Faculty Bibliography

BACKGROUND:Sudden cardiac death (SCD) is the most common etiology of death in hemodialysis patients but not much is known about its risk factors. The goal of our study was to determine the association and risk prediction of SCD by serum N-terminal prohormone of brain natriuretic peptide (NTproBNP) troponin I (cTnI) in hemodialysis patients. METHODS:We measured NTproBNP and cTnI in 503 hemodialysis patients of a national prospective cohort study. We determined their association with SCD using Cox regression, adjusting for demographics, co-morbidities, and clinical factors and risk prediction using C-statistic and Net Reclassification Improvement (NRI). RESULTS:Patients' mean age was 58 years and 54 % were male. During follow-up (median 3.5 years), there were 75 outpatient SCD events. In unadjusted and fully-adjusted models, NTproBNP had a significant association with the risk of SCD. Analyzed as a continuous variable, the risk of SCD increased 27 % with each 2-fold increase in NTproBNP (HR, 1.27 per doubling; 95 % CI, 1.13-1.43; p < 0.001). In categorical models, the risk of SCD was 3-fold higher in the highest tertile of NTproBNP (>7,350 pg/mL) compared with the lowest tertile (<1,710 pg/mL; HR for the highest tertile, 3.03; 95 % CI, 1.56-5.89; p = 0.001). Higher cTnI showed a trend towards increased risk of SCD in fully adjusted models, but was not statistically significant (HR, 1.17 per doubling; 95 % CI, 0.98-1.40; p = 0.08). Sensitivity analyses using competing risk models showed similar results. Improvement in risk prediction by adding cardiac biomarkers to conventional risk factors was greater with NTproBNP (C-statistic for 3-year risk: 0.810; 95 % CI, 0.757 to 0.864; and continuous NRI: 0.270; 95 % CI, 0.046 to 0.495) than with cTnI. CONCLUSIONS:NTproBNP is associated with the risk of SCD in hemodialysis patients. Further research is needed to determine if biomarkers measurement can guide SCD risk prevention strategies in dialysis patients.

BACKGROUND:Obesity is a risk factor for heart failure (HF) but is associated with lower N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. It is unclear whether the prognostic value and implications of NT-proBNP levels for HF risk differ across body mass index (BMI) categories. METHODS AND RESULTS/RESULTS:We followed up 12 230 ARIC participants free of prior HF at baseline (visit 2, 1990-1992) with BMI ≥18.5 kg/m(2). We quantified and compared the relative and absolute risk associations of NT-proBNP with incident HF across BMI categories. There were 1861 HF events during a median 20.6 years of follow-up. Despite increased HF risk in obesity, a weak inverse association was seen between baseline BMI and NT-proBNP levels (r=-0.10). Nevertheless, higher baseline NT-proBNP was associated with increased HF risk in all BMI categories. NT-proBNP improved HF risk prediction overall, even among those with severe obesity (BMI ≥35 kg/m(2); improvement in C statistic, 0.032; 95% confidence interval, 0.011-0.053). However, given the higher HF rates among those with obesity, at each NT-proBNP level, higher BMI was associated with greater absolute HF risk. Indeed, among those with NT-proBNP of 100 to <200 pg/mL, the average 10-year HF risk was <5% among normal-weight individuals but >10% among the severely obese. CONCLUSIONS:Despite its inverse relationship with BMI, NT-proBNP provides significant prognostic information on the risk of developing HF even among individuals with obesity. Given the higher baseline HF risk among persons with obesity, even slight elevations in NT-proBNP may have implications for increased absolute HF risk in this population.

Mild head injury such as concussions and subconcussive repetitive impact may lead to subtle changes in brain function and it is imperative to find sensitive and reliable tests to detect such changes. Tests involving the visual system, in particular eye movements, can incorporate higher cortical functioning and involve diffuse pathways in the brain, including many areas susceptible to head impact. With concussions, the clinical neuro-ophthalmic exam is important for detecting abnormalities in vergence, saccades, pursuit, and visual fixation. On the sidelines, the King-Devick test has been used as a visual performance measure that incorporates eye movements and increases the sensitivity in detecting possible concussions in conjunction with standard sideline tests of cognition, symptom checklists, and balance. Much promise lies in the eye movement laboratory to quantitate changes in saccades and pursuit with concussions using video-oculography. A combination of eye movement tasks coupled with neuroimaging techniques and other objective biomarkers may lead to a better understanding of the anatomical and physiological consequences of concussion and to better understand the natural history of this condition.

BACKGROUND:Cardiovascular diseases stem from modifiable risk factors. Peer support is a proven strategy for many chronic illnesses. Randomized trials assessing the efficacy of this strategy for global cardiovascular risk factor modification are lacking. OBJECTIVES/OBJECTIVE:This study assessed the hypothesis that a peer group strategy would help improve healthy behaviors in individuals with cardiovascular risk factors. METHODS:A total of 543 adults 25 to 50 years of age with at least 1 risk factor were recruited; risk factors included hypertension (20%), overweight (82%), smoking (31%), and physical inactivity (81%). Subjects were randomized 1:1 to a peer group-based intervention group (IG) or a self-management control group (CG) for 12 months. Peer-elected leaders moderated monthly meetings involving role-play, brainstorming, and activities to address emotions, diet, and exercise. The primary outcome was mean change in a composite score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT score, 0 to 15). Multilevel models with municipality as a cluster variable were applied to assess differences between groups. RESULTS:Participants' mean age was 42 ± 6 years, 71% were female, and they had a mean baseline Fuster-BEWAT score of 8.42 ± 2.35. After 1 year, the mean scores were significantly higher in the IG (n = 277) than in the CG (n = 266) (IG mean score: 8.84; 95% confidence interval (CI): 8.37 to 9.32; CG mean score: 8.17; 95% CI: 7.55 to 8.79; p = 0.02). The increase in the overall score was significantly larger in the IG compared with the CG (difference: 0.75; 95% CI: 0.32 to 1.18; p = 0.02). The mean improvement in the individual components was uniformly greater in the IG, with a significant difference for the tobacco component. CONCLUSIONS:The peer group intervention had beneficial effects on cardiovascular risk factors, with significant improvements in the overall score and specifically on tobacco cessation. A follow-up assessment will be performed 1 year after the final assessment reported here to determine long-term sustainability of the improvements associated with peer group intervention. (Peer-Group-Based Intervention Program [Fifty-Fifty]; NCT02367963).

BACKGROUND:Evaluation of candidates to serve as living kidney donors relies on screening for individual risk factors for end-stage renal disease (ESRD). To support an empirical approach to donor selection, we developed a tool that simultaneously incorporates multiple health characteristics to estimate a person's probable long-term risk of ESRD if that person does not donate a kidney. METHODS:We used risk associations from a meta-analysis of seven general population cohorts, calibrated to the population-level incidence of ESRD and mortality in the United States, to project the estimated long-term incidence of ESRD among persons who do not donate a kidney, according to 10 demographic and health characteristics. We then compared 15-year projections with the observed risk among 52,998 living kidney donors in the United States. RESULTS:A total of 4,933,314 participants from seven cohorts were followed for a median of 4 to 16 years. For a 40-year-old person with health characteristics that were similar to those of age-matched kidney donors, the 15-year projections of the risk of ESRD in the absence of donation varied according to race and sex; the risk was 0.24% among black men, 0.15% among black women, 0.06% among white men, and 0.04% among white women. Risk projections were higher in the presence of a lower estimated glomerular filtration rate, higher albuminuria, hypertension, current or former smoking, diabetes, and obesity. In the model-based lifetime projections, the risk of ESRD was highest among persons in the youngest age group, particularly among young blacks. The 15-year observed risks after donation among kidney donors in the United States were 3.5 to 5.3 times as high as the projected risks in the absence of donation. CONCLUSIONS:Multiple demographic and health characteristics may be used together to estimate the projected long-term risk of ESRD among living kidney-donor candidates and to inform acceptance criteria for kidney donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others.).

BACKGROUND: Until 1990, there was an upward trend in mortality from breast, lung, prostate, and colon cancers in the United Kingdom. With improvements in cancer treatment there has, in general, been a fall in mortality over the last 20 years. We evaluate regional cancer mortality trends in the United Kingdom between 1991 and 2007. METHODS: We analysed mortality trends for breast, lung, prostate, and colon cancers using data obtained from the EUREG cancer database. We have described changes in age-standardised rates (using European standard population) per 100,000 for cancer mortality and generated trends in mortality for the 11 regions using Joinpoint regression. RESULTS: Across all regions in the United Kingdom there was a downward trend in mortality for the four most common cancers in males and females. Overall, deaths from colon cancer decreased most rapidly and deaths from prostate cancer decreased at the slowest rate. Similar downward trends in mortality were observed across all regions of the United Kingdom with the data for lung cancer exhibiting the greatest variation. CONCLUSIONS: Mortality from the four most common cancers decreased across all regions of the United Kingdom; however, the rate of decline varied between cancer type and in some instances by region.

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

Executive function abilities, including working memory, inhibitory control, and the flexible volitional shifting of the focus of attention provide a foundation for reflection on experience, reasoning, and the purposeful regulation of behavior. These abilities and their underlying neurobiology, however, are inherently malleable and influenced by characteristics of individuals and contexts. Implications of this malleability for research on the development of executive function in early childhood, for the prospect that these abilities can be fostered and promoted by specific types of activities, and for issues relating to the reliable and valid measurement of executive function are considered.

Using a sample of 171 children, we examined classroom quality as a potential moderator of the link between three distinct but related aspects of cognition (fluid intelligence, crystallized intelligence, and executive functioning) and math achievement across the kindergarten year. Multilevel modeling analyses were conducted to account for nesting of students within classrooms. Results revealed significant aptitude by treatment interactions for fluid and crystallized intelligence, suggesting that classroom practices may affect children differently depending on their abilities. Children with higher levels of fluid intelligence and of crystallized intelligence fared better in higher quality classrooms. Results also provide some support for Cattell's investment hypothesis. Implications of the results are discussed.

Based on a focus group study conducted in New York City (NYC), this paper examines the traditional staples (i.e., nostalgic foods) that Latinas regularly consume in the U.S., along with their beliefs regarding the impact of such foods on weight gain and related body image. Our research findings highlight the "double-bind" of nostalgic foods, defined by Latinas' retention of highly caloric familiar items along with their progressive abandonment of fresh produce and fruits. Despite participants' efforts to eat healthy staples from their homelands, they mostly kept foods perceived as unhealthy (e.g., fatty meats, fried foods). This phenomenon was informed by the "same-food paradox," represented by Latinas' beliefs that the same traditional foods that would make them lose weight in their native countries would lead them to gain weight in the U.S. Our qualitative data show that participants' concerns about their weight gain in the U.S. is in tune with their general body dissatisfaction, as indicated by our quantitative results. Finally, our findings reveal the role of stress in promoting Latinas' deleterious daily habits, including their consumption of fat-saturated snacks. Overall, these results speak to the cultural and structural barriers to healthy eating that financially strapped study participants experienced in NYC. In order to design successful public health interventions targeting Latinas, the nostalgic aspects of food preferences should be considered in conjunction with the barriers that keep them from engaging with healthier lifestyles in the U.S.