Faculty Bibliography

Adolescents and young adults (AYA) in Nigeria with increased HIV risk, such as those who engage in multiple sexual partnerships (i.e., more than one sexual partner within a specified period), transactional sex (i.e., exchange of money or gifts for sex), or needle-sharing (i.e., needles or other injection equipment are shared by multiple people), are eligible for pre-exposure prophylaxis (PrEP). One strategy that has the potential to reach PrEP-eligible AYA is HIV self-testing, which can expand existing HIV testing services and support differentiated PrEP programs. However, little is known about HIV self-testing in these AYA populations. We examined associations between these three high-risk behaviors and HIV self-testing. We analyzed data from Innovative Tools to Expand Youth-friendly HIV Self-Testing (I-TEST), a stepped-wedge trial examining the impact of a combination intervention package on HIV self-testing among AYA aged 14-24 years in Nigeria. We fit generalized linear models, with an identity link and a binomial error distribution, using generalized estimating equations. We generalized trial estimates to all AYA in Nigeria using a two-stage weighted approach. Of 1,429 participants, the median age was 20 years (IQR: 18-22), 50.3% were female, and 69.4% reported secondary school as their highest education level completed. AYA who engaged in transactional sex had higher HIV self-testing uptake (8.1% [4.8, 11.5]) than AYA with no history of transactional sex. There were no statistically significant differences in recent HIV self-testing uptake among AYA by sexual partnerships or needle-sharing history. The trial estimates were similar in the adjusted models. The estimates for the trial and generalized samples were in the same direction, except for AYA with two recent sexual partners. There was a high level of HIV self-testing uptake across all categories of sexual partnerships, transactional sex, and needle-sharing, with significantly higher uptake among those who engaged in transactional sex, indicating that HIV self-testing strategies are reaching these various AYA populations and the need to sustain access for these groups.

OBJECTIVE:To examine the early experiences influencing research career intentions (RCI) among MD students from racial and ethnic backgrounds underrepresented in medicine (URiM). METHODS:We conducted semi-structured, in-depth interviews with 31 first-year URiM medical students from MD-granting programs across the US to examine student-reported experiences influencing RCI. RESULTS:Participants were first-year medical students (N = 31; mean age 24.8 ± 2.6 years; 64.5% female) identifying as Black (38.7%), Hispanic (32.3%), or Multiracial (29%). Four themes were identified: (1) structured premedical research exposure was described as pivotal to developing early research engagement and interest in research careers; (2) research orientations reflected a commitment to using research as a vehicle for social justice and community impact; (3) high-quality research mentorship was characterized by authentic relational investment, skill development, and the distinct value of racial and ethnic identity-concordant role models; and (4) the research arms race for residency placement was described as amplifying systemic inequities that constrained students' research engagement. Across themes, students described tensions between academic research culture and their personal values, including a desire to advance equity and contribute meaningfully to science. For some, this misalignment made research feel less purposeful or personally aligned. CONCLUSIONS:Medical training programs seeking to support URiM students' RCI should invest in structured premedical research programs and expand access to research mentorship that is both relationally invested and identity concordant. Efforts to cultivate sustained engagement should address publication pressures tied to residency competitiveness, which amplify structural barriers and misalign with students' motivations for pursuing research. Broadening definitions of scholarly contribution and fostering research environments that affirm students' values may be critical to building a robust physician-scientist workforce.

BACKGROUND:Timely transport of critically injured patients by Emergency Medical Services to verified trauma centers significantly reduces morbidity and mortality. Prior studies demonstrate that undertriage in the prehospital setting impacts outcomes, with rural communities facing additional geographic and systemic barriers to timely trauma care. The area deprivation index, a validated measure of neighborhood-level socioeconomic disadvantage, is associated with poorer health outcomes and may further influence access to trauma centers. Yet, the association between socioeconomic deprivation, rurality, and trauma center transport remains poorly defined. This study aimed to evaluate the extent of urban-rural inequities in Emergency Medical Services transport of critically injured patients to verified trauma centers across all regions of the United States and to assess the association between area deprivation index and likelihood of transport to a trauma center. METHODS:We identified all Emergency Medical Services transported critically injured patients meeting Centers for Disease Control and Prevention field triage criteria for trauma center transport in the National Emergency Medical Services Information System from 2018 to 2022 and mapped Zone Improvement Plan (ZIP) Codes containing verified trauma centers (Levels I-V) using data from the American College of Surgeons, the Trauma Center Association of America, and the American Trauma Society. The cohort was stratified by regions in the United States: Northeast, Midwest, South, and West. The incident scene area deprivation index was obtained from the Neighborhood Atlas at the census block group level. The total number and percentage of patients located in urban and rural Zone Improvement Plan (ZIP) codes transported either to a confirmed trauma center (via the National Emergency Medical Services Information System data) or to a Zone Improvement Plan (ZIP) code that contains a trauma center and the area deprivation index distribution in tertiles (low area deprivation index, moderate area deprivation index, and high area deprivation index) within regions in the United States were calculated with their statistical significance derived from t tests and analyses of variance with post hoc Tukey tests. RESULTS:A total of 36,897,269 critically injured patients met the inclusion criteria, of which 19,874,008 (53.86%) were brought to a trauma center. When stratified by rurality, 7,608,704 (54.01%) and 12,265,304 (53.77%) of critically injured patients within rural and urban areas, respectively, were transported to a trauma center. When comparing across regions, the Northeast region of the United States had the lowest percentage of critically injured patients being transported to a trauma center, whereas the Midwest region had the highest percentage (44.04% vs 67.40%; P < .001). When stratified by rurality, 35.33% vs 46.92% of critically injured patients within rural versus urban areas of the Northeast were transported to a trauma center, whereas 65.47% vs 68.57% of critically injured patients within rural versus urban areas of the Midwest were transported to a trauma center (P < .001). When evaluating area deprivation index, critically injured patients who were injured in more disadvantaged versus advantaged Zone Improvement Plan (ZIP) codes had a higher percentage of patients being transported to a trauma center even when controlling for rurality (56% vs 47%; P < .001). CONCLUSION/CONCLUSIONS:Substantial geographic inequities in the Emergency Medical Services transport of critically injured adult patients to verified trauma centers, varied by geographic region, rurality, and neighborhood-level socioeconomic disadvantage that exist. These findings highlight the complex and regionally variable landscape of trauma access in the United States and underscore the need for targeted, equity-focused strategies to optimize prehospital triage and ensure timely, trauma-informed care across diverse communities.

OBJECTIVE:Masked hypertension [nonhigh office blood pressure (BP) and high out-of-office BP] is associated with cardiovascular risk. Obstructive sleep apnea (OSA) is associated with high office BP, but few data exist on its association with masked hypertension, especially in Black adults who have a high prevalence of both conditions. METHODS:We analyzed pooled data from 1078 Black adults, 713 in the Jackson Heart Study and 365 in the Coronary Artery Risk Development in Young Adults study, with office BP less than 140/90 mmHg, who completed 24-h ambulatory BP monitoring. Masked hypertension was defined as mean awake BP at least 135/85 mmHg, asleep BP at least 120/70 mmHg, or 24-h BP at least 130/80 mmHg. A high likelihood of OSA was defined using sleep questionnaires and physical measurements. Poisson regression was used to estimate prevalence ratios, adjusting for demographics, lifestyle behaviors, and comorbidities. Analyses were stratified by antihypertensive medication use. RESULTS:Overall, 34% of participants had a high likelihood of OSA; 53.3% had masked hypertension. Among participants not taking antihypertensive medication (n = 505), adjusted prevalence ratios comparing those with versus without a high likelihood of OSA were 1.31 [95% confidence interval (CI) 1.06-1.61], 0.88 (95% CI 0.59-1.29), 1.37 (95% CI 1.09-1.73), and 1.35 (95% CI 1.00-1.83) for any, awake, asleep, and 24-h masked hypertension. Among those taking antihypertensive medication (n = 573), the adjusted prevalence ratios were 1.15 (95% CI 0.99-1.32), 1.04 (95% CI 0.83-1.31), 1.14 (95% CI 0.97-1.33), and 1.19 (95% CI 0.96-1.47), respectively. CONCLUSION/CONCLUSIONS:A high likelihood of OSA was associated with a higher prevalence of masked hypertension among participants not taking antihypertensive medication.

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.