Faculty Bibliography

INTRODUCTION:As the utility of genomic sequencing increases, its use in healthcare will continue to expand beyond expert clinics toward nonspecialist practices such as primary care. At the same time, discordance in genetic variant identification and classification between laboratories remains a concern for the field. This research assesses how clinicians with and without genetics expertise understand and trust genetic test results, underscoring how variation in the handling of genetic test results can have real impact on patient care. METHODS:We conducted 40 interviews with genetics experts, including clinical geneticists and genetic counselors, and nonexpert clinicians including primary care providers and cardiologists. RESULTS:Clinical geneticists and genetic counselors reported spending significant time assessing the validity of results from genetic testing laboratories, conversing with laboratories about those results, and potentially reinterpreting results. Conversely, primary care providers and cardiologists without specific genetics expertise reported high levels of trust in laboratory accuracy and variant interpretation, and did not reassess results. CONCLUSION:We find significant variation in how genetics experts and nonexperts understand the trustworthiness of genetic laboratory reports. This variation could lead to differences in patient care between clinical settings and requires additional guidance for clinicians regarding the handling of genetic test results.

PURPOSE:To compare the effects of enhanced and limited patient-clinician relationships during patient history taking on objective functional measures and pain appraisals for individuals with chronic low back pain (CLBP). METHODS:Fifty-two (52) participants with CLBP, unaware of the two groups, were randomized using concealed allocation to an enhanced (n=26) or limited (n=26) patient-clinician relationship condition. Participants shared their history of CLBP with a clinician who enacted either enhanced or limited communication strategies. Fingertip-to-floor, one-minute lift, and Biering-Sorensen tests, and visual analogue scale for pain at rest were assessed before and after the patient-clinician relationship conditions. FINDINGS:The enhanced condition resulted in significantly greater improvements in the one-minute lift test (F(1,49)=7.47, p<.01, ηp2=0.13) and pain at rest (F(1,46)=4.63, p=.04, ηp2=0.09), but not the fingertip-to-floor or Biering-Sorensen tests, compared with the limited group. CONCLUSIONS:Even without physical treatment, differences in patient-clinician relationships acutely affected lifting performance and pain among individuals with CLBP.

There is consensus about the importance of developing a strong cadre of effective multilevel interventions to eliminate the impacts of unjust social processes, such as structural racism and other harmful social determinants of health (SDOH), on health inequities in the USA. However, the available cadre of rigorously evaluated evidence-based interventions for SDOH mitigation remains underdeveloped relative to the magnitude of historic and current health inequities. The proposed manuscript addresses this gap in two ways: first, by introducing a heuristic framework to inform decisions in multilevel intervention development, study design, and selection of analytic methods and, second, by providing a roadmap for future applications of the framework in multilevel intervention research through an exemplar application using the ongoing NIH-funded evaluation study of the Nurse-Community-Family Partnership (NCFP) intervention. NCFP leverages individual, family, institutional, and system factors to shape COVID-19 mitigation outcomes at the individual and household levels. NCFP takes an approach informed by the heuristic framework to addressing and mitigating unjust social processes and other harmful SDOH. We discuss the application of a two-arm parallel explanatory group randomized trial to evaluate the efficacy of NCFP in improving the primary (COVID-19 testing uptake) and secondary (adoption of COVID-19 control measures, COVID-19 vaccine uptake, mutual aid capacity, etc.) outcomes at the individual and household levels. The analysis approach relies on random-intercept models, and we calculate the variance partitioning coefficient to estimate the extent to which household- and individual-level variables contribute to the outcome, allowing examination of NCFP effects at multiple levels.

Central body fat distribution affects kidney function. Abdominal fat measurements using computed tomography (CT) may prove superior in assessing body composition-related kidney risk in living kidney donors. This retrospective cohort study including 550 kidney donors aimed to determine the association between CT-measured abdominal fat areas and kidney function before and after donor nephrectomy. Donors underwent glomerular filtration rate measurements (¹²⁵I-Iothalamate, mGFR) before and 3 months after donation. Linear regression analyses with body surface area (BSA)-standardized and crude mGFR were performed to assess the association of height-indexed tomographic fat measurements with kidney function. In age-, and sex-adjusted analyses higher levels of total abdominal, visceral, subcutaneous, and intramuscular adipose tissue index were significantly associated with lower mGFR levels before donation (BSA-standardized mGFR: visceral adipose tissue index: Βeta=-0.11, p < 0.001, subcutaneous: Βeta=-0.10, p < 0.001, intramuscular: Βeta=-1.18, p < 0.001, total abdominal: Βeta=-0.07, p < 0.001). Higher tomographic abdominal fat is associated with lower BSA-standardized mGFR after donation and a greater decrease in mGFR between screening and 3 months post-donation. This study shows that CT-measured abdominal fat area is associated with kidney function before and after living kidney donation.

AIM/OBJECTIVE:Chemoradiation therapy (CRT) is considered as the first line of treatment for patients with squamous cell carcinoma of the anal canal. Following initial CRT, patients who present with either persistent or locally recurrent disease are treated by surgical intervention. The aim of our study is to determine the prognostic factors associated with failure of CRT and overall mortality in patients with anal squamous cell carcinoma (SCC). METHODS:We performed a 14-year analysis (2004-2017) of the National Cancer Database and included patients diagnosed with non-metastatic SCC of the anal canal who underwent CRT. Baseline patient characteristics including demographics, comorbidities and tumour characteristics were analysed. Outcome measures were needed for operative intervention after 4 months of initiation of CRT (failure of CRT) and 5-year overall mortality. Multivariate logistic regression analysis identified prognostic factors independently associated with failure of CRT. RESULTS:We included a total of 37 615 patients with anal SCC who received CRT. Predictors of operative intervention included male sex, higher Deyo-Charlson Comorbidity Index (DCCI) and higher primary tumour stage. The 5-year overall survival rate was 77.6%, and 2.4% of patients failed CRT, defined as requiring and undergoing surgical intervention within 4 months post-initiation of CRT. Median follow-up time was 47 (95% CI 24-84) months. Independent predictors of overall mortality within the first 5 years of diagnosis were increased age, male sex, Black race, non-insured status, higher DCCI, higher primary tumour grade, and higher primary tumour and lymph node stage. The 5-year survival rate was significantly lower in patients who underwent operative intervention compared to those who received CRT alone (57.4% vs. 78.1%; P < 0.01). CONCLUSION/CONCLUSIONS:Our study showed that male sex, younger age, DCCI of 1 and 3, and increased tumour size were predictive of CRT failure among patients with anal SCC. Increased age, male sex, Black race, non-insured status, increased DCCI, and more aggressive tumour characteristics were associated with increased 5-year overall mortality. More importantly, patients who failed CRT had worse 5-year overall survival. Our findings support increased emphasis on intensive surveillance for these high-risk patient cohorts.

BACKGROUND:Jehovah's Witness patients refuse blood transfusion because of their religious beliefs making total hip arthroplasty (THA) challenging. This study aims to determine the safety of THA in Jehovah's Witness patients using standard perioperative protocols as well as evaluate the effectiveness of tranexamic acid (TXA) in controlling blood loss. METHODS:Databases from two tertiary academic centers were queried from 2003 to 2021 to identify THA patients. Demographics, pre- and postoperative hemoglobin (hgb) and hematocrit (hct) lab values, use of TXA intraoperatively, 90-day postoperative hospital utilization, and need for subsequent revision were extracted. Patients who identified as Jehovah's Witness were then compared to a 3:1 propensity score matched cohort of non-Jehovah's Witness patients. Linear regression analysis assessed the effect of intraoperative TXA on change in hgb from pre- to post-THA and logistic regression was used to assess risk of reaching hgb levels < 8.0 g/dL. RESULTS:A total of 207 non-Jehovah's Witness patients and 69 Jehovah's Witness patients who underwent THA were analyzed. Both groups were found to have similar preoperative hgb and hct as well as postoperative hgb, hct, and hgb shift. Of the Jehovah's Witness patients 3 (6.4%) patients reached a hgb < 8.0 g/dL. Additionally, a higher proportion of Jehovah's Witness patients receive intraoperative TXA (55 [79.7%]) compared to non-Jehovah's Witness patients (127 [61.4%]) (p = 0.01; SMD = 0.41). Logistic regression analysis found that Jehovah's Witness did not have greater odds of reaching a hgb < 8.0 g/dL (OR = 1.03 [0.95, 1.10]; p = 0.49) and that patient who received intraoperative TXA had decreased odds of reaching a hgb < 8.0 (OR = 0.87 [0.80, 0.95]; p = 0.001). Multivariate linear regression found that intraoperative TXA was also associated with a smaller decrease in hgb from pre- to post-THA (β = 0.69 [0.16, 1.22]; p = 0.01). Overall, Jehovah's Witness patients had excellent revision-free (97% [93%, 100%]) and infection-free (99% [96%, 100%]) survival at 7 years. CONCLUSION/CONCLUSIONS:Although Jehovah's Witness patients refuse transfusion, THA can be performed safely in these patients with excellent implant survivorship by optimizing preoperative hgb levels and utilizing intraoperative TXA. LEVEL OF EVIDENCE/METHODS:Level III Evidence.