Faculty Bibliography

BACKGROUND:Approximately 30% of kidney transplant recipients undergo early steroid withdrawal (ESW) for maintenance immunosuppression. However, there is no consensus on which patients are suitable for ESW, and transplant centers may disagree on how various clinical factors characterize individual recipients' suitability for ESW. METHODS:To examine center-level variation in the association of clinical factors with the choice of ESW, we studied 206 544 kidney transplant recipients from 278 centers in 2002-2017 using SRTR data. We conducted multi-level logistic regressions to characterize the association of clinical factors with the choice of ESW at each transplant center. RESULTS:). When estimated at each center, this odds ratio was significantly lower than the population odds ratio at 48 (17.3%) centers and significantly higher at 28 (10.1%) centers. CONCLUSIONS:We have observed apparent inconsistencies across transplant centers in the practice of tailoring ESW to the recipient's risk profile. Standardized guidelines for ESW tailoring are needed.

Kidney transplant (KT) outcomes for HIV-infected (HIV+) persons are excellent, yet acute rejection (AR) is common and optimal immunosuppressive regimens remain unclear. Early steroid withdrawal (ESW) is associated with AR in other populations, but its utilization and impact are unknown in HIV+ KT. Using SRTR, we identified 1225 HIV+ KT recipients between January 1, 2000, and December 31, 2017, without AR, graft failure, or mortality during KT admission, and compared those with ESW with those with steroid continuation (SC). We quantified associations between ESW and AR using multivariable logistic regression and interval-censored survival analysis, as well as with graft failure and mortality using Cox regression, adjusting for donor, recipient, and immunologic factors. ESW utilization was 20.4%, with more zero HLA mismatch (8% vs 4%), living donors (26% vs 20%), and lymphodepleting induction (64% vs 46%) compared to the SC group. ESW utilization varied widely across 129 centers, with less use at high- versus moderate-volume centers (6% vs 21%, P < .001). AR was more common with ESW by 1 year (18.4% vs 12.3%; aOR: _1.08 1.61_2.41 , P = .04) and over the study period (aHR: _1.02 1.39_1.90 , P = .03), without difference in death-censored graft failure (aHR _0.60 0.91_1.36 , P = .33) or mortality (aHR: _0.75 1.15_1.77 , P = .45). To reduce AR after HIV+ KT, tailoring of ESW utilization is reasonable.

SCOPE:Serum metabolomic markers of the Dietary Approaches to Stop Hypertension (DASH) diet are previously reported. In an independent study, the similarity of urine metabolomic markers are investigated. METHODS AND RESULTS:In the DASH-Sodium trial, participants are randomly assigned to the DASH diet or control diet, and received three sodium interventions (high, intermediate, low) within each randomized diet group in random order for 30 days each. Urine samples are collected at the end of each intervention period and analyzed for 938 metabolites. Two comparisons are conducted: 1) DASH-high sodium (n = 199) versus control-high sodium (n = 193), and 2) DASH-low sodium (n = 196) versus control-high sodium. Significant metabolites identified using multivariable linear regression are compared and the top 10 influential metabolites identified using partial least-squares discriminant analysis to the results from the DASH trial. Nine out of 10 predictive metabolites of the DASH-high sodium and DASH-low sodium diets are identical. Most candidate biomarkers from the DASH trial replicated. N-methylproline, chiro-inositol, stachydrine, and theobromine replicated as influential metabolites of DASH diets. CONCLUSIONS:Candidate biomarkers of the DASH diet identified in serum replicated in urine. Replicated influential metabolites are likely to be objective biomarkers of the DASH diet.

OBJECTIVE:Altered hormonal regulation, including cortisol, is a proposed mechanism linking adiposity to obesity-related disorders. We examined the association of anthropometric, adipokine, and body fat distribution measures of adiposity with morning serum cortisol in an African American (AA) cohort. METHODS:We investigated the cross-sectional associations of adiposity measures (BMI, waist circumference, leptin, adiponectin, leptin:adiponectin ratio, subcutaneous and visceral adipose tissue) and liver attenuation with cortisol in the Jackson Heart Study. Linear regression models were used to analyze the association between exposures and cortisol. Models were adjusted for multiple covariates. RESULTS:Among 4,211 participants, a 1-SD higher BMI and waist circumference were associated with a 3.92% and 3.05% lower cortisol, respectively. A 1-SD higher leptin and leptin:adiponectin ratio were associated with a 6.48% and 4.97% lower morning serum cortisol, respectively. A 1-SD higher subcutaneous adipose tissue was associated with a 4.97% lower cortisol (all P < 0.001). There were no associations of liver attenuation or visceral adipose tissue with cortisol. CONCLUSIONS:Several measures of adiposity are associated with lower morning serum cortisol among AAs, with leptin having the greatest magnitude. Future studies examining the role of morning serum cortisol in the pathway from adiposity to cardiometabolic disease in AAs are warranted.

OBJECTIVE:The purpose of this study was to investigate the associations of urinary phthalates and bisphenols at age 6 years old with body fat and cardiovascular risk factors at 6 and 10 years and with the change from 6 to 10 years. METHODS:Among 471 Dutch children, the phthalates and bisphenols urinary concentrations at 6 years and BMI, fat mass index, android fat mass, blood pressure, glucose, insulin, and lipids blood concentrations at 6 and 10 years were measured. RESULTS:An interquartile range increase in di-n-octyl phthalate (DNOP) metabolites concentrations at 6 years was associated with an increased risk of overweight at 6 and 10 years (odds ratio: 1.44; 95% CI: 1.11-1.87, and 1.43; 95% CI: 1.09-1.86, respectively). Also, higher DNOP metabolites concentrations were associated with higher fat mass index at 6 years, higher systolic blood pressure at 10 years, a decrease in high-density lipoprotein cholesterol, and an increase in triglycerides concentrations from 6 to 10 years (P < 0.05). Higher total bisphenols and bisphenol A concentrations were associated with a decrease in BMI from 6 to 10 years (P < 0.01). CONCLUSIONS:DNOP metabolites are associated with overweight and an adverse cardiovascular profile in childhood. Total bisphenols and bisphenol A are associated with a decrease in BMI from 6 to 10 years.

PURPOSE/OBJECTIVE:Alterations in the urinary microbiome have been associated with urological diseases. The microbiome of patients with urethral stricture disease (USD) remains unknown. Our objective is to examine the microbiome of USD with a focus on inflammatory USD caused by lichen sclerosus (LS). METHODS:We collected mid-stream urine samples from men with LS-USD (cases; n = 22) and non-LS USD (controls; n = 76). DNA extraction, PCR amplification of the V4 hypervariable region of the 16S rRNA gene, and sequencing was done on the samples. Operational taxonomic units (OTUs) were defined using a > 97% sequence similarity threshold. Alpha diversity measurements of diversity, including microbiome richness (number of different OTUs) and evenness (distribution of OTUs) were calculated and compared. Microbiome beta diversity (difference between microbial communities) relationships with cases and controls were also assessed. RESULTS:Fifty specimens (13 cases and 37 controls) produced a 16S rRNA amplicon. Mean sample richness was 25.9 vs. 16.8 (p = 0.076) for LS-USD vs. non-LS USD, respectively. LS-USD had a unique profile of bacteria by taxonomic order including Bacillales, Bacteroidales and Pasteurellales enriched urine. The beta variation of observed bacterial communities was best explained by the richness. CONCLUSIONS:Men with LS-USD may have a unique microbiologic richness, specifically inclusive of Bacillales, Bacteroidales and Pasteurellales enriched urine compared to those with non-LS USD. Further work will be required to elucidate the clinical relevance of these variations in the urinary microbiome.

Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran's Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility "hub" could expand mental health resources to remote "spoke" clinics and veterans' residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

BACKGROUND:Vitamin D supplementation may prevent falls in older persons, but evidence is inconsistent, possibly because of dosage differences. OBJECTIVE:supplements on falls. DESIGN:2-stage Bayesian, response-adaptive, randomized trial. (ClinicalTrials.gov: NCT02166333). SETTING:2 community-based research units. PARTICIPANTS:688 participants, aged 70 years and older, with elevated fall risk and a serum 25-hydroxyvitamin D [25-(OH)D] level of 25 to 72.5 nmol/L. INTERVENTION:doses, and the best noncontrol dose for preventing falls was determined. After dose finding, participants previously assigned to receive noncontrol doses received the best dose, and new enrollees were randomly assigned to receive 200 IU/d or the best dose. MEASUREMENTS:Time to first fall or death over 2 years (primary outcome). RESULTS: = 0.54). Analysis of falls with adverse outcomes suggested greater risk in the experience-with-best-dose group versus the 200-IU/d group (serious fall: HR, 1.87 [CI, 1.03 to 3.41]; fall with hospitalization: HR, 2.48 [CI, 1.13 to 5.46]). LIMITATIONS:per day, not a placebo. Dose finding ended before the prespecified thresholds for dose suspension and dose selection were reached. CONCLUSION:doses of 1000 IU/d or higher. PRIMARY FUNDING SOURCE:National Institute on Aging.

Diabetes and hypertension are socially patterned by individual race/ethnicity and by neighborhood economic context, but distributions among Asian subgroups are undercharacterized. We examined variation in prevalence for both conditions, comparing between US Asian subgroups, including within South Asian nationalities, and comparing within subgroups by neighborhood economic context. We obtained data on a non-probability sample of 633,664 patients ages 18-64 in New York City, NY, USA (2014-2017); 30,138 belonged to one of seven Asian subgroups (Asian Indian, Bangladeshi, Pakistani, Chinese, Korean, Japanese, and Filipino). We used electronic health records to classify disease status. We characterized census tract economic context using the Index of Concentration at the Extremes and estimated prevalence differences using multilevel models. Among Asian men, hypertension prevalence was highest for Filipinos. Among Asian women, hypertension prevalence was highest for Filipinas and Bangladeshis. Diabetes prevalence was highest among Pakistanis and Bangladeshis of both genders, exceeding all other Asian and non-Asian groups. There was consistent evidence of an economic gradient for both conditions, whereby persons residing in the most privileged neighborhood tertile had the lowest disease prevalence. The economic gradient was particularly strong for diabetes among Pakistanis, whose prevalence in the most deprived tertile exceeded that of the most privileged by 9 percentage points (95% CI 3, 14). Only Koreans departed from the trend, experiencing the highest diabetes prevalence in the most privileged tertile. US Asian subgroups largely demonstrate similar neighborhood economic gradients as other groups. Disaggregating Asian subgroups, including within South Asian nationalities, reveals important heterogeneity in prevalence.