Faculty Bibliography

INTRODUCTION/BACKGROUND:Aldosterone dysregulation (excess aldosterone production at the source within the adrenal glands) in the absence of primary aldosteronism is a complex physiologic driver of uncontrolled hypertension and cardiovascular and kidney outcomes. Understanding the manifestations and burden of aldosterone dysregulation is critical to optimizing treatment and improving outcomes in patients with hypertension. This review examines the prevalence, patient attributes and burden of aldosterone dysregulation, and its impact on patient outcomes. METHODS:A targeted literature review of articles published between 2013 and 2024 was conducted. A patient/population, intervention, comparison, and outcomes framework was used, with a predefined search and selection protocol. Articles focused on primary aldosteronism were excluded unless they also referenced essential hypertension. A screening tool that used methods including artificial intelligence, trained using manual (human) screening, was employed to select relevant articles, which underwent human review to confirm inclusion/exclusion. RESULTS:Initial searches yielded 16,501 unique articles. Following abstract screening, 327 full-text articles were reviewed, yielding 123 relevant articles. Included studies utilized a range of aldosterone-related thresholds and measures to characterize patients with aldosterone dysregulation. Several patient attributes impact aldosterone levels, including age, race, ethnicity, sex, and body mass index. Lifestyle factors such as sodium intake also impact aldosterone, but the effect varies by race and body weight. Long-term excess aldosterone was associated with elevated blood pressure (BP), cardiovascular-kidney-metabolic diseases, and end-organ damage, leading to a greater risk of adverse clinical outcomes and mortality. Further evidence is needed to determine whether these occur independently of BP levels. CONCLUSION/CONCLUSIONS:Excess aldosterone is associated with poor cardiovascular-kidney-metabolic outcomes, including increased morbidity and mortality. Aldosterone dysregulation (excess aldosterone production at the source) is an underlying driver of cardiovascular-kidney-metabolic diseases, which may not be adequately addressed by current antihypertensive therapies.

BACKGROUND:Implementation strategies are dynamic and multi-faceted, and may require adaptations to fit implementation contexts, especially in lower-and-middle income countries. We report the adaptations for an ongoing late-stage implementation science trial (R01HL147811) that integrates hypertension management into HIV care in Lagos, Nigeria - a country with a high dual-disease burden - through the Task Strengthening Strategy for Hypertension (TASSH) intervention and Practice Facilitation implementation strategy. METHODS:FRAME (Framework for Reporting Adaptations and Modifications-Enhanced) modules were used to record adaptations to the intervention (i.e., TASSH) respectively, enhance participant recruitment and retention rates, and increase frequency of trainings. Data collection sources included (not limited to) patient records, nurses' logs, and minutes of implementation review meetings. Data across these sources was coded retrospectively by trained research staff and triangulated during virtual meeting discussions. Once consensus was reached, data was mapped onto the relevant framework modules using Microsoft Excel. RESULTS:We modified FRAME to include an additional component on 'what was originally planned' for the context of the adaptations. There were twelve adaptations identified during the implementation of the study. The adaptations characterized by using the frameworks included reordering recruitment start dates of study cohorts, providing patients incentives to attend follow-up visits, adding feeder sites to the study sites, and increasing the frequency of training to account for the high nurse turnover in the primary healthcare centers. Overall, 25% of the adaptations involved expanding the structure of the intervention and implementation strategies, and 33% involved adding new elements to the strategies. All adaptations occurred in the implementation phase of the trial. CONCLUSION/CONCLUSIONS:Based on our experiences, the characterization of the adaptations using FRAME demonstrates their combined applicability to an ongoing trial that can be tailored to fit the local context. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov ( NCT04704336). Registered on 11 January 2021.

BACKGROUND:Motivational text messages can encourage increased physical activity. This study aimed to validate motivational text messages among older adults and care partners and to assess differences in perceived motivational value between the two groups. METHODS:We designed nine motivational text messages to capture nine distinct physical activity scenarios. For this cross-sectional observational study, we enrolled 14 content experts, 310 older adults, and 305 care partners. Content experts assessed the relevance, while the older adults and care partners assessed the perceived motivational value of each text message on a 5-point Likert scale. We computed the item content validity index and assessed differences in perceived motivational value among older adults and care partners using quantile regression while adjusting for sociodemographic and health characteristics. RESULTS:The item content validity index ranged from 0.86 to 1.00. The median (interquartile range) perceived motivational value for each text message was 4.0 (3.0-5.0), and there were no statistically significant differences in reported motivational values between older adults and care partners. CONCLUSION/CONCLUSIONS:We present nine content-validated text messages with high motivational value for older adults and care partners that can be integrated into technology-based intervention studies and may improve physical activity behavior in both groups.

BACKGROUND:Improved access to antiretroviral therapy (ART) has increased survival among people living with HIV (PLWH) but also the burden of cardiovascular risk factors like hypertension. While the task-strengthening strategy for hypertension control (TASSH) is a viable integrated care model, evidence of its clinical impact in Africa is limited. This report presents baseline findings from a trial evaluating two implementation strategies for integrating TASSH into HIV care across primary health centers (PHCs) in Lagos, Nigeria. METHODS:A total of 3504 PLWH on ART in 30 PHCs were screened, and 830 were enrolled. Baseline data on patient sociodemographic, clinical, laboratory results, and lifestyle characteristics were gathered. RESULTS:Among the 3504 screened, 1046 (29.9%) had hypertension. Of the 830 enrolled, mean [SD] age was 49.4 [9.5] years, 63.5% were women, 69.5% had at least secondary school education, 92.3% were employed, and 84.6% earned less than 100,000 Naira (64.74 USD) monthly. The median BP was 150.0/95.3 mmHg, and 63.9% were overweight or obese. 25.8% continued previously prescribed antihypertensive medications, while 66.3% received new prescriptions. Additionally, 25.1% and 1.8% were alcohol users and current smokers, while 30.9% were physically inactive. CONCLUSIONS:The prevalence of hypertension among PLWH was higher than previously reported. Although most participants adopted healthy lifestyle behaviors, the majority were overweight or obese, and many were not on antihypertensive medications. These findings highlight the importance of integrating hypertension control into HIV care across PHCs in Nigeria.

IMPORTANCE/UNASSIGNED:At a time when diversity in higher education is increasingly perceived as beneficial only to minority students and disadvantaging to majority-group students, it is crucial to investigate its benefits broadly. OBJECTIVE/UNASSIGNED:To assess whether meaningful interactional diversity (ie, cross-cultural engagement that influences knowledge or opinions) is associated with key educational outcomes among White medical students. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study included self-identified White-only medical students who matriculated to a US allopathic medical school between 2013 and 2022, graduated between 2015 and 2024, and responded to the Association of American Medical Colleges Graduation Questionnaire (GQ). GQ responses were anonymous. Data were analyzed from September 2024 to April 2025. EXPOSURE/UNASSIGNED:Meaningful interactional diversity, defined by agreement on a 5-point Likert scale with the GQ item, "My knowledge or opinion was influenced or changed by becoming more aware of the perspectives of individuals from different backgrounds." MAIN OUTCOMES AND MEASURES/UNASSIGNED:Six self-reported binary outcomes derived from the GQ were assessed: personal and professional development fostered by medical schools, ability to care for and work with people from different backgrounds, and intention to work in an underserved area and with an underserved population regardless of practice location. RESULTS/UNASSIGNED:Among 80 542 students (38 589 [47.91%] female) from 155 medical schools, 495 (0.61%) strongly disagreed, 1416 (1.76%) disagreed, 7387 (9.17%) were neutral, 35 155 (43.65%) agreed, and 36 089 (44.81%) strongly agreed with meaningful interactional diversity. Across increasing agreement with meaningful interactional diversity, higher likelihoods of personal and professional development and care and teamwork competence were observed, whereas associations with service intentions were confined to strong agreement. Compared with strong disagreement, strong agreement was associated with greater personal (adjusted relative risk [aRR], 2.37; 95% CI, 2.05-2.74) and professional (aRR, 1.59; 95% CI, 1.42-1.69) development, competence to care for (aRR, 1.23; 95% CI, 1.17-1.29) and work with (aRR, 10.69; 95% CI, 7.84-14.57) people from different backgrounds, and plans to work in underserved areas (aRR, 1.31; 95% CI, 1.08-1.58) or with underserved populations regardless of practice location (aRR, 1.59; 95% CI, 1.30-1.93). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study of White medical students, meaningful interactional diversity was associated with graded improvements in core developmental outcomes and threshold-level associations with service intentions.

OBJECTIVE:In Nigeria, adolescents and young adults (AYA) who engage in multiple sexual partnerships, transactional sex, and needle-sharing are eligible for preexposure prophylaxis (PrEP) and are prioritized for HIV testing. AYA with PrEP-eligible behaviors should be using facility-based HIV testing services. We examined associations between these behaviors and facility-based HIV testing among AYA aged 14-24 years. DESIGN/METHODS:A longitudinal analysis of a stepped-wedge trial. METHODS:Using Innovative Tools to Expand Youth-friendly HIV Self-Testing (I-TEST) data, we fit generalized linear models using generalized estimating equations. We used a two-stage weighted approach to generalize I-TEST estimates to all AYA in Nigeria. RESULTS:Of 1429 trial participants, the median age was 20 years (IQR: 18-22), 50.3% were female, and 69.4% reported secondary education as highest level of education completed. Recent facility-based HIV testing uptake was higher among AYA with one [unadjusted risk difference: 11.7%, 95% confidence interval (95% CI): 8.1-15.2], two [11% (5.3, 16.8)], and three or more sexual partners in the past 3 months [17.3% (10.5, 24)], compared to AYA with no recent sexual partners. AYA who engaged in transactional sex had higher facility-based testing uptake [14.7% (9.8, 19.5)] than AYA who never engaged in transactional sex. AYA who shared needles had lower facility-based testing uptake [-3.3% (-6.7, 0.2)] than AYA with no needle-sharing history. The trial and generalized estimates were in the same direction. CONCLUSION/CONCLUSIONS:While facility-based testing may reach AYA who engaged in multiple sexual partnerships or transactional sex, AYA who shared needles may require more tailored HIV testing approaches.

OBJECTIVES/OBJECTIVE:To identify stakeholder perceived challenges and facilitators for implementing a clean fuel and clean stove intervention to reduce household air pollution and hypertension in Lagos, Nigeria. DESIGN/METHODS:Qualitative study guided by the Exploration and Preparation phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, using focus group discussions and in-depth semi-structured interviews with inductive and deductive thematic analysis. SETTING/METHODS:Peri-urban communities across the five administrative divisions of Lagos State, Nigeria. PARTICIPANTS/METHODS:128 stakeholders from 32 communities, including community, religious, market and youth leaders, primary healthcare staff, and household decision makers. Approximately half were female. INTERVENTIONS/METHODS:This was a pre-implementation needs assessment that included demonstrations of the clean stove and fuel. PRIMARY AND SECONDARY OUTCOME MEASURES/METHODS:Thematic domains describing barriers and enablers to adoption and implementation, mapped to EPIS inner, outer, and bridging factors. RESULTS:Stakeholders reported barriers that included stove stacking, upfront stove cost, concerns about long-term fuel price and availability, equipment durability and maintenance, safety, mistrust of new technology, and uncertainty about stove performance for dishes requiring high heat and long cooking times. Reported facilitators included payment flexibility and subsidies, opportunities to test the stove, perceived benefits of cleaner and faster cooking with less soot, endorsement by community leaders, and interest in local retail and distribution to improve access. CONCLUSIONS:Implementation planning for clean fuel and clean stove programmes should address affordability, reliable fuel supply chains, durability and service, culturally relevant cooking needs, and trust building through community leadership. These findings inform adaptation strategies for scale-up in similar low-resource settings. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

BACKGROUND:Obstructive sleep apnea (OSA) is associated with Alzheimer's disease (AD) risk. Racial-, ethnic-, and sex-specific mechanisms of OSA and AD risk were examined. METHODS:We analyzed data from 3978 polysomnography patients without cognitive decline aged ≥ 60 including 663 OSA+ patients (284 non-Hispanic White, 207 Black, 172 Hispanic) matched to OSA- cohorts (1:1, n = 663; 1:4, n = 2652) and followed for AD through 2013. RESULTS:During the 8.5 (standard deviation 1.4) year period, 358 patients developed AD. AD risk was higher for Black (adjusted hazard ratio [aHR] 2.24 [1.24-2.71]), Hispanic (aHR 1.73, [1.38-3.51]), White (aHR 1.83, [1.21-3.37]), male (aHR 2.38, [1.31-3.47]), and female (aHR 1.37, [1.14-2.41]) patients. Hypoxia, sleep fragmentation, and sleep duration (p < 0.01) were associated with increased risk. Black and Hispanic, and female patients showed stronger effects for hypoxia and duration, and fragmentation, respectively. DISCUSSION/CONCLUSIONS:Hypoxia, fragmentation, and duration may underlie racial-, ethnic-, and sex-specific effects of AD risk.