Faculty Bibliography

UNLABELLED:Kidney transplantation (KT) is controversial in patients with pretransplant pulmonary hypertension (PtPH). We aimed to quantify post-KT graft and patient survival as well as survival benefit in recipients with PtPH. METHODS/UNASSIGNED:Using UR Renal Data System (2000-2018), we studied 90 819 adult KT recipients. Delayed graft function, death-censored graft failure, and mortality were compared between recipients with and without PtPH using inverse probability weighted logistic and Cox regression. Survival benefit of KT was determined using stochastic matching and stabilized inverse probability treatment Cox regression. RESULTS/UNASSIGNED: < 0.01) compared with those who remained on the waitlist. CONCLUSIONS/UNASSIGNED:Although PtPH is associated with inferior post-KT outcomes, KT is associated with better survival compared with remaining on the waitlist. Therefore, KT is a viable treatment modality for appropriately selected patients with PtPH.

PURPOSE/OBJECTIVE:Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS:We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS:The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS:Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Purpose of Review/UNASSIGNED:In 2019, over 50 million Americans were expected to use wearables at least monthly. The technologies have varied capabilities, with many designed to monitor health conditions. We present a narrative review to raise awareness of wearable technologies that may be relevant to the field of neurology. We also discuss the implications of these wearables for our patients and briefly discuss issues related to researching new wearable technologies. Recent Findings/UNASSIGNED:There are a variety of wearables for neurologic conditions, e.g., stroke (for potential arrhythmia capture), epilepsy, Parkinson disease, and sleep. Research is being performed to capture the risk of neuropsychiatric relapse. However, data are limited and adherence to these wearables is often poorly studied. Summary/UNASSIGNED:The care of neurology patients may ultimately be improved with the use of wearable technologies. More research needs to examine efficacy and implementation strategies.

The Adverse Childhood Experiences (ACEs) framework has contributed to advances in developmental science by examining the interdependent and cumulative nature of adverse childhood environmental exposures on life trajectories. Missing from the ACEs framework, however, is the role of pervasive and systematic oppression that afflicts certain racialized groups and that leads to persistent threat and deprivation. In the case of children from immigrant parents, the consequence of a limited ACEs framework is that clinicians and researchers fail to address the psychological violence inflicted on children from increasingly restrictive immigration policies, ramped up immigration enforcement, and national anti-immigration rhetoric. Drawing on the literature with Latinx children, the objective of this conceptual article is to integrate the ecological model with the dimensional model of childhood adversity and psychopathology to highlight how direct experience of detention and deportation, threat of detention and deportation, and exposure to systemic marginalization and deprivation are adverse experiences for many Latinx children in immigrant families. This article highlights that to reduce bias and improve developmental science and practice with immigrants and with U.S.-born children of immigrants, there must be an inclusion of immigration-related threat and deprivation into the ACEs framework. We conclude with a practical and ethical discussion of screening and assessing ACEs in clinical and research settings, using an expanded ecological framework that includes immigration-related threat and deprivation.

INTRODUCTION/BACKGROUND:Kratom is a plant with partial opioid agonist effects, and its use has become popular to ameliorate symptoms of opioid withdrawal. However, use has been linked to thousands of poisonings, although most have involved use of other drugs. Little is known regarding prevalence and correlates of use in the general U.S. POPULATION/METHODS/: METHODS:Data were examined from the 2019 National Survey on Drug Use and Health, a nationally representative probability sample of non-institutionalized individuals aged ≥12 years in the U.S. (N=56,136). Prevalence and correlates of past-year kratom use were estimated. Data were analyzed in 2020. RESULTS:An estimated 0.7% (95% CI=0.6, 0.8) of individuals in the U.S. have used kratom in the past year. Past-year proxy diagnosis of prescription opioid use disorder was associated with increased odds for kratom use (AOR=3.20, 95% CI=1.38, 7.41), with 10.4% (95% CI=6.7, 15.9) of those with use disorder reporting use. Opioid misuse not accompanied with use disorder was not associated with kratom use. Those reporting past-year cannabis use both with (AOR=4.33, 95% CI=2.61, 7.19) and without (AOR=4.57, 95% CI=3.29, 6.35) use disorder and those reporting past-year cocaine use (AOR=1.69, 95% CI=1.06, 2.69) and prescription stimulant misuse (AOR=2.10, 95% CI=1.44, 3.05) not accompanied with use disorder were at higher odds for kratom use. CONCLUSIONS:Kratom use is particularly prevalent among those with prescription opioid use disorder, but it is also prevalent among people who use other drugs. Research is needed to determine reasons for use and potential dangers associated with adding kratom to drug repertoires.

BACKGROUND:Gender disparities exist in the careers of women in medicine. This review explores the qualitative literature to understand how gender influences professional trajectories, and identify opportunities for intervention. METHODS:A systematic review and thematic synthesis included articles obtained from PubMed, Cochrane Central Register of Controlled Trials (Ovid), EMBASE (Ovid), APA PsycInfo (Ovid), and GenderWatch (ProQuest) on June 26 2020, updated on September 10, 2020. Included studies explored specialty choice, leadership roles, practice setting, burnout, promotion, stigma, mentoring, and organizational culture. Studies taking place outside of the USA, using only quantitative data, conducted prior to 2000, or focused on other health professions were excluded. Data were extracted using a standardized extraction tool and assessed for rigor and quality using a 9-item appraisal tool. A three-step process for thematic synthesis was used to generate analytic themes and construct a conceptual model. The study is registered with PROSPERO (CRD42020199999). FINDINGS/RESULTS:Among 1524 studies identified, 64 were eligible for analysis. Five themes contributed to a conceptual model for the influence of gender on women's careers in medicine that resembles a developmental socio-ecological model. Gender influences career development externally through culture which valorizes masculine stereotypes and internally shapes women's integration of personal and professional values. CONCLUSION/CONCLUSIONS:Medical culture and structures are implicitly biased against women. Equitable environments in education, mentoring, hiring, promotion, compensation, and support for work-life integration are needed to address gender disparities in medicine. Explicit efforts to create inclusive institutional cultures and policies are essential to support a diverse workforce.

The health impacts of climate change are substantial and represent a primary motivating factor to mitigate climate change. However, the health impacts in economic models that estimate the social cost of carbon dioxide (SC-CO₂) have generally been made in isolation from health experts and have never been rigorously evaluated. Version 3.10 of the Framework for Uncertainty, Negotiation and Distribution (FUND) model was used to estimate the health-based portion of current SC-CO₂ estimates across low-, middle-, and high-income regions. In addition to the base model, three additional experiments assessed the sensitivity of these estimates to changes in the socio-economic assumptions in the model. Economic impacts from adverse health outcomes represent ∼8.7% of current SC-CO₂ estimates. The majority of these health impacts (74%) were attributable to diarrhea mortality (from both low- and high-income regions) followed by diarrhea morbidity (12%) and malaria mortality (11%); no other health impact makes a meaningful contribution to SC-CO₂ estimates in current economic models. The results of the socio-economic experiments show that the health-based portion of SC-CO₂ estimates are highly sensitive to assumptions regarding income elasticity of health effects, income growth, and use of equity weights. Improving the health-based portion of SC-CO₂ estimates could have substantial impacts on magnitude of the SC-CO₂. Incorporating additional health impacts not previously included in estimates of SC-CO₂ will be a critical component of model updates. This effort will be most successful through coordination between economists and health researchers and should focus on updating the form and function of concentration-response functions.

BACKGROUND:Genetic counseling and germline testing have an increasingly important role for patients with prostate cancer (PCa); however, recent data suggests they are underutilized. Our objective was to perform a qualitative study of the barriers and facilitators of germline genetic evaluation among physicians who manage PCa. METHODS:We conducted semi-structured interviews with medical oncologists, radiation oncologists, and urologists from different U.S. practice settings until thematic saturation was achieved at n = 14. The interview guide was based on the Tailored Implementation in Chronic Diseases Framework to identify key determinants of practice. Interview transcripts were independently coded by ≥2 investigators using a constant comparative method. RESULTS:The decision to perform or refer for germline genetic evaluation is affected by factors at multiple levels. Although patient factors sometimes play a role, the dominant themes in the decision to conduct germline genetic evaluation were at the physician and organizational level. Physician knowledge, coordination of care, perceptions of the guidelines, and concerns about cost were most frequently discussed as the main factors affecting utilization of germline genetic evaluation. CONCLUSIONS:There are currently numerous barriers to implementation of germline genetic evaluation for PCa. Efforts to expand physician education, to develop tools to enhance genetics in practice, and to facilitate coordination of care surrounding genetic evaluation are important to promote guideline-concordant care.

The genome-wide association study (GWAS) is a powerful means to study genetic determinants of disease traits and generate insights into disease pathophysiology. To date, few GWAS of circulating metabolite levels have been performed in African Americans with chronic kidney disease. Hypothesizing that novel genetic-metabolite associations may be identified in a unique population of African Americans with a lower glomerular filtration rate (GFR), we conducted a GWAS of 652 serum metabolites in 619 participants (mean measured glomerular filtration rate 45 mL/min/1.73m²) in the African American Study of Kidney Disease and Hypertension, a clinical trial of blood pressure lowering and antihypertensive medication in African Americans with chronic kidney disease. We identified 42 significant variant metabolite associations. Twenty associations had been previously identified in published GWAS, and eleven novel associations were replicated in a separate cohort of 818 African Americans with genetic and metabolomic data from the Atherosclerosis Risk in Communities Study. The replicated novel variant-metabolite associations comprised eight metabolites and eleven distinct genomic loci. Nine of the replicated associations represented clear enzyme-metabolite interactions, with high expression in the kidneys as well as the liver. Three loci (ACY1, ACY3, and NAT8) were associated with a common pool of metabolites, acetylated amino acids, but with different individual affinities. Thus, extensive metabolite profiling in an African American population with chronic kidney disease aided identification of novel genome-wide metabolite associations, providing clues about substrate specificity and the key roles of enzymes in modulating systemic levels of metabolites.