e., …

Interventions To Promote Menstrual Health Among Adolescents In Lmic’S: Protocol For A Systematic Review, Precilla Dsilva, Sudhir Prabhu Dr, Prajna Kumari Dr, Baby S. Nayak Dr, Judith Noronha Dr

Manipal Journal of Nursing and Health Sciences

Background: Menarche brings out significant change in each girl’s life. Coping with the discomforts and adopting the body changes becomes a biggest challenge for every teen. Cost effective non pharmacological interventions will help to bring about improvement in the general wellbeing and quality of life in each adolescents life.

Objective: This review aims to determine the different menstrual interventions adopted by adolescent girls residing in Low and Middle Income Countries (LMIC’s). The Review question will be :What interventions are currently available, and how do they contribute in promoting menstrual health among adolescents from LMICs

Methods: This review will include …

Impact Of The Covid-19 Outbreak On The Emotional Responses And Self-Protective Behaviors Of Nursing Students., Banisha Lyngdoh Nonglait, Jyothsna Jennifer Hans, S P Sagar, Gayatri Poojari, Sanju Pant, Maria Pais Dr

Manipal Journal of Nursing and Health Sciences

Background: The COVID-19 pandemic has disrupted nearly every aspect of our society. The higher education sector is no exception. Students face an increasingly unstable environment, impacting their physical and emotional health.

Objectives: The study aims to determine students' emotional responses to the impacts of the COVID-19 outbreak. It also assesses their behavior in protecting themselves from cross-contamination during this period.

Methods: A descriptive survey design was used in this study, which included 61 undergraduate students. To collect data, researchers employed socio-demographic questionnaires alongside a structured attitude survey designed to assess emotional responses and self-protective behaviors related to COVID-19. The reliability …

Prevalence Of Aminoglycoside Resistance Genes Among Esβl Producer P. Aeruginosa In Burn Cases, Yasser Rabee Ibraheem, Majida Malik Alshammari

Al-Esraa University College Journal for Medical Sciences

Pseudomonas aeruginosa recurrently develops resistant towards aminoglycosides by gaining of aminoglycoside modifying enzyme (AME) genes. The study aimed to assess the antibiotic susceptibility profile of P. aeruginosa isolated from burn infections in hospitals in Baquba, AL Najaf and Karbala. Detection of genes that mediate the production of AMEs. 175 Burn swab (110 males and 65 females) were collected then cultured on MacConkey‘s and Blood agar for primary culture, and Cetrimide agar was used to isolate and purify the bacteria and incubated aerobically at 37°C for 24 hours. Then, Vitek 2 system to validate the results. Results revealed that 70 (40%) …

Sleep Menus: A Personalized Approach To Enhancing Patient Rest And Improving Sleep Quality, Justin W. Dorman

Doctor of Nursing Practice (DNP) Manuscripts

Sleep disruptions among hospitalized patients can negatively impact healing, recovery, and patient satisfaction. Hospital noise remains a persistent barrier to restful sleep, yet previous hospital-based noise reduction strategies have shown limited sustained success. This quality improvement project aimed to enhance patient-perceived sleep quality by implementing a patient-centered Sleep Menu offering patients earplugs or sound machines. A pre-post design was employed, using the Richard-Campbell Sleep Questionnaire (RCSQ) to assess patients' sleep quality before and after the Sleep Menu intervention. Sixty patients were approached; 25 chose earplugs, and 7 selected the sound machine. Despite environmental decibel levels remaining above the WHO recommendations …

Impact Of Staff Education To Clinical Documentation Integrity Team, Leyna Belcher

Walden Dissertations and Doctoral Studies

The doctoral project investigates the impact of education on Clinical Documentation Integrity (CDI) nurses in enhancing the accuracy and quality of clinical documentation within healthcare organizations. Clinical documentation plays a crucial role in accurately reflecting patient care and is essential for capturing proper diagnoses, coding, and reimbursement. In contrast, inaccurate or incomplete documentation can lead to misdiagnoses, poor patient outcomes, and financial deficits. Due to frequent updates in clinical guidelines and coding standards, CDI professionals require continuous, specialized training to stay informed with ever-changing medical terminology, disease processes, and coding regulations. By enhancing the CDI education, the aim is to …

A Quality Improvement Initiative To Streamline Flu Vaccine Documentation And Increase Staff Engagement, Carla E. Giron

Master's Projects and Capstones

Objective: This quality improvement project was implemented in an urban community health clinic primarily serving low-income and Latinx patients. Factors such as demographics, socioeconomic status, health, and transportation contribute to low U.S. influenza vaccination rates (Chen et al., 2020), while EHR training can improve provider satisfaction and efficiency (DiAngi et al., 2019). This microsystem faced inconsistent workflow processes, limited EHR training, and documentation errors that contributed to low staff satisfaction rates and influenza vaccination rates. An average of 11.4% of patients received a flu vaccine in October 2023 and 2024. Medical assistants (MAs) completed a pre-intervention survey indicating that 35% …

Practice Matters: Measles, Maria E. Main, Melissa K. Travelsted, Maire M. Blankenship

International Journal of Faith Community Nursing

Measles has re-emerged as a significant public health concern, with an estimated 10.3 million global cases and more than 100,000 deaths in 2023, primarily among young children. In the United States, measles incidence has risen sharply due to declining vaccination rates and increased international travel, resulting in a growing number of locally transmitted outbreaks. Faith community nurses, who play key roles in health education, advocacy, and illness prevention, are uniquely positioned to support community-level efforts that reduce measles transmission. This article addresses key aspects of measles epidemiology, clinical presentation, and complications, emphasizing the virus’s high communicability and potential for severe …

The Use Of Storytelling In Covid-19 Vaccine Promotion: A Scoping Review Of Interventions And Campaigns, Suha Ballout, Sabreen A. Darwish, Patricia J. Kelly, Teresa Keller, Ross Shegog, Basil H. Aboul-Enein

College of Nursing Faculty Papers & Presentations

BACKGROUND: The development of the COVID-19 vaccine, a groundbreaking scientific advancement, also fueled vaccine hesitancy mainly due to vaccine misinformation and the limited public understanding of the new technology and its rapid pace of development and deployment. A variety of public health communication strategies have been used that include engaging the community in identifying and developing messages, using culturally appropriate communication methods, applying behavioral health principles, and storytelling. The purpose of this scoping review was to assess the most relevant evidence from the research literature on storytelling interventions to mitigate COVID vaccine hesitancy during the pandemic.

METHODS: A scoping review …

Holistic Approaches To Lyme Disease Symptom Management, Leah Van Antwerp

Honors Theses

Lyme disease is a multisystem tick-borne infection that can lead to long-lasting symptoms even after standard antibiotic therapy, with Lyme arthritis being one of the most common and persistent complications. Due to limited research on this issue, rheumatoid arthritis (RA) will be discussed as a reference for understanding treatment options because it is a similar condition. Since many people continue to experience debilitating pain and reduced quality of life after treatment for Lyme disease, holistic approaches have become increasingly popular for symptom management. This literature review examines three holistic modalities-yoga, acupuncture, and diet modifications- and their effectiveness in alleviating arthritic …

Clinical Practice Guideline On Reducing Catheter -Associated Urinary Tract Infections (Cautis), Nkechi Christiana Udah

Walden Dissertations and Doctoral Studies

The project was a clinical practice guideline (CPG) for early catheter removal to prevent catheter-associated urinary tract infections (CAUTIs). At the project site, the practice gap was the surgical nurses’ nonadherence to clinical guidelines for reducing CAUTIs. This gap resulted in inconsistent catheter care practices and delays in catheter removal. The purpose of this CPG was to enhance surgical nurses’ knowledge and adherence to clinical guidelines for reducing CAUTI rates. The following practice-focused question guided the project: In hospitalized patients in acute care settings, does early removal of the urinary catheter compared to leaving the catheter until discharge reduce the …

Enhancing Sepsis Prevention In Long-Term Care Facilities: Development Of An Infection Prevention Sepsis Toolkit, Emmalyn A. Tuhin

Student Scholarly Projects

Objectives: The purpose of this Doctor of Nursing Practice (DNP) project was to create, validate, and refine an Evidence-Based Sepsis Prevention Toolkit to enhanced early sepsis recognition and interprofessional coordination of care within long-term care facilities (LTCFs).

Background: Sepsis remains a leading cause of mortality and preventable transfer to the hospital for the elderly residents within the LTCFs. A significant practice gap persists because sepsis in this population often presents atypically, resulting in delayed or inaccurate diagnosis and treatment.

Methods: This project was guided by the following PICOT question: For healthcare professionals caring for patients aged 65 years and older …

Facilitating Timely Initiation Of Hiv Care Through An Interdisciplinary, Algorithm-Guided Approach, Courtney Harris

DNP Projects

ABSTRACT

BACKGROUND: Initiation of antiretroviral therapy (ART) within twenty-four hours of an HIV diagnosis is safe, shortens time to viral suppression, improves retention in care, and contributes to reduced HIV transmission at the community level (Bacon et al., 2021). Despite this evidence, patients across the United States do not universally receive timely HIV care (Bertolino et al., 2023). Barriers to early ART initiation include lack of staff buy-in, logistical challenges, and socioeconomic factors affecting patients (Doshi et al., 2023).

LOCAL PROBLEM: A small HIV care clinic in the southern United States observed a similar discrepancy, noting inconsistent timely initiation of …

Reducing Opioid Overdose Harm Through Narcan Access And Education, Shane Alexander Role Alihan, Jared Timothy Chua, Siwapond (Taylor) Yuen, Matthew Reynon

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Background: The overuse of opioids has led to an epidemic that affects the health of young adults in Sacramento, CA. Social and economic factors have influenced the use of opioids which has led those individuals to acquire an addiction and dependency to such drugs. This age group is typically engaged in college and career-minded endeavors. Thus, the impact on this age group is substantial, requiring impactful interventions.

Aim: The purpose of this intervention is to provide a foundation for educating those affected by opioid overdose. This strategic goal is to equip students at the University of the Pacific’s Entry-Level …

A Change In Practice: Improving Uti Management In A Long-Term Care Facility By Implementing Rapid Urinary Culture Collection Protocols To Enhance Timely Treatment And Reduce Hospitalizations, Tania Ojeda

Doctor of Nursing Practice

ABSTRACT

Background: Urinary tract infections (UTIs) remain a leading cause of morbidity among elderly residents in long-term care facilities, where diagnosis is frequently delayed due to atypical presentation, cognitive impairment, and inconsistent urine specimen handling. Purpose: This quality improvement (QI) project aimed to improve the timeliness and accuracy of UTI management in a memory care facility through standardized evidence-based protocols. Objectives: The project sought to ensure that: (a) 100% of staff would be educated on the protocol; (b) 100% of residents with suspected UTIs would have urine sent for urinalysis and culture within 8 hours of symptom onset; (c) 100% …

Implementing A Cardiac Catheterization Pre-Procedure Protocol To Decrease Avoidable Same-Day Cancellations, Christina C. Perry

Doctor of Nursing Practice

Background and significance of the problem: Pediatric congenital heart defect patients are amongst the sickest hospital population. These patients require planned palliation in the cardiac catheterization lab (cath lab), which has a limited number of providers and appointments available. In the cath lab, the percentage of avoidable same-day cancellations for interventional procedures was found to be greater than 30%, representing significant resource utilization opportunities.

Purpose: The purpose of this project was to develop and implement a standardized, evidence-based pre-procedure protocol to decrease avoidable same-day cath lab cancellations.

Goals and objectives: The goals of this project were a 10% decrease in …

Factors Associated With Preterm Premature Rupture Of Membranes: A Case-Control Study In A Tertiary Hospital In Kabul, Afghanistan, Atia Sharif Nadi, Freshta Sharif Tawakkuli, Zainab Sharif Ezadi, Sayed Murtaza Sadat Hofiani, Shoaib Murtaza Sadat Naeemi, Ahmad Komail Frogh

Journal of Asian Midwives (JAM)

Background: It is essential to identify preterm premature rupture of membranes (PPROM) and its associated risk factors to reduce its impact. This study aims to find the demographic, reproductive, and obstetric factors associated with PPROM among women in Kabul, Afghanistan.
Methods: This case-control study was conducted over six months in 2023 at a tertiary hospital in Kabul, Afghanistan. We included 40 cases of PPROM and 80 controls without PPROM in this study. We used structured questionnaires to collect demographic, reproductive, and obstetric characteristics of the participants. To find the factors associated with PPROM, Logistic regression was performed using IBM SPSS …

A Scoping Review Of Maternal Active Smoking During Pregnancy And Low-Birth Weight, Naomi Sondang, Nindi Oktavia, Qorinah Estiningtyas Sakilah Adnani, Lani Gumilang, Hadi Susiarno, Victor Abiola Adepoju

Journal of Asian Midwives (JAM)

Background: Low-birth weight (LBW; < 2.5 kg) infants are at increased risk of early mortality, impaired growth, neuro-developmental delay and chronic disease later in life. Maternal behavior, especially cigarette smoking, remains one of the most modifiable determinants of birth weight. We therefore synthesized recent evidence on the association between active maternal smoking during pregnancy and LBW.
Methods: Following PRISMA guidance, we systematically searched PubMed, Scopus and ScienceDirect for the period January 2020 to 31 January 2025 for English-language observational studies that quantified the relationship between active prenatal smoking and LBW. Risk of bias was appraised, and findings were summarized narratively.
Results: In total 26,650 papers were found and eight eligible studies (four cohort, three cross-sectional, one case-control) from Asia, Europe and the Middle East were included. Across all designs and exposure metrics—self-report, exhaled carbon-monoxide, urinary cotinine, and cord-blood DNA-methylation, active smoking was consistently associated with …