Faculty Bibliography

OBJECTIVE:Cardiovascular and renal complications contribute to higher mortality in patients with diabetes. We assessed novel and conventional predictors of mortality in African American-Diabetes Heart Study (AA-DHS) participants. RESEARCH DESIGN AND METHODS:) were assessed in 513 African Americans with type 2 diabetes; analyses were performed using Cox proportional hazards models. RESULTS:renal-risk genotypes (HR 0.07 [95% CI 0.01-0.69]) as the strongest predictors of mortality. CONCLUSIONS:non-renal-risk genotypes associated with higher mortality in African Americans with diabetes. These data add to growing evidence supporting FGF23 association with mortality; mechanisms whereby these novel predictors impact survival remain to be determined.

Galectin-3 has been proposed as a novel biomarker of heart failure and cardiac fibrosis, and may also be associated with fibrosis of other organs such as the kidney. To determine this, we prospectively analyzed data from 9,148 Atherosclerosis Risk in Communities (ARIC) Study participants with measured plasma galectin-3 levels (baseline, visit 4, 1996-98) and without prevalent chronic kidney disease (CKD) or heart failure. We identified 1,983 incident CKD cases through December 31, 2013 over a median follow-up of 16 years. At baseline, galectin-3 was cross-sectionally associated with estimated glomerular filtration rate and urine albumin-to-creatinine ratio; both significant. The results were adjusted for age, sex, race-center, education, physical activity, smoking status, body mass index, systolic blood pressure, anti-hypertensive medication use, history of cardiovascular disease, diabetes, fasting blood glucose, and rs4644 (a single nucleotide polymorphism of galactin-3). There was a significant, graded, and positive association between galectin-3 and incident CKD (quartile 4 vs. 1 hazard ratio: 2.22 [95% confidence interval: 1.89, 2.60]). The association was attenuated but remained significant after adjustment for estimated glomerular filtration rate, urine albumin-to-creatinine ratio, troponin T, and N-terminal pro-brain natriuretic peptide (quartile 4 vs. 1 hazard ratio: 1.75 [95% confidence interval: 1.49, 2.06]), and was stronger among those with hypertension at baseline (significant interaction). Thus, in this community-based population, higher plasma galectin-3 levels were associated with an elevated risk of developing incident CKD, particularly among those with hypertension.

Food and beverage marketing has been identified as a major driver of obesity yet sports sponsorship remains common practice and represents millions of dollars in advertising expenditures. Research shows that food and beverage products associated with sports (e.g., M&M's with National Association for Stock Car Auto Racing logo) generate positive feelings, excitement, and a positive self-image among adults and children. Despite this, self-regulatory pledges made by food companies to limit exposure of unhealthy products to children have not improved the nutritional quality of foods marketed to children. We reviewed the literature about sports-related food marketing, including food and beverage companies' use of sports sponsorships, athlete endorsements, and sports video games. This review demonstrates that sports sponsorships with food and beverage companies often promote energy-dense, nutrient-poor products and while many of these promotions do not explicitly target youth, sports-related marketing affects food perceptions and preferences among youth. Furthermore, endorsement of unhealthy products by professional athletes sends mixed messages; although athletes may promote physical activity, they simultaneously encourage consumption of unhealthy products that can lead to negative health outcomes. We argue that more athletes and sports organizations should stop promoting unhealthy foods and beverages and work with health experts to encourage healthy eating habits among youth.

In 2011, a National Academy of Medicine report recommended that packaged food in the U.S. display a uniform front-of-package nutrition label, using a system such as a 0-3 star ranking. Few studies have directly compared this to other labels to determine which best informs consumers and encourages healthier purchases. In 2013, we randomized adult participants (N=1247) in an Internet-based survey to one of six conditions: no label control; single traffic light; multiple traffic light; Facts Up Front; NuVal; or 0-3 star ranking. We compared groups on purchase intentions and accuracy of participants' interpretation of food labels. There were no differences in the nutritional quality of hypothetical shopping baskets across conditions (p=0.845). All labels improved consumers' abilities to judge the nutritional quality of foods relative to no label, but the best designs varied by outcomes. NuVal and multiple traffic light labels led to the greatest accuracy identifying the healthier of two products (p<0.001), while the multiple traffic light also led to the most accurate estimates of saturated fat, sugar, and sodium (p<0.001). The single traffic light outperformed other labels when participants compared nutrient levels between similar products (p<0.03). Single/multiple traffic light and Facts Up Front labels led to the most accurate calories per serving estimations (p<0.001). Although front-of-package labels helped participants more accurately assess products' nutrition information relative to no label, no conditions shifted adults' purchase intentions. Results did not point to a clearly superior label design, but they suggest that a 3-star label might not be best for educating consumers.

CONTEXT:Mindfulness practices in the workplace have experienced rapid growth, with initial evidence suggesting positive outcomes. Even so, little is known about implementing mindfulness-based interventions (MBI), especially internally driven programs led by volunteers rather than experts. OBJECTIVE:This study qualitatively explores volunteer facilitators' perceptions of a short-dose MBI (the mindfulness moment initiative) before and 6 weeks after implementation. METHODS:Mindfulness moments were 1-3-minute-guided periods of mindfulness led at the beginning of various staff meetings at an inner-city community medical center. Facilitators' perceptions were collected through thirty-one 30-minute semi-structured interviews before and after the MMI's first 6 weeks. Categorizing and connecting strategies were employed to explore the emergence of themes and patterns across responses. RESULTS:Mindfulness moment facilitators interviewed before the intervention expected their groups to experience several intra- and interpersonal benefits. After implementation, they perceived all of these benefits to have occurred, but some benefits were mentioned more frequently before than after implementation and vice versa. Five of six expected obstacles were reported after implementation, with timing issues emerging as the most frequently mentioned theme. Facilitators believed that benefits outweighed obstacles. Our data also suggested that mindfulness moments may provide managers with an additional way to address moments of tension occurring between co-workers. Most facilitators intended to continue leading mindfulness moments and wished to expand the practice to new departments. CONCLUSION:The mindfulness moment intervention may provide a way to bring mindfulness into organizations that is not dependent on formal training programs, a large time commitment, or a commitment to extended training. Prior knowledge of the obstacles and benefits found here may result in a more successful intervention.

The primary objective of this study was to investigate the relationship between neighborhood stigma and sleep in a sample of low-income housing residents in New York City. Data were derived from the NYC Low-Income Housing, Neighborhoods, and Health Study (N = 120). Adults living in low-income housing completed a survey consisting of measures of neighborhood stigma, sleep quality, and sleep duration. Neighborhood stigma and sleep were self-reported. Associations between neighborhood stigma and sleep health were analyzed using generalized linear models with cluster variance estimation. Multivariable models adjusted for age, gender, race/ethnicity, income, education, employment status, obesity, the census block percentage of non-Hispanic black residents, and the census block percentage median household income. Results indicate that a reported negative media perception of the neighborhood was negatively associated with sleep quality and duration (p < 0.01). However, additional research is needed to explore neighborhood stigma as it relates to sleep.

OBJECTIVES/OBJECTIVE:Many children in low- and middle-income countries fail to reach their developmental potential. We sought to determine if a parenting program focused on the promotion of reading aloud enhanced parent-child interactions and child development among low-income families in northern Brazil. METHODS:This was a cluster-randomized study of educational child care centers randomly assigned to receive an additional parenting program (intervention) or standard child care without a parenting component (control). Parent-child dyads were enrolled at the beginning of the school year and were assessed at enrollment and at the end of the school year. Families in intervention centers could borrow children's books on a weekly basis and could participate in monthly parent workshops focused on reading aloud. We compared parents and children in intervention and control centers 9 months after the start of the intervention on measures of parent-child interaction and child language, cognitive, and social-emotional development. RESULTS:= 0.33). CONCLUSIONS:An innovative program focused on the promotion of parent-child reading aloud resulted in benefits to parent-child interactions and to child language and cognitive development that were greater than those provided by educational child care alone. This promising approach merits further evaluation at scale.

BACKGROUND AND OBJECTIVE: Few studies have examined the possible cardiometabolic consequences of World Trade Center-related exposures on children who lived and/or attended school near the disaster site. Our objective was to compare cardiometabolic profiles of participants in the World Trade Center Health Registry (WTCHR) with a matched comparison group. METHODS: We evaluated WTCHR enrollees who resided in New York City and were born between September 11, 1993 and September 10, 2001, and a matched comparison group. We assessed exposure to dust cloud, home dust, as well as traumatic exposure, and associations with blood pressure, arterial wall stiffness, body mass index (BMI), total cholesterol, triglycerides, HDL, and LDL. RESULTS: A total of 402 participants completed the study, 222 in the comparison group and 180 in the WTCHR group. In multivariable regression analysis, after adjusting for relevant confounders we detected a weak association between participation in the WTCHR group and lower BMI (-1.12kg/m2, 95% CI -2.11, -0.12; p = 0.03), which became non-significant after adjusting for multiple comparisons. With respect to traumatic and psychosocial exposures, the only association that persisted in our multivariable model, below our predefined level of significance, was between post-traumatic stress disorder and higher BMI (2.06kg/m2, 95% CI 0.37, 3.74; p = 0.02). CONCLUSIONS: Our findings do not support an association between self-reported exposures to the WTC disaster and adverse cardiometabolic profile. However, further longitudinal studies may better inform the full extent of WTC-related conditions associated with exposure to the disaster.

Grade IV glioma is the most common and aggressive primary brain tumour. Gross total resection with 5-aminolevulinic acid (5-ALA) guided surgery combined with local chemotherapy (carmustine wafers) is an attractive treatment strategy in these patients. No previous studies have examined the benefit carmustine wafers in a treatment programme of 5-ALA guided resection followed by a temozolomide-based chemoradiotherapy protocol. The objective of this study was to examine the benefit of carmustine wafers on survival in patients undergoing 5-ALA guided resection. A retrospective cohort study of 260 patients who underwent 5-ALA resection of confirmed WHO 2007 Grade IV glioma between July 2009 and December 2014. Survival curves were calculated using the Kaplan-Meier method from surgery. The log-rank test was used to compare survival curves between groups. Cox regression was performed to identify variables predicting survival. A propensity score matched analysis was used to compare survival between patients who did and did not receive carmustine wafers while controlling for baseline characteristics. Propensity matched analysis showed no significant survival benefit of insertion of carmustine wafers over 5-ALA resection alone (HR 0.97 [0.68-1.26], p = 0.836). There was a trend to higher incidence of wound infection in those who received carmustine wafers (15.4 vs. 7.1%, p = 0.064). The Cox regression analysis showed that intraoperative residual fluorescent tumour and residual enhancing tumour on post-operative MRI were significantly predictive of reduced survival. Carmustine wafers have no added benefit following 5-ALA guided resection. Residual fluorescence and residual enhancing disease following resection have a negative impact on survival.

CONTEXT: A diagnosis of advanced chronic kidney disease (CKD), or end stage renal disease (ESRD) represents a significant life change for patients and families. Individuals often experience high symptom burden, decreased quality of life, increased health care utilization, and end-of-life care discordant with their preferences. Early integration of palliative care with standard nephrology practice in the outpatient setting has the potential to improve quality of life through provision of expert symptom management, emotional support, and facilitation of advance care planning that honors the individual's values and goals. OBJECTIVES: This special report describes application of participatory action research (PAR) methods to develop an outpatient integrated nephrology and palliative care program. METHODS: Stakeholder concerns were thematically analyzed to inform translation of a known successful model of outpatient kidney palliative care to a practice in a large, urban medical center in the United States. RESULTS: Stakeholder needs and challenges to meeting these needs were identified. We uncovered a shared understanding of the clinical need for palliative care services in nephrology practice, but apprehension towards practice change. Action steps to modify the base model were created in response to stakeholder feedback. CONCLUSIONS: The development of a model of care that provides a new approach to clinical practice requires attention to relevant stakeholder concerns. PAR is a useful methodological approach that engages stakeholders and builds partnerships. This creation of shared ownership can facilitate innovation and practice change. We synthesized stakeholder concerns to build a conceptual model for an integrated nephrology and palliative care clinical program.