Faculty Bibliography

BACKGROUND:Black heart transplant recipients have higher risk of mortality than White recipients. Better understanding of this disparity, including subgroups most affected and timing of the highest risk, is necessary to improve care of Black recipients. We hypothesize that this disparity may be most pronounced among young recipients, as barriers to care like socioeconomic factors may be particularly salient in a younger population and lead to higher early risk of mortality. METHODS:We studied 22 997 adult heart transplant recipients using the Scientific Registry of Transplant Recipients data from January 2005 to 2017 using Cox regression models adjusted for recipient, donor, and transplant characteristics. RESULTS:=0.1). CONCLUSIONS:Young Black recipients have a high risk of mortality in the first year after heart transplant, which has been masked in decades of research looking at disparities in aggregate. To reduce overall racial disparities, clinical research moving forward should focus on targeted interventions for young Black recipients during this period.

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.

OBJECTIVE:To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation. STUDY DESIGN/METHODS:The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating). RESULTS:All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability. CONCLUSIONS:The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

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 aim of this study was to identify longitudinal trajectories of conjoint development of executive function (EF) and obesity among a diverse sample of poor, rural youth and to evaluate individual differences in infant growth, parental BMI, and cumulative risk. METHODS:Participants included 948 youth from the Family Life Project. Child anthropometrics were measured at 2 and 6 months and at 2, 3, 4, 5, 7, and 12 years. EF tasks were administered at 3, 4, and 5 years. Mothers reported youth birth weight, parental height and weight, and cumulative risk indicators. RESULTS:Multidimensional growth mixture modeling identified three classes: "High EF - High Obesity Resilience"; "Low EF - Delayed-Onset Severe Obesity"; and "Low EF - Early-Onset Severe Obesity." Youth in the low-EF, early-onset class displayed higher birth weight and BMI at 6 months, whereas the low-EF, delayed-onset class had rapid weight gain during infancy, parents with class II obesity, and greater cumulative risk and was more likely to be Black and female. CONCLUSIONS:Despite increased obesity risk among this sample, the majority of youth exhibited higher EF and some degree of obesity resilience. Youth with EF deficits displayed the greatest risk for severe obesity but had differing BMI trajectories and obesity risk profiles, which has implications for obesity intervention.

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).

CONTEXT/BACKGROUND:Germline testing (GT) is increasingly impacting prostate cancer (PCa) management and screening, with direct effects in urology, medical oncology, and radiation oncology. The majority of testing indications and recommendations center on men with metastatic disease, although guidelines now encompass newly diagnosed, early-stage PCa and entail assessment of personal history, pathologic features, and family history to determine eligibility for testing. OBJECTIVE:To describe current guidelines on GT for men with PCa and the impact on management. An additional objective was to review the literature on current uptake of GT across practice settings. EVIDENCE ACQUISITION/METHODS:A nonsystematic review was performed of current guidelines on GT in PCa from professional societies and consensus conferences, detailing supporting evidence for these recommendations. This was supplemented by a literature review of uptake of GT and precision medicine in practice. EVIDENCE SYNTHESIS/RESULTS:Multiple guidelines and consensus panels recommend GT for men with metastatic PCa. Guidelines endorse BRCA2 testing in metastatic PCa because of strong evidence for PCa risk, aggressiveness, and PARP inhibitor candidacy. Testing of additional DNA repair genes in metastatic disease is also endorsed across guidelines. Immunotherapy with pembrolizumab is an option in some guidelines for men with DNA mismatch repair deficiency. In localized disease, GT is recommended on the basis of histologic features and family history; criteria vary between guidelines. GT for localized disease informs hereditary cancer risk and will probably impact future PCa management. Practice gaps exist regarding utilization of GT. CONCLUSIONS:Germline evaluation is increasingly important in the management of men with metastatic PCa and may also affect the prognosis for men with localized disease. The presence of germline mutations has important hereditary cancer implications for men and their families. Uptake of germline evaluation may be underutilized in some practice settings, so strategies for optimization are required. PATIENT SUMMARY/UNASSIGNED:Patients with prostate cancer should talk to their doctor about the pros and cons of genetic testing, with attention to family history and cancer features. Genetic testing can have important implications for treatment, cancer screening, and family cancer risk.

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.

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.