Faculty Bibliography

Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis.

To assess apolipoprotein L1 gene (APOL1) renal-risk-variant effects on the brain, magnetic resonance imaging (MRI)-based cerebral volumes and cognitive function were assessed in 517 African American-Diabetes Heart Study (AA-DHS) Memory IN Diabetes (MIND) and 2568 hypertensive African American Systolic Blood Pressure Intervention Trial (SPRINT) participants without diabetes. Within these cohorts, 483 and 197 had cerebral MRI, respectively. AA-DHS participants were characterized as follows: 60.9% female, mean age of 58.6 years, diabetes duration 13.1 years, estimated glomerular filtration rate of 88.2 ml/min/1.73 m(2), and a median spot urine albumin to creatinine ratio of 10.0 mg/g. In additive genetic models adjusting for age, sex, ancestry, scanner, intracranial volume, body mass index, hemoglobin A1c, statins, nephropathy, smoking, hypertension, and cardiovascular disease, APOL1 renal-risk-variants were positively associated with gray matter volume (β = 3.4 × 10(-3)) and negatively associated with white matter lesion volume (β = -0.303) (an indicator of cerebral small vessel disease) and cerebrospinal fluid volume (β= -30707) (all significant), but not with white matter volume or cognitive function. Significant associations corresponding to adjusted effect sizes (β/SE) were observed with gray matter volume (0.16) and white matter lesion volume (-0.208), but not with cerebrospinal fluid volume (-0.251). Meta-analysis results with SPRINT Memory and Cognition in Decreased Hypertension (MIND) participants who had cerebral MRI were confirmatory. Thus, APOL1 renal-risk-variants are associated with larger gray matter volume and lower white matter lesion volume suggesting lower intracranial small vessel disease.

BACKGROUND: This study used cross-sectional data to test the independent relationship of proximity to chain fast-food outlets and proximity to full-service supermarkets on the frequency of mealtime dining at fast-food outlets in two major urban areas, using three approaches to define access. Interactions between presence of a supermarket and presence of fast-food outlets as predictors of fast-food dining were also tested. METHODS: Residential intersections for respondents in point-of-purchase and random-digit-dial telephone surveys of adults in Philadelphia, PA, and Baltimore, MD, were geocoded. The count of fast-food outlets and supermarkets within quarter-mile, half-mile, and 1-mile street network buffers around each respondent's intersection was calculated, as well as distance to the nearest fast-food outlet and supermarket. These variables were regressed on weekly fast-food dining frequency to determine whether proximity to fast food and supermarkets had independent and joint effects on fast-food dining. RESULTS: The effect of access to supermarkets and chain fast-food outlets varied by study population. Among telephone survey respondents, supermarket access was the only significant predictor of fast-food dining frequency. Point-of-purchase respondents were generally unaffected by proximity to either supermarkets or fast-food outlets. However, >/=1 fast-food outlet within a 1-mile buffer was an independent predictor of consuming more fast-food meals among point-of-purchase respondents. At the quarter-mile distance, >/=1 supermarket was predictive of fewer fast-food meals. CONCLUSIONS: Supermarket access was associated with less fast-food dining among telephone respondents, whereas access to fast-food outlets were associated with more fast-food visits among survey respondents identified at point-of-purchase. This study adds to the existing literature on geographic determinants of fast-food dining behavior among urban adults in the general population and those who regularly consume fast food.

The deployment of health information technologies promises to optimize clinical outcomes for populations with substance use disorders. Electronic health records, web-based counseling interventions, and mobile phone applications enhance the delivery of evidence-based behavioral and pharmacological treatments, with minimal burden to clinical personnel, infrastructure, and work flows. This clinical case shares a recent experience utilizing mobile phone text messaging between an office-based buprenorphine provider in a safety net ambulatory clinic and a patient seeking buprenorphine treatment for opioid use disorder. The case highlights the use of text message-based physician-patient communication to facilitate unobserved "home" induction onto buprenorphine.

STUDY OBJECTIVE: Language barriers are known to negatively affect many health outcomes among limited English proficiency patient populations, but little is known about the quality of care such patients receive in the emergency department (ED). This study seeks to determine whether limited English proficiency patients experience different quality of care than English-speaking patients in the ED, using unplanned revisit within 72 hours as a surrogate quality indicator. METHODS: We conducted a retrospective cohort study in an urban adult ED in 2012, with a total of 41,772 patients and 56,821 ED visits. We compared 2,943 limited English proficiency patients with 38,829 English-speaking patients presenting to the ED after excluding patients with psychiatric complaints, altered mental status, and nonverbal states, and those with more than 4 ED visits in 12 months. Two main outcomes-the risk of inpatient admission from the ED and risk of unplanned ED revisit within 72 hours-were measured with odds ratios from generalized estimating equation multivariate models. RESULTS: Limited English proficiency patients were more likely than English speakers to be admitted (32.0% versus 27.2%; odds ratio [OR]=1.20; 95% confidence interval [CI] 1.11 to 1.30). This association became nonsignificant after adjustments (OR=1.04; 95% CI 0.95 to 1.15). Included in the analysis of ED revisit within 72 hours were 32,857 patients with 45,546 ED visits; 4.2% of all patients (n=1,380) had at least 1 unplanned revisit. Limited English proficiency patients were more likely than English speakers to have an unplanned revisit (5.0% versus 4.1%; OR=1.19; 95% CI 1.02 to 1.45). This association persisted (OR=1.24; 95% CI 1.02 to 1.53) after adjustment for potential confounders, including insurance status. CONCLUSION: We found no difference in hospital admission rates between limited English proficiency patients and English-speaking patients. Yet limited English proficiency patients were 24% more likely to have an unplanned ED revisit within 72 hours, with an absolute difference of 0.9%, suggesting challenges in ED quality of care.

OBJECTIVE: The purpose of this article is to compare the effectiveness of a treatment algorithm for small renal tumors incorporating the nephrometry score, a renal tumor anatomy scoring system developed by urologists, with the current standard of uniformly recommended partial nephrectomy in patients with mild-to-moderate chronic kidney disease (CKD). MATERIALS AND METHODS: We developed a state-transition microsimulation model to project life expectancy (LE) in hypothetic patients with baseline mild or moderate CKD undergoing treatment of small renal masses. Our model incorporated the nephrometry score, which is predictive of postsurgical renal function loss. The two tested strategies were uniform treatment with partial nephrectomy and selective treatment based on nephrometry score and CKD stage, including percutaneous ablation for CKD stages 2 or 3a and intermediate-to-high nephrometry score or stage 3b CKD and any nephrometry score; otherwise, partial nephrectomy was assumed for other CKD stages and nephrometry scores. The model accounted for benign and malignant lesions, renal function decline, recurrence, and metastatic disease rates specific to each treatment, mortality by CKD stage, and comorbidities. Sensitivity analysis tested the stability of results when varying key parameters. RESULTS: Selective treatment with partial nephrectomy resulted in an average LE benefit of 0.48 year (95% interpercentile range, 0.42-0.54 year) in 65-year-old men and 0.37 year (95% interpercentile range, 0.30-0.43 year) in 65-year-old women relative to nondiscriminatory surgery, due to worsening CKD and cardiovascular mortality associated with partial nephrectomy. Model results were most sensitive to the rate of renal function decline and CKD-related mortality. CONCLUSION: Nephron-sparing treatment selection for small renal masses based on nephrometry score may improve LE in patients with mild or moderate CKD.

Young gay, bisexual, and other men who have sex with men (YMSM) are at increased likelihood of experiencing depression and engaging in condomless sexual behaviors. The goal of the current investigation was to examine the relationship between negative mood and compulsive sexual behavior (CSB) and to assess for their individual and combined influence on sexual risk-taking behavior among a diverse sample of YMSM in New York City (the P18 Cohort Study). We first analyzed sociodemographic, depressive symptoms, CSB, and sexual risk-taking from the cross-sectional data of 509, 18- or 19-year-old YMSM recruited using non-probability sampling. We found a significant positive correlation between CSB and depression and between CSB and frequency of condomless anal sex acts reported over the last 30 days. Multivariate results found that the presence of both depression and CSB contributed to elevated sexual risk-taking among these urban YMSM. Clinical implications include the importance of assessing for CSB when depression is present and vice versa in order to improve HIV prevention. Informed by minority stress theory and syndemic theory, our results suggest that interventions focused on the health of YMSM recognize that mental health and social context all interact to increase physical health vulnerability vis-a-vis sexual behaviors, depression, and CSB. Thus, HIV prevention and intervention programs need to incorporate mental health components and services that address these needs.

OBJECTIVE: The objectives were to: assess the availability of on-site mental health professionals (MHP) in primary care; examine practice/pediatrician characteristics associated with on-site MHPs; and determine whether presence of on-site MHPs is related to pediatricians' co-managing or more frequently identifying, treat/managing or referring MH problems. METHODS: Analyses included AAP members who participated in an AAP Periodic Survey in 2013 and who practiced general pediatrics (N=321). Measures included socio-demographics, practice characteristics, questions on about on-site MHPs, co-management of MH problems and pediatricians' behaviors in response to 5 prevalent MH problems. Weighted univariate, bivariate and multivariable analyses were performed. RESULTS: Thirty-five percent reported on-site MHPs. Practice characteristics (medical schools/universities/HMOs, <100 visits/week, <80% of patients privately insured), and interactions of practice location (urban) with visits and patient insurance, were associated with on-site MHPs. There was no overall association between co-location and co-management or whether pediatricians usually identified, treat/managed or referred 5 common child MH problems. Among the subset of pediatricians who reported co-managing there was an association with co-management when the on-site MHP was a child psychiatrist, SA counselor, or social worker. CONCLUSIONS: On-site MHPs are more frequent in settings where low-income children are served and where pediatricians train. Pediatricians who co-manage MH problems are more likely to do so when the on-site MHP is a child psychiatrist, SA counselor, or social worker. Overall, on-site MHPs were not associated with co-management or increased likelihood of pediatricians identifying, treating/managing, or referring children with 5 common child MH problems.

OBJECTIVE: Cumulative adverse childhood experiences (ACE) can have profound and lasting effects on parenting. Parents with a history of multiple ACE have greater challenges modulating their own stress responses and helping their children adapt to life stressors. This paper examines pediatric practice in inquiring about parents' childhood adversities as of 2013. METHODS: Using data from the 85th Periodic Survey of the American Academy of Pediatrics (AAP), we restricted analyses to the 302 pediatricians exclusively practicing general pediatrics who answered questions regarding their beliefs about childhood stressors, their role in advising parents, and whether they asked about parents' ACE. Weighted descriptive and logistic regression analyses were conducted. RESULTS: Despite endorsing the influence of positive parenting on a child's life-course trajectory (96%), that their advice can impact parenting skills (79%), and that screening for social-emotional risks is within their scope of practice ((81%), most pediatricians (61%) did not inquire about parents' ACE. Pediatricians who believed that their advice influences positive parenting skills inquired about more parents' ACE CONCLUSION: As of 2013, few pediatricians inquired about parents' ACE despite recognizing their negative impact on parenting behaviors and child development.. Research is needed regarding the best approaches to the prevention and amelioration of ACE and the promotion of family and child resilience. Pediatricians need resources and education about the AAP's proposed dyadic approach to assessing family and child risk factors and strengths and to providing guidance and management.

OBJECTIVE: The aim of this study was to compare the outcome of immediate versus delayed radical prostatectomy (RP) in men with low-grade prostate cancer. MATERIALS AND METHODS: The study included a nationwide population-based cohort in the National Prostate Cancer Register of Sweden, of 7608 men with clinically localized, biopsy Gleason score 6 prostate cancer who underwent immediate or delayed RP in 1997-2007. Multivariable models compared RP pathology, use of salvage radiotherapy and prostate cancer mortality based on timing of RP (< 1, 1-2 or >2 years after diagnosis). Median follow-up was 8.1 years. RESULTS: Men undergoing RP more than 2 years after diagnosis had a higher risk of Gleason upgrading [odds ratio 2.93, 95% confidence interval (CI) 2.34-3.68] and an increased risk of salvage radiotherapy [hazard ratio (HR) 1.90, 95% CI 1.41-2.55], but no significant increase in prostate cancer-specific mortality (HR 1.85, 95% CI 0.57-5.99). In competing risk analysis, 7 year prostate cancer-specific cumulative mortality was similar, at less than 1%, for immediate RP and active surveillance regardless of later intervention. Limitations of this study include the lack of data on follow-up biopsies and the limited follow-up time. CONCLUSION: Men undergoing RP more than 2 years after diagnosis had more adverse pathological features and second line therapy, highlighting the trade-off in deferring immediate curative therapy. However, men with delayed RP constitute a minority with higher risk cancer among the much larger group of low-risk men initially surveilled, and the overall risk of prostate cancer mortality at 7 years was similarly low with immediate RP or active surveillance.