A green tea extract confection decreases circulating endotoxin and fasting glucose by improving gut barrier function but without affecting systemic inflammation: A double-blind, placebo-controlled randomized trial in healthy adults and adults with metabolic syndrome

Anti-inflammatory activities of catechin-rich green tea extract (GTE) in obese rodents protect against metabolic endotoxemia by decreasing intestinal permeability and absorption of gut-derived endotoxin. However, translation to human health has not been established. We hypothesized that GTE would reduce endotoxemia by decreasing gut permeability and intestinal and systemic inflammation in persons with metabolic syndrome (MetS) compared with healthy persons. A randomized, double-blind, placebo-controlled, crossover trial in healthy adults (n = 19, 34 ± 2 years) and adults with MetS (n = 21, 40 ± 3 years) examined 4-week administration of a decaffeinated GTE confection (890 mg/d total catechins) on serum endotoxin, intestinal permeability, gut and systemic inflammation, and cardiometabolic parameters. Compared with the placebo, the GTE confection decreased serum endotoxin (P = .023) in both healthy persons and those with MetS, while increasing concentrations of circulating catechins (P < .0001) and γ-valerolactones (P = .0001). Fecal calprotectin (P = .029) and myeloperoxidase (P = .048) concentrations were decreased by GTE regardless of health status. Following the ingestion of gut permeability probes, urinary lactose/mannitol (P = .043) but not sucralose/erythritol (P > .05) was decreased by GTE regardless of health status. No between-treatment differences (P > .05) were observed for plasma aminotransferases, blood pressure, plasma lipids, or body mass nor were plasma tumor necrosis factor-α, interleukin-6, or the ratio of lipopolysaccharide-binding protein/soluble cluster of differentiation-14 affected. However, fasting glucose in both study groups was decreased (P = .029) by the GTE confection compared with within-treatment arm baseline concentrations. These findings demonstrate that catechin-rich GTE is effective to decrease circulating endotoxin and improve glycemic control in healthy adults and those with MetS, likely by reducing gut inflammation and small intestinal permeability but without affecting systemic inflammation.

A Pilot Study: Free Flap Atrophy in Tongue Reconstruction Using 3D Volumetric Analysis

OBJECTIVE

To identify factors influencing volume change in non-osseous oral free flap reconstruction using postoperative cross-sectional imaging and 3-dimensional segmentation of the free flap's muscular and adipose tissue content.

METHODS

Oral tongue free flap reconstruction cases (2014-2019) were reviewed with inclusion of patients with 3 postoperative, cross-sectional imaging studies with 1 within 6 months, 1 within 1 year, and 1 that spanned 2 years post-reconstruction. Exclusion criteria included recurrence, significant dental artifact, bony reconstruction, and flap failure. Demographics, risk factors, and surgical/clinical treatments were identified. Flap volumes were measured using Materialise MIMICS.

RESULTS

Twenty-two patients met strict inclusion criteria. Four flaps were anterolateral thighs and 18 radial forearms. Median percent volume loss greater than 2 years post-reconstruction was 53.2% overall, 58.1% for radial forearms, and 45.4% for ALTs (21.4% for adipose tissue and 57.4% for muscular tissue). Univariate analysis revealed glossectomy amount was associated with percent volume loss (P = .0417). Each successive postoperative month, the flap decreased by 1.54% (P < .0001). Checking for the interaction effect, the percent of flap loss across time was different for glossectomy amount (P = .0093), obesity status (P = .0431), and base of tongue involvement (P = .0472).

CONCLUSION

Glossectomy type, and thus flap size, is a positive predictor for flap atrophy. Obesity and base of tongue involvement are negative predictors for flap atrophy. The amount of tissue loss may differ from classical teachings with median atrophy 53.2% greater than 2 years post-reconstruction.

Evidence for the Association Between Adverse Childhood Family Environment, Child Abuse, and Caregiver Warmth and Cardiovascular Health Across the Lifespan: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

This study aimed to quantify the association between childhood family environment and longitudinal cardiovascular health (CVH) in adult CARDIA (Coronary Artery Risk Development in Young Adults) Study participants. We further investigated whether the association differs by adult income.

METHODS

We applied the CVH framework from the American Heart Association including metrics for smoking, cholesterol, blood pressure, glucose, body mass index, physical activity, and diet. CVH scores (range, 0-14) were calculated at years 0, 7, and 20 of the study. Risky Family environment (range, 7-28) was assessed at year 15 retrospectively, for childhood experiences of abuse, caregiver warmth, and family or household challenges. Complete case ordinal logistic regression and mixed models associated risky family (exposure) with CVH (outcome), adjusting for age, sex, race, and alcohol use.

RESULTS

The sample (n=2074) had a mean age of 25.3 (±3.5) years and 56% females at baseline. The median risky family was 10 with ideal CVH (≥12) met by 288 individuals at baseline (28.4%) and 165 (16.3%) at year 20. Longitudinally, for every 1-unit greater risky family, the odds of attaining high CVH (≥10) decreased by 3.6% (OR, 0.9645 [95% CI, 0.94-0.98]). Each unit greater child abuse and caregiver warmth score corresponded to 12.8% lower and 11.7% higher odds of ideal CVH (≥10), respectively (OR, 0.872 [95% CI, 0.77-0.99]; OR, 1.1165 [95% CI, 1.01-1.24]), across all 20 years of follow-up. Stratified analyses by income in adulthood demonstrated associations between risky family environment and CVH remained significant for those of the highest adult income (>$74k), but not the lowest (<$35k).

CONCLUSIONS

Although risky family environmental factors in childhood increase the odds of poor longitudinal adult CVH, caregiver warmth may increase the odds of CVH, and socioeconomic attainment in adulthood may contextualize the level of risk. Toward a paradigm of primordial prevention of cardiovascular disease, childhood exposures and economic opportunity may play a crucial role in CVH across the life course.

Improving mental health in black men through a 24-week community-based lifestyle change intervention: the black impact program

BACKGROUND

Poor mental health is a leading cause of morbidity and mortality among Black men in the United States. Efforts to improve mental health among Black men have been hampered by a lack of access and utilization of mental health services. Physical activity and social networks have been shown to improve mental health. Thus, we examined the effect of a community team-based physical activity, health education and social needs intervention among Black men on mental health over 24 weeks.

METHODS

Black adult males (n = 74) from a large Midwestern city participated in Black Impact, a 24-week community-based lifestyle change program adapted from the Diabetes Prevention Program and American Heart Association's (AHA) Check, Change, Control Blood Pressure Self-Management Program, which incorporates AHA's Life's Simple 7 (LS7) framework. Measures of mental health including the Center for Epidemiological Studies Depression Scale (CES-D), Patient Health Questionnaire 2-question depression screener (PHQ-2), and Perceived Stress Scale-10 (PSS-10) were completed at baseline, 12 and 24 weeks. The change in mental health scores from baseline to 12 and 24 weeks were evaluated using linear mixed-effects models adjusting for age, education, and income. The change in cardiovascular health scores, defined as objective metrics of LS7 (LS5 [blood pressure, total cholesterol, fasting glucose, body mass index and smoking]), by baseline mental health were evaluated using linear mixed-effects models with an interaction term (time*baseline mental health variable) and a random intercept for each participant.

RESULTS

Among 71 Black men (mean age 51, 85% employed) at 24 weeks, CES-D scores decreased from 10.54 to 7.90 (-2.64, 95%CI:-4.74, -0.55), PHQ-2 decreased from 1.04 to 0.63 (-0.41, 95%CI: -0.75, -0.07), and PSS-10 decreased from 14.62 to 12.91 (-1.71, 95%CI: -3.53, 0.12). A 1-unit higher CES-D at baseline was associated with less improvement in LS5 scores by -0.04 (95%CI: -0.076, -0.005) and - 0.032 (95%CI:-0.067, 0.003) units at week 12 and 24, respectively, with similar findings for PSS.

CONCLUSIONS

The Black Impact community-based lifestyle program has the potential to reduce depressive symptoms and stress in Black men. There is a dire need for larger, randomized studies to test the impact of Black Impact on mental health in Black men to advance health equity.

TRIAL REGISTRATION

Retrospectively Registered, ClinicalTrials.gov Identifier: NCT04787978.

Role of Sex in the Association of Socioeconomic Status With Cardiovascular Health in Black Americans: The Jackson Heart Study

BACKGROUND

Socioeconomic status (SES) is associated with cardiovascular health (CVH). Potential differences by sex in this association remain incompletely understood in Black Americans, where SES disparities are posited to be partially responsible for cardiovascular inequities. The association of SES measures (income, education, occupation, and insurance) with CVH scores was examined in the Jackson Heart Study.

METHODS AND RESULTS

American Heart Association CVH components (non-high-density-lipoprotein cholesterol, blood pressure, diet, tobacco use, physical activity, sleep, glycemia, and body mass index) were scored cross-sectionally at baseline (scale: 0-100). Differences in CVH and 95% CIs (Estimate, 95% CI) were calculated using linear regression, adjusting for age, sex, and discrimination. Heterogeneity by sex was assessed. Participants had a mean age of 54.8 years (SD 12.6 years), and 65% were women. Lower income, education, occupation (non-management/professional versus management/professional occupations), and insurance status (uninsured, Medicaid, Veterans Affairs, or Medicare versus private insurance) were associated with lower CVH scores (all P<0.01). There was heterogeneity by sex, with greater magnitude of associations of SES measures with CVH in women versus men. The lowest education level (high school) was associated with 8.8-point lower (95% CI: -10.2 to -7.3) and 5.4-point lower (95% CI: -7.2 to -3.6) CVH scores in women and men, respectively (interaction P=0.003). The lowest (<25 000) versus highest level of income (≥$75 000) was associated with a greater reduction in CVH scores in women than men (interaction P=0.1142).

CONCLUSIONS

Among Black Americans, measures of SES were associated with CVH, with a greater magnitude in women compared with men for education and income. Interventions aimed to address CVH through SES should consider the role of sex.

Exome sequencing in the pediatric neuromuscular clinic leads to more frequent diagnosis of both neuromuscular and neurodevelopmental conditions

INTRODUCTION/AIMS

Exome sequencing (ES) has proven to be a valuable diagnostic tool for neuromuscular disorders, which often pose a diagnostic challenge. The aims of this study were to investigate the clinical outcomes associated with utilization of ES in the pediatric neuromuscular clinic and to determine if specific phenotypic features or abnormal neurodiagnostic tests were predictive of a diagnostic result.

METHODS

This was a retrospective medical record review of 76 pediatric neuromuscular clinic patients who underwent ES. Based upon clinical assessment prior to ES, patients were divided into two groups: affected by neuromuscular (n = 53) or non-neuromuscular (n = 23) syndromes.

RESULTS

A diagnosis was made in 28/76 (36.8%), with 29 unique disorders identified. In the neuromuscular group, a neuromuscular condition was confirmed in 78% of those receiving a genetic diagnosis. Early age of symptom onset was associated with a significantly higher diagnostic yield. The most common reason neuromuscular diagnoses were not detected on prior testing was due to causative genes not being present on disease-specific panels. Changes to medical care were made in 57% of individuals receiving a diagnosis on ES.

DISCUSSION

These data further support ES as a powerful diagnostic tool in the pediatric neuromuscular clinic and highlight the advantages of ES over gene panels, including the ability to identify diagnoses regardless of etiology, identify genes newly associated with disease, and identify multiple confounding diagnoses. Rapid and accurate diagnosis by ES can not only end the patient's diagnostic odyssey, but often impacts patients' medical management and genetic counseling of families.

Association of Socioeconomic Status With Life's Essential 8 Varies by Race and Ethnicity

Background The American Heart Association's Life's Essential 8 (LE8) are 8 risk factors for cardiovascular disease, with poor attainment across all racial, ethnic, and socioeconomic groups. Attainment is lowest among Americans of low socioeconomic status (SES). Evidence suggests the association of SES with LE8 may vary by race and ethnicity. Methods and Results The association of 4 SES categories (education, income-to-poverty line ratio, employment, insurance) with LE8 was computed in age-adjusted linear regression models, with an interaction term for race and ethnicity, using National Health and Nutrition Examination Survey data, years 2011 to 2018. The sample (n=13 529) had a median age of 48 years (51% female) with weighting to be representative of the US population. The magnitude of positive association of college education (relative to ≤high school) with LE8 was greater among non-Hispanic White Americans (NHWA) compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA had a greater magnitude of positive association of income-to-poverty line ratio with LE8, compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA with Medicaid compared with private insurance had a greater magnitude of negative association with LE8 compared with non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.01). NHWA unemployed due to disability or health condition (compared with employed) had a greater magnitude of negative association with LE8 than non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.05). Conclusions The magnitude of association of SES with LE8 is greatest among NHWA. More research is needed on SES's role in LE8 attainment in minority group populations.

Outcomes After Deceased Donor Kidney Transplantation Using Kidney Allografts With Marginal Perfusion Parameters

BACKGROUND

This study examines outcomes of deceased donor kidney transplantation (DDKT) in recipients of kidney allografts with marginal perfusion parameters.

METHODS

Allografts with marginal perfusion parameters (resistance index [RI] >0.4 and pump flow rate [F] <70 mL/min; MP group) were compared with those with good parameters (RI <0.4 and F >70 mL/min; GP group) for DDKT recipients between January 1996 and November 2017 after hypothermic pulsatile perfusion. Demographics, creatinine, cold ischemia times (CIT), delayed graft function (DGF), and recipient glomerular filtration rate at pre- and post-transplant were noted. The primary outcome was graft survival post-transplant.

RESULTS

In the MP (n = 31) versus GP (n = 1281) group, the median recipient was aged 57 years versus 51 years; the median donor was aged 47 versus 37 years; terminal creatinine was 0.9 versus 0.9 mg/dL; CIT was 10.2 versus 13 hours, and the RI and flow were 0.46 and 60 mL/min versus 0.21 and 120 mL/min. The DGF rate was 19% (MP) versus 8% (GP). The graft survival in the MP versus GP group was 81% versus 90% (1 year), 65% versus 79% (3 years), 65% versus 73% (4 years), and 45% versus 68% (5 years).

CONCLUSION

Carefully selected kidney allografts after comprehensive donor and recipient evaluation may allow for the use of these routinely discarded kidneys with marginal perfusion parameters.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

The association of aldosterone and endothelin-1 with incident diabetes among African Americans: The Jackson Heart Study

Introduction

African Americans (AAs) have the highest prevalence of hypertension among United States racial/ethnic groups. Regulators of blood pressure, such as aldosterone and endothelin-1, impact glucose regulation. The relationship between these factors and incident diabetes is not well elucidated among AAs.

Methods

Among 3914 AA participants without prevalent diabetes in the Jackson Heart Study, linear regression models were used to examine cross-sectional associations of exposures (aldosterone, endothelin-1, and a combined aldosterone-endothelin-1 score [2-8]) with glycemic measures (fasting plasma glucose [FPG], HbA1c, homeostatic model assessments of beta cell function [HOMA-β] and insulin resistance [HOMA-IR]). Longitudinal associations of exposures with incident diabetes were examined using Cox proportional hazard models. Models were adjusted for age, sex, education, occupation, systolic blood pressure, smoking, physical activity, dietary intake, alcohol use and adiponectin.

Results

Aldosterone and the combined aldosterone-endothelin score were positively associated with FPG, HOMA-IR, and HOMA-β (all p < 0.05). Endothelin-1 was negatively associated with FPG but positively associated with HOMA-β (both p < 0.05). Only the aldosterone-endothelin score was positively associated with HbA1c (p < 0.01). A 1-SD higher serum aldosterone and endothelin-1 was associated with a 22 % and 14 % higher risk of incident diabetes, respectively, while a 1-point higher aldosterone-endothelin score was associated with a 13 % higher risk of incident diabetes after adjustment for diabetes risk factors (all p < 0.01).

Conclusions

Aldosterone and endothelin-1, factors integral in blood pressure regulation, may play a significant role in the development of diabetes among AAs.

Effects of Hypocaloric Low-Fat, Ketogenic, and Ketogenic and Ketone Supplement Diets on Aldosterone and Renin

CONTEXT

Ketogenic diets (KDs) and low-fat diets (LFD) result in similar weight loss, but have differential cardiometabolic effects on lipids and insulin. Generally, weight loss decreases renin-angiotensin-aldosterone system (RAAS) activity.

OBJECTIVE

Investigate the effects of KDs with varying sodium content vs LFD on RAAS in overweight and obese adults.

METHODS

Twenty-eight participants were randomized 1:1 to a KD + ketone salt supplement (KD + KS) or a KD + placebo (KD + PL) arm with prepared hypocaloric meals. Twelve participants were enrolled in a post hoc LFD arm. Serum renin, aldosterone, and anthropometric and metabolic biomarkers were assessed at 0, 2, 4, and 6 weeks. Linear mixed models with random intercepts were used to compare between group differences controlling for sex and body mass index.

RESULTS

Participants had a median age of 33 years, 51% female, weighed 91.3 kg, with body mass index 30.6 kg/m2. At 6 weeks, weight decreased by 6, 8, and 7 kg on average in the KD + KS, KD + PL, and LFD groups, respectively (P < .05). Aldosterone increased by 88% and 144% in the KD + PL and KD + KS groups, respectively, but did not change in the LFD after 6 weeks while renin decreased across groups. Systolic and diastolic blood pressure did not change in the KD + PL and KD + KS groups. Log ketones were positively associated with aldosterone (P < .001). Aldosterone was not associated with cardiovascular measures including blood pressure and ejection fraction (P > .05).

CONCLUSION

KD reduced weight and increased aldosterone without worsening cardiometabolic risk factors. Future KD studies are needed to elucidate mechanistic connections between ketones and aldosterone.

Associations of minor histocompatibility antigens with outcomes following allogeneic hematopoietic cell transplantation

The role of minor histocompatibility antigens (mHAs) in mediating graft versus leukemia and graft versus host disease (GvHD) following allogeneic hematopoietic cell transplantation (alloHCT) is recognized but not well-characterized. By implementing improved methods for mHA prediction in two large patient cohorts, this study aimed to comprehensively explore the role of mHAs in alloHCT by analyzing whether (1) the number of predicted mHAs, or (2) individual mHAs are associated with clinical outcomes. The study population consisted of 2249 donor-recipient pairs treated for acute myeloid leukemia and myelodysplastic syndrome with alloHCT. A Cox proportional hazard model showed that patients with a class I mHA count greater than the population median had an increased hazard of GvHD mortality (hazard ratio [HR] = 1.39, 95% confidence interval [CI] = 1.01, 1.77, p = .046). Competing risk analyses identified the class I mHAs DLRCKYISL (GSTP), WEHGPTSLL (CRISPLD2), and STSPTTNVL (SERPINF2) were associated with increased GVHD mortality (HR = 2.84, 95% CI = 1.52, 5.31, p = .01), decreased leukemia-free survival (LFS) (HR = 1.94, 95% CI = 1.27, 2.95, p = .044), and increased disease-related mortality (DRM) (HR = 2.32, 95% CI = 1.5, 3.6, p = .008), respectively. One class II mHA YQEIAAIPSAGRERQ (TACC2) was associated with increased risk of treatment-related mortality (TRM) (HR = 3.05, 95% CI = 1.75, 5.31, p = .02). WEHGPTSLL and STSPTTNVL were both present within HLA haplotype B*40:01-C*03:04 and showed a positive dose-response relationship with increased all-cause mortality and DRM and decreased LFS, indicating these two mHAs contribute to the risk of mortality in an additive manner. Our study reports the first large-scale investigation of the associations of predicted mHA peptides with clinical outcomes following alloHCT.

Association between skeletal muscle mitochondrial dysfunction and insulin resistance in patients with rheumatoid arthritis: a case-control study

BACKGROUND

Insulin resistance affects a substantial proportion of patients with rheumatoid arthritis (RA). Skeletal muscle mitochondrial dysfunction results in the accumulation of lipid intermediates that interfere with insulin signaling. We therefore sought to determine if lower oxidative phosphorylation and muscle mitochondrial content are associated with insulin resistance in patients with RA.

METHODS

This was a cross-sectional prospective study of RA patients. Matsuda index from the glucose tolerance test was used to estimate insulin sensitivity. Mitochondrial content was measured by citrate synthase (CS) activity in snap-frozen muscle samples. Mitochondrial function was measured by using high-resolution respirometry of permeabilized muscle fibers and electron transport chain complex IV enzyme kinetics in isolated mitochondrial subpopulations.

RESULTS

RA participants demonstrated lower insulin sensitivity as measured by the Matsuda index compared to controls [median 3.95 IQR (2.33, 5.64) vs. 7.17 (5.83, 7.75), p = 0.02]. There was lower muscle mitochondrial content among RA vs. controls [median 60 mU/mg IQR (45, 80) vs. 79 mU/mg (65, 97), p = 0.03]. Notably, OxPhos normalized to mitochondrial content was higher among RA vs. controls [mean difference (95% CI) = 0.14 (0.02, 0.26), p = 0.03], indicating a possible compensatory mechanism for lower mitochondrial content or lipid overload. Among RA participants, the activity of muscle CS activity was not correlated with the Matsuda index (ρ =  - 0.05, p = 0.84), but it was positively correlated with self-reported (IPAQ) total MET-minutes/week (ρ = 0.44, p = 0.03) and Actigraph-measured time on physical activity (MET rate) (ρ = 0.47, p = 0.03).

CONCLUSIONS

Mitochondrial content and function were not associated with insulin sensitivity among participants with RA. However, our study demonstrates a significant association between muscle mitochondrial content and physical activity level, highlighting the potential for future exercise interventions that enhance mitochondrial efficiency in RA patients.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study

BACKGROUND

Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes.

METHODS

A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions.

SETTING

Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest.

DESIGN

2 × 2 factorial design.

INTERVENTIONS

Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce.

OUTCOMES

Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months.

DISCUSSION

Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity.

CLINICALTRIALS

gov: NCT05472441.

The Role of Aldosterone and Ideal Cardiovascular Health in Incident Cardiovascular Disease: The Jackson Heart Study

Background

Higher levels of ideal cardiovascular health (ICH) are associated with lower levels of aldosterone and incidence of cardiovascular disease (CVD). However, the degree to which aldosterone mediates the association between ICH and CVD incidence has not been explored. Thus, we investigated the mediational role of aldosterone in the association of 5 components of ICH (cholesterol, body mass index (BMI), physical activity, diet and smoking) with incident CVD and the mediational role of blood pressure (BP) and glucose in the association of aldosterone with incident CVD in a cohort of African Americans (AA).

Methods

The Jackson Heart Study is a prospective cohort of AAs adults with data on CVD outcomes. Aldosterone, ICH metrics and baseline characteristics were collected at exam 1 (2000-2004). ICH score was developed by summing 5 ICH metrics (smoking, dietary intake, physical activity, BMI, and total cholesterol) and grouped into two categories (0-2 and ≥3 metrics). Incident CVD was defined as stroke, coronary heart disease, or heart failure. Cox proportional hazard regression models were used to model the association of categorical ICH score with incident CVD. The R Package Mediation was utilized to examine: 1) The mediational role of aldosterone in the association of ICH with incident CVD and 2) The mediational role of blood pressure and glucose in the association of aldosterone with incident CVD.

Results

Among 3,274 individuals (mean age: 54±12.4 years, 65% female), there were 368 cases of incident CVD over a median of 12.7 years. The risk of incident CVD was 46% lower (HR: 0.54; 95%CI 0.36, 0.80) in those with ≥3 ICH metrics at baseline compared to 0-2. Aldosterone mediated 5.4% (p = 0.006) of the effect of ICH on incident CVD. A 1-unit increase in log-aldosterone was associated with a 38% higher risk of incident CVD (HR 1.38, 95%CI: 1.19, 1.61) with BP and glucose mediating 25.6% (p<0.001) and 4.8% (p = 0.048), respectively.

Conclusion

Aldosterone partially mediates the association of ICH with incident CVD and both blood pressure and glucose partially mediate the association of aldosterone with incident CVD, emphasizing the potential importance of aldosterone and ICH in risk of CVD among AAs.

High surgical volume is associated with improved survival in head and neck cancer

OBJECTIVES

Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS & METHODS

A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival.

RESULTS

Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]).

CONCLUSIONS

Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.

Feasibility of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet <10% of adults with diabetes manage their condition successfully. Feasible interventions are needed urgently.

OBJECTIVE

Our aim was to assess the feasibility of a cooking intervention with food provision and diabetes self-management education and support.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Thirteen adults with type 1 or type 2 diabetes who participated in Cooking Matters for Diabetes (CMFD) participated in 2 focus groups.

INTERVENTION

CMFD was adapted from Cooking Matters and the American Diabetes Association's diabetes self-management education and support intervention into a 6-week program with weekly lesson-aligned food provisions.

MAIN OUTCOME MEASURES

Feasibility was evaluated quantitatively and qualitatively along the following 5 dimensions: demand, acceptability, implementation, practicality, and limited efficacy.

STATISTICAL ANALYSIS

Two coders extracted focus group themes with 100% agreement after iterative analysis, resulting in consensus. Administrative data were analyzed via descriptive statistics.

RESULTS

Mean (SD) age of focus group participants was 57 (14) years; 85% identified as female; 39% identified as White; 46% identified as Black; and income ranged from <$5,000 per year (15%) to $100,000 or more per year (15%). Mean (SD) baseline hemoglobin A1c was 8.6% (1.2%). Mean attendance in CMFD was 5 of 6 classes (83%) among all participants. Demand was high based on attendance and reported intervention utilization and was highest among food insecure participants, who were more likely to report using the food provisions and recipes. Acceptability was also high; focus groups revealed the quality of instructors and interaction with peers as key intervention strengths. Participant ideas for implementation refinement included simplifying recipes, lengthening class sessions, and offering more food provision choices. Perceived effects of the intervention included lower hemoglobin A1c and body weight and improvements to health-related quality of life.

CONCLUSIONS

The CMFD intervention was feasible according to the measured principles of demand, acceptability, implementation, practicality, and limited efficacy.

Youth Suicide During the First Year of the COVID-19 Pandemic

OBJECTIVE

To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies.

METHODS

This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020).

RESULTS

Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected.

CONCLUSIONS

Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Childhood environment early life stress, caregiver warmth, and associations with the cortisol diurnal curve in adulthood: The coronary artery risk development in young adults (CARDIA) study

BACKGROUND

Early life stress (ELS) is associated with increased morbidity and mortality across the lifecourse. Studies observing a relationship between ELS and stress physiology (cortisol), may help explain the connection to poor health outcomes, but have been limited by cortisol measures used.

PURPOSE

We examined the association between ELS measured by a Risky Family (RF) environment questionnaire, and adult diurnal cortisol profile inclusive of multiple cortisol measures.

METHODS

RF and cortisol were collected from Coronary Artery Risk Development in Young Adults Study participants at follow-up (Year 15). Complete case (n = 672) data were included in multi-variable regression analyses with log transformed cortisol measures (outcomes) including wake-up cortisol, cortisol awakening response [CAR], AUC and five other cortisol diurnal curve measures.

RESULTS

Participants were age 39.9 + /- 3.7 years and 51.6% Black. For every 1 unit increase in RF, there was a 1.4% greater wake-up cortisol and flatter CAR after adjustment for age, sex, income, and smoking (B=0.014, p = 0.023; B=-0.014, p = 0.028, respectively). Each unit increase in caregiver warmth/affection was associated with a 6.9% higher (steeper) CAR (B=0.069, p = 0.03). Results remained significant after adjusting for other covariates except social support in adulthood. An interaction between child abuse and caregiver warmth was nearly significant (p = 0.068), such that for those with exposure to the greatest caregiver warmth and lowest child abuse, CAR was steepest CONCLUSIONS: We demonstrate that ELS is associated with altered cortisol regulation in adulthood. However, further research is needed to assess how healthy relationships throughout the life course may modulate cortisol regulation in adulthood.

Outcomes of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet only 1 in 2 adults with diabetes attain hemoglobin A1c (HbA1c) targets. Food insecurity makes diabetes management and HbA1c control more difficult.

OBJECTIVE

Our aim was to test whether a cooking intervention with food provision and diabetes self-management education and support improves HbA1c and diabetes management.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Participants were 48 adults with type 1 or type 2 diabetes.

INTERVENTION

Cooking Matters for Diabetes was adapted from Cooking Matters and the American Diabetes Association diabetes self-management education and support intervention into a 6-week program with weekly food provision (4 servings).

MAIN OUTCOME MEASURES

Surveys (ie, Summary of Diabetes Self-Care Activities; Medical Outcomes Study Short Form Health Survey, version 1; Diet History Questionnaire III; 10-item US Adult Food Security Survey Module; and Stanford Diabetes Self-Efficacy Scale) were administered and HbA1c was measured at baseline, post intervention, and 3-month follow-up.

STATISTICAL ANALYSIS

Mixed-effects linear regression models controlling for sex and study wave were used.

RESULTS

Mean (SD) age of participants was 57 (12) years; 65% identified as female, 52% identified as White, 40% identified as Black, and 19 (40%) were food insecure at baseline. Intervention participants improved Summary of Diabetes Self-Care Activities general diet score (0 to 7 scale) immediately post intervention (+1.51; P = .015) and 3 months post intervention (+1.23; P = .05), and improved Medical Outcomes Study Short Form Health Survey, version 1, mental component score (+6.7 points; P = .025) compared with controls. Healthy Eating Index 2015 total vegetable component score improved at 3 months (+0.917; P = .023) compared with controls. At baseline, food insecure participants had lower self-efficacy (5.6 vs 6.9 Stanford Diabetes Self-Efficacy Scale; P = .002) and higher HbA1c (+0.77; P = .025), and demonstrated greater improvements in both post intervention (+1.2 vs +0.4 Stanford Diabetes Self-Efficacy Scale score; P = .002, and -0.12 vs +0.39 HbA1c; P = .25) compared with food secure participants.

CONCLUSIONS

Cooking Matters for Diabetes may be an effective method of improving diet-related self-care and health-related quality of life, especially among food insecure patients, and should be tested in larger randomized controlled trials.

Addressing non-medical health-related social needs through a community-based lifestyle intervention during the COVID-19 pandemic: The Black Impact program

BACKGROUND

Non-medical health-related social needs (social needs) are major contributors to worse health outcomes and may have an adverse impact on cardiovascular risk factors and cardiovascular disease. The present study evaluated the effect of a closed-loop community-based pathway in reducing social needs among Black men in a lifestyle change program.

METHODS

Black men (n = 70) from a large Midwestern city participated in Black Impact, a 24-week community-based team lifestyle change single-arm pilot trial adapted from the Diabetes Prevention Program and American Heart Association's (AHA) Check, Change, Control Blood Pressure Self-Management Program, which incorporates AHA's Life's Simple 7 (LS7) framework. Participants were screened using the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs Screening Tool. Participants with affirmative responses were referred to a community hub pathway to address social needs. The primary outcome for this analysis is change in social needs based on the CMS social needs survey at 12 and 24 weeks using mixed effect logistic regressions with random intercepts for each participant. Change in a LS7 score (range 0-14) from baseline to 12 and 24 weeks was evaluated using a linear mixed-effects model stratified by baseline social needs.

RESULTS

Among 70 participants, the mean age of participants was 52 ±10.5 years. The men were sociodemographically diverse, with annual income ranging from <$20,000 (6%) to ≥$75,000 (23%). Forty-three percent had a college degree or higher level of education, 73% had private insurance, and 84% were employed. At baseline 57% of participants had at least one social need. Over 12 and 24 weeks, this was reduced to 37% (OR 0.33, 95%CI: 0.13, 0.85) and 44% (OR 0.50, 95%CI: 0.21, 1.16), respectively. There was no association of baseline social needs status with baseline LS7 score, and LS7 score improved over 12 and 24 weeks among men with and without social needs, with no evidence of a differential effect.

CONCLUSIONS

The Black Impact lifestyle change single-arm pilot program showed that a referral to a closed-loop community-based hub reduced social needs in Black men. We found no association of social needs with baseline or change in LS7 scores. Further evaluation of community-based strategies to advance the attainment of LS7 and address social needs among Black men in larger trials is warranted.

A comprehensive survey of collaborative biostatistics units in academic health centers

The organizational structures of collaborative biostatistics units in academic health centers (AHCs) in the United States and their important contributions to research are an evolving and active area of discussion and inquiry. Collaborative biostatistics units may serve as a centralized resource to investigators across various disciplines or as shared infrastructure for investigators within a discipline (e.g., cancer), or a combination of both. The characteristics of such units vary greatly, and there has been no comprehensive review of their organizational structures described in the literature to date. This manuscript summarizes the current infrastructure of such units using responses from 129 leaders. Most leaders were over 45 years old, held doctoral degrees, and were on a 12-month appointment. Over half were tenured or on a tenure track and held primary appointments in a school of medicine. Career advancement metrics most important included being funded as co-investigator on NIH grants and being either first or second author on peer-reviewed publications. Team composition was diverse in terms of expertise and training, and funding sources were typically hybrid. These results provide a benchmark for collaboration models and evaluation and may be used by institutional administrators as they build, evaluate, or restructure current collaborative quantitative support infrastructure.

Association Between Social Determinants of Health and Glycemic Control Among African American People with Type 2 diabetes: The Jackson Heart Study

BACKGROUND

Social determinants of health have a significant impact on health outcomes. However, the complexity and interaction of multiple factors influencing glycemic control remain understudied.

PURPOSE

This study examined associations of socioeconomic position (income, education, and occupation), environmental (physical activity facilities, neighborhood social cohesion, neighborhood problem, and violence), behavioral (physical activity, nutrition, and smoking), and psychological factors (depressive symptoms, stress, and discrimination) with glycemic control (hemoglobin A1c [A1c]) using the World Health Organization Social Determinants of Health framework in African American adults with type 2 diabetes.

METHODS

A secondary data analysis was conducted using a longitudinal cohort of 1,240 African American adults with type 2 diabetes who participated in the community-based Jackson Heart Study. Socioeconomic position, environmental, behavioral, and psychological factors were measured using validated instruments in the Jackson Heart Study. Longitudinal structural equation modeling was used with glycemic control (A1c) collected over time (Exams 1-3) as the study outcome.

RESULTS

Our study presents the complex interplay of socioeconomic determinants of health and glycemic control over time. Higher socioeconomic position (higher income, higher level of education, and professional occupation) was directly associated with improvement in glycemic control over time. An association of socioeconomic position on glycemic control mediated through health behavior factors was also observed.

CONCLUSIONS

In this analysis, socioeconomic position components were determinants of glycemic control in African American adults with type 2 diabetes. Future studies aimed at reducing health disparities and achieving equality of outcomes in this population will benefit from embedding socioeconomic position components into their design.

Associations of Cardiometabolic Multimorbidity With All-Cause and Coronary Heart Disease Mortality Among Black Adults in the Jackson Heart Study

IMPORTANCE

A combination of diabetes, coronary heart disease (CHD), and stroke has multiplicative all-cause mortality risk compared with any individual morbidity in White populations, but there is a lack of studies in Black populations in the US.

OBJECTIVE

To examine the association of cardiometabolic multimorbidity (diabetes, stroke, and CHD) individually and collectively with all-cause and CHD mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included Black adults in the Jackson Heart Study followed over a median of 15 years. Baseline examinations were performed between 2000 and 2004, with follow-up on all-cause and CHD mortality through May 31, 2018. Participants were categorized into mutually exclusive groups at baseline: (1) free of cardiometabolic morbidity, (2) diabetes, (3) CHD, (4) stroke, (5) diabetes and stroke, (6) CHD and stroke, (7) diabetes and CHD, and (8) diabetes, stroke, and CHD. Data were analyzed from 2019 to 2021.

EXPOSURE

Cardiometabolic disease alone or in combination.

MAIN OUTCOMES AND MEASURES

The main outcomes were all-cause mortality and CHD mortality. Cox models estimated hazard ratios (HRs) with 95% CIs adjusted for sociodemographic and cardiovascular risk factors.

RESULTS

Among 5064 participants (mean [SD] age, 55.4 [12.8] years; 3200 [63%] women) in the Jackson Heart Study, 897 (18%) had diabetes, 192 (4%) had CHD, and 104 (2%) had a history of stroke. Among participants with cardiometabolic morbidities, the crude all-cause mortality rates were lowest for diabetes alone (24.4 deaths per 1000 person-years) and highest for diabetes, CHD, and stroke combined (84.1 deaths per 1000 person-years). For people with only 1 cardiometabolic morbidity, risk for all-cause mortality was highest for people with stroke (HR, 1.74; 95% CI, 1.24-2.42), followed by CHD (HR, 1.59 (95% CI, 1.22-2.08) and diabetes (HR, 1.50; 95% CI, 1.22-1.85), compared with no cardiometabolic morbidities. There were also increased risks of mortality with combinations of diabetes and stroke (HR, 1.71; 95% CI, 1.09-2.68), CHD and stroke (HR, 2.23; 95% CI, 1.35-3.69), and diabetes and CHD (HR, 2.28; 95% CI, 1.65-3.15). The combination of diabetes, stroke, and CHD was associated with the highest all-cause mortality (HR, 3.68; 95% CI, 1.96-6.93). Findings were similar for CHD mortality, but with a larger magnitude of association (eg, diabetes, stroke, and CHD: HR, 13.52; 95% CI, 3.38-54.12).

CONCLUSIONS AND RELEVANCE

In this cohort study, an increasing number of cardiometabolic multimorbidities was associated with a multiplicative increase in risk of all-cause mortality among Black adults, with a greater magnitude of association for CHD mortality.

Association of Bariatric Surgery With Cardiovascular Outcomes in Adults With Severe Obesity and Nonalcoholic Fatty Liver Disease

IMPORTANCE

There are no approved treatments for nonalcoholic fatty liver disease (NAFLD) despite its association with obesity and increased risk of cardiovascular disease (CVD).

OBJECTIVE

To examine the association between bariatric surgery and CVD risk in individuals with severe obesity and NAFLD.

DESIGN, SETTING, AND PARTICIPANTS

This large, population-based retrospective cohort study obtained data from the MarketScan Commercial Claims and Encounters database from January 1, 2007, to December 31, 2017. Participants included insured adults aged 18 to 64 years with NAFLD and severe obesity (body mass index ≥40) without a history of bariatric surgery or CVD before NAFLD diagnosis. Baseline characteristics were balanced between individuals who underwent surgery (surgical group) and those who did not (nonsurgical group) using inverse probability of treatment weighting. Data were analyzed from March 2020 to April 2021.

EXPOSURES

Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, and other bariatric procedures) vs nonsurgical care.

MAIN OUTCOMES AND MEASURES

The main outcome was the incidence of cardiovascular events (primary or secondary composite CVD outcomes). The primary composite outcome included myocardial infarction, heart failure, or ischemic stroke, and the secondary composite outcome included secondary ischemic heart events, transient ischemic attack, secondary cerebrovascular events, arterial embolism and thrombosis, or atherosclerosis. Cox proportional hazards regression models with inverse probability treatment weighting were used to examine the associations between bariatric surgery, modeled as time varying, and all outcomes.

RESULTS

The study included 86 964 adults (mean [SD] age, 44.3 [10.9] years; 59 773 women [68.7%]). Of these individuals, 30 300 (34.8%) underwent bariatric surgery and 56 664 (65.2%) received nonsurgical care. All baseline covariates were balanced after applying inverse probability treatment weighting. In the surgical group, 1568 individuals experienced incident cardiovascular events compared with 7215 individuals in the nonsurgical group (incidence rate difference, 4.8 [95% CI, 4.5-5.0] per 100 person-years). At the end of the study, bariatric surgery was associated with a 49% lower risk of CVD (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.48-0.54) compared with nonsurgical care. The risk of primary composite CVD outcomes was reduced by 47% (aHR, 0.53 [95% CI, 0.48-0.59), and the risk of secondary composite CVD outcomes decreased by 50% (aHR, 0.50; 95% CI, 0.46-0.53) in individuals with vs without surgery.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that, compared with nonsurgical care, bariatric surgery was associated with significant reduction in CVD risk in individuals with severe obesity and NAFLD.

Long-term changes in plasma proteomic profiles in premenopausal and postmenopausal Black and White women: the Atherosclerosis Risk in Communities study

OBJECTIVE

The activity, localization, and turnover of proteins within cells and plasma may contribute to physiologic changes during menopause and may influence disease occurrence. We examined cross-sectional differences and long-term changes in plasma proteins between premenopausal and naturally postmenopausal women.

METHODS

We used data from 4,508 (19% Black) women enrolled in the Atherosclerosis Risk in Communities study. SOMAscan multiplexed aptamer technology was used to measure 4,697 plasma proteins. Linear regression models were used to compare differences in proteins at baseline (1993-1995) and 18-year change in proteins from baseline to 2011-2013.

RESULTS

At baseline, 472 women reported being premenopausal and 4,036 women reported being postmenopausal, with average ages of 52.3 and 61.4 years, respectively. A greater proportion of postmenopausal women had diabetes (15 vs 9%), used hypertension (38 vs 27%) and lipid-lowering medications (10 vs 3%), and had elevated total cholesterol and waist girth. In multivariable adjusted models, 38 proteins differed significantly between premenopausal and postmenopausal women at baseline, with 29 of the proteins also showing significantly different changes between groups over the 18-year follow-up as the premenopausal women also reached menopause. These proteins were associated with various molecular/cellular functions (cellular development, growth, proliferation and maintenance), physiological system development (skeletal and muscular system development, and cardiovascular system development and function), and diseases/disorders (hematological and metabolic diseases and developmental disorders).

CONCLUSIONS

We observed significantly different changes between premenopausal and postmenopausal women in several plasma proteins that reflect many biological processes. These processes may help to understand disease development during the postmenopausal period.

MR Elastography of Abdominal Aortic Aneurysms: Relationship to Aneurysm Events

Background Abdominal aortic aneurysm (AAA) diameter remains the standard clinical parameter to predict growth and rupture. Studies suggest that using solely AAA diameter for risk stratification is insufficient. Purpose To evaluate the use of aortic MR elastography (MRE)-derived AAA stiffness and stiffness ratio at baseline to identify the potential for future aneurysm rupture or need for surgical repair. Materials and Methods Between August 2013 and March 2019, 72 participants with AAA and 56 healthy participants were enrolled in this prospective study. MRE examinations were performed to estimate AAA stiffness and the stiffness ratio between AAA and its adjacent remote normal aorta. Two Cox proportional hazards models were used to assess AAA stiffness and stiffness ratio for predicting aneurysmal events (subsequent repair, rupture, or diameter >5.0 cm). Log-rank tests were performed to determine a critical stiffness ratio suggesting high-risk AAAs. Baseline AAA stiffness and stiffness ratio were studied using Wilcoxon rank-sum tests between participants with and without aneurysmal events. Spearman correlation was used to investigate the relationship between stiffness and other potential imaging markers. Results Seventy-two participants with AAA (mean age, 71 years ± 9 [SD]; 56 men and 16 women) and 56 healthy participants (mean age, 42 years ± 16; 27 men and 29 women) were evaluated. In healthy participants, aortic stiffness positively correlated with age (ρ = 0.44; P < .001). AAA stiffness (event group [n = 21], 50.3 kPa ± 26.5 [SD]; no-event group [n = 21], 86.9 kPa ± 52.6; P = .01) and the stiffness ratio (event group, 0.7 ± 0.4; no-event group, 2.0 ± 1.4; P < .001) were lower in the event group than the no-event group at a mean follow-up of 449 days. AAA stiffness did not correlate with diameter in the event group (ρ = -0.06; P = .68) or the no-event group (ρ = -0.13; P = .32). AAA stiffness was inversely correlated with intraluminal thrombus area (ρ = -0.50; P = .01). Conclusion Lower abdominal aortic aneurysm stiffness and stiffness ratio measured with use of MR elastography was associated with aneurysmal events at a 15-month follow-up. © RSNA, 2022 See also the editorial by Sakuma in this issue.

Vitamin D, parathyroid hormone, glucose metabolism and incident diabetes in the multiethnic study of atherosclerosis

INTRODUCTION

Higher concentrations of serum 25-hydroxyvitamin D (25(OH)D) and lower concentrations of parathyroid hormone (PTH) are associated with lower insulin resistance and incident diabetes in non-Hispanic White and Hispanic Americans. Results are mixed in other populations, with no observational studies in a large multiethnic cohort. The association of serum 25(OH)D with diabetes may vary by adiposity level.

RESEARCH DESIGN AND METHODS

Among 5611 participants in the Multi-Ethnic Study of Atherosclerosis without diabetes at baseline, cross-sectional associations of serum 25(OH)D with homeostasis model assessment of insulin resistance (HOMA-IR) and HOMA-β were examined using linear regressions. The association of 25(OH)D with incident diabetes over 9 years was examined using Cox proportional hazard regression.

RESULTS

Black Americans had the highest proportion of individuals with 25(OH)D<20 ng/mL (61%) and White Americans had the least (17%). Serum 25(OH)D was inversely associated with HOMA-IR in fully adjusted models (-0.34% difference in HOMA-IR per ng/mL higher 25(OH)D, p<0.0001). Longitudinally, a 1 ng/mL higher serum 25(OH)D was associated with 2% lower risk of incident diabetes (HR 0.982, CI 0.974 to 0.991), and a 1 pg/mL higher serum PTH was associated with 1% higher risk of incident diabetes (HR 1.007, CI 1.004 to 1.010), both prior to adjustment for waist circumference. After adjusting for waist circumference, a 1 ng/mL higher 25(OH)D was associated with 1% lower risk of incident diabetes (HR 0.991, CI 0.983 to 1.000). The magnitude of association of serum 25(OH)D with incident diabetes was largest at lower waist circumference (p for interaction=0.025). There was no heterogeneity by race/ethnicity (p=0.317).

CONCLUSIONS

Serum 25(OH)D is inversely associated with insulin resistance and incident diabetes in a diverse cohort, including non-Hispanic White, Black, Hispanic and Chinese Americans. Future research should explore mechanisms for the interaction between serum 25(OH)D and adiposity in this relationship.

Quantitative dynamic wearable motion-based metric compared to patient-reported outcomes as indicators of functional recovery after lumbar fusion surgery

BACKGROUND

Low back pain is a debilitating condition with poor patient outcomes despite the use of a wide variety of diagnostic and treatment modalities. A lack of objective metrics to support clinical decision-making may be a reason for these poor outcomes. This study aimed to compare patient recovery following lumbar fusion surgery using an objective motion-based metric (functional performance) and subjective patient-reported outcomes for pain, disability and kinesophobia.

METHODS

A prospective observational study was conducted on 121 patients that received a lumbar fusion surgery. A wearable motion system was used to quantify three-dimensional multi-planar lumbar motion and benchmark each patient's lumbar function prior to surgery and post-operatively at follow-up time points for up to 2 years. Patient recovery profiles after surgery were evaluated using the acquired functional motion data and compared to patient-reported outcomes.

FINDINGS

Our results found significant improvement after surgery in objective functional performance as well as patient-reported pain, disability, and kinesophobia. However, we found a delayed response in the objective metric, with meaningful improvement occurring only 6 months after fusion surgery. In contrast, we found significant improvement in all subjective scores as early as 6 weeks post-surgery.

INTERPRETATION

Objective motion-based metric provides a unique perspective to assessing patient's functional recovery. While it is associated with dimensions of pain, disability and fear avoidance, it is also distinct and assesses a uniquely different dimension of functional health. This information can form the basis for the use of objective metrics to gauge patient recovery after lumbar fusion surgery.

LTBK-05. Outcomes of Infants and Young Children with Newly Diagnosed Localized (M0) SHH Medulloblastoma Treated on The NEXT Consortium “Head Start” 4 Protocol

Advances in RNA and DNA profiling have identified four core molecular subgroups of medulloblastoma of prognostic significance: Sonic Hedgehog (SHH) subtype, WNT subtype, Group 3, and Group 4. Infants and young children with SHH medulloblastoma have demonstrated a favorable outcome in clinical trials utilizing either high-dose chemotherapy (“Head Start”) or a combination of intravenous and intraventricular methotrexate (HIT-SKK). Two recently conducted clinical trials (COG ACNS1221 and St. Jude – SJYC07) failed to demonstrate similar survival advantage with conventional dose chemotherapy and without intraventricular methotrexate. “Head Start” 4 (HS 4) is a prospective randomized clinical trial that tailors treatment based on medulloblastoma molecular subgroups and response to induction chemotherapy to compare the efficacy of one versus versus three (tandem) cycles of myeloablative therapy. Eligibility includes newly diagnosed children less than six years of age with localized medulloblastoma. Eligible patients with SHH medulloblastoma were considered “low-risk” and non-randomly assigned to receive three cycles of induction chemotherapy (vincristine, cisplatin, cyclophosphamide, etoposide, and high-dose methotrexate) followed by consolidation with single cycle of myeloablative chemotherapy (thiotepa, carboplatin, etoposide) and autologous hematopoietic progenitor cell rescue. Patients with less than a complete response after three induction cycles received two additional cycles prior to consolidation therapy. Only children between 6 -10 years old, or those with confirmed residual tumor post-consolidation, were meant to receive irradiation after consolidation. Twenty-eight children with localized SHH medulloblastoma were enrolled on the trial with a median age of 2.1 years (range: 0.3-5.9 years). Median follow-up for this cohort is 29.6 months (range: 7.0-58.6 months). The estimated 3-year event-free (EFS) and overall survival (OS) is 96% (CI: 89-100%) and 100%, respectively. The estimated 3-year EFS for SHH subtype 1 and 2 patients is 100% and 95%, respectively (p=0.65). None of the M0 SHH medulloblastoma patients received irradiation.

0363 Perceptions of the Need for Perioperative OSA Education: An Interdisciplinary and Multi-Institutional Survey

Introduction

Advanced Practice Providers (APPs; Advanced practice registered nurses, physician assistants) and physicians-in-training (residents, fellows) receive inadequate education on obstructive sleep apnea (OSA)/perioperative OSA risks. However, they are front-line providers assessing these patients. Failure to mitigate this risk has led to significant postoperative morbidity/mortality. We assessed these providers’ perceptions to OSA/perioperative OSA training.

Methods

Surveys were sent to three provider roles, APPs, residents, and fellows, in four categories of practice at nine academic institutions between May 9-June 30, 2021. Chi-square and Fisher’s exact tests assessed association between survey responses and participant characteristics. False discovery rate adjustment accounted for multiple comparisons, threshold of q&lt;0.05 for statistical significance. Cochran-Mantel-Haenzsel tests evaluated associations stratified by institution.

Results

2236 of 6724 (33.3%) participants responded: 48.4% APPs, 11% Fellows and 40.6% Residents. Primary category of practice included: 20.3% Anesthesiology, 8.9% Family Medicine, 34.1%, Internal Medicine (IM)/IM subspecialties, 6.7% Obstetrics/Gynecology/Gynecologic Oncology, 25.9% Surgery/Surgery subspecialties, 4.1% Other.While 93.2% of respondents believed OSA is a risk factor for perioperative complications, fewer respondents reported that they felt adequately trained to assess for OSA (50.9%) in general, with significant differences noted by provider role (range 42-70%, q=0.001) and across the categories of practice (range 12-82%, q=0.001). Even fewer felt adequately trained to assess for OSA in perioperative patients (38.2%) with significant differences noted by provider role (range 31-52%, q=0.001) and across the categories of practice (range 15-84%, q=0.001).Across all categories of practice, respondents indicated that they would like additional educational training about OSA (76.7%). This varied by clinical role (range 64-82%, q=0.003), but not categories of practice (range 73-84%, q=0.13). Furthermore, respondents indicated they also desired additional education about OSA in the perioperative patient (75.5%). This extended across all clinical roles (range 68-77%, q=0.09) and categories of practice (range 72-80%, q=0.09).

Conclusion

We found significant differences in APP and physician-in-training perceptions of the adequacy of their current training and desire for further OSA/perioperative OSA education. Our study identifies a critical gap and opportunity to improve provider understanding and patient care.

Support (If Any)

American Academy of Sleep Medicine Foundation (AASMF) award.

Rationale and design of a randomized controlled clinical trial; Titration of oxygen levels (TOOL) during mechanical ventilation

BACKGROUND

Both hyperoxemia and hypoxemia are deleterious in critically ill patients. Targeted oxygenation is recommended to prevent both of these extremes, however this has not translated to the bedside. Hyperoxemia likely persists more than hypoxemia due to absence of immediate discernible adverse effects, cognitive biases and delay in prioritization of titration.

METHODS

We present the methodology for the Titration Of Oxygen Levels (TOOL) trial, an open label, randomized controlled trial of an algorithm-based FiO₂ titration with electronic medical record-based automated alerts. We hypothesize that the study intervention will achieve targeted oxygenation by curbing episodes of hyperoxemia while preventing hypoxemia. In the intervention arm, electronic alerts will be used to titrate FiO₂ if SpO₂ is ≥94% with FiO₂ levels ≥0.4 over 45 min. FiO₂ will be titrated per standard practice in the control arm. This study is being carried out with deferred consent. The sample size to determine efficacy is 316 subjects, randomized in a 1:1 ratio to the intervention vs. control arm. The primary outcome is proportion of time during mechanical ventilation spent with FiO₂ ≥ 0.4 and SpO₂ ≥ 94%. We will also assess proportion of time during mechanical ventilation spent with SpO₂ < 88%, duration of mechanical ventilation, length of ICU and hospital stay, hospital mortality, and adherence to electronic alerts as secondary outcomes.

CONCLUSION

This study is designed to evaluate the efficacy of a high fidelity, bioinformatics-based, electronic medical record derived electronic alert system to improve targeted oxygenation in mechanically ventilated patients by reducing excessive FiO₂ exposure.

Correlates of deliberate self-harm among youth with bipolar disorder

OBJECTIVE

Youth with bipolar disorder (BD) are at high risk for deliberate self-harm (DSH) and suicide. However, research regarding factors associated with DSH, a key suicide risk factor, among youth with BD is limited. In a population-based sample of youth with BD, we therefore investigated associations between demographic, clinical, and service utilization factors and DSH incidence and compared suicide, unintentional injury, and all-cause mortality to the general population.

METHOD

We analyzed a retrospective cohort of youth aged 5 to 19 years with a new BD episode between 2010 and 2017 (n = 25,244) using Ohio Medicaid claims and death certificate data. Cox proportional hazards models examined associations between different factors and DSH. Mortality rates were compared to the general population using standardized mortality ratios.

RESULTS

During follow-up, 1,517 (6.0%) youth had at least one DSH event. Older index age, female sex, comorbid psychiatric/medical conditions, prior DSH/suicidal ideation, and prior ER mental healthcare were associated with increased DSH risk. Prior DSH was most strongly associated with increased DSH risk for 3 months after a new BD episode. Being non-Hispanic Black (vs. White, non-Hispanic) and prior psychiatric hospitalization were associated with decreased DSH hazard. DSH risk was highest for 3 months after a new BD episode. Suicide, unintentional injury, and all-cause mortality rates were elevated in youth with BD.

LIMITATIONS

May not generalize to other states or non-Medicaid populations; claims data cannot distinguish suicidal intent of self-harm CONCLUSION: Early intervention following a new BD episode, particularly among high-risk groups, is key to prevent DSH.

Mental Health Service Utilization Among Medical Students with a Perceived Need for Care

OBJECTIVE

The authors investigated levels of perceived need for help, patterns of mental health service utilization, and barriers to care among US medical students with a focus on students who perceived a need for help but did not report service use in the past 12 months.

METHODS

The authors administered an online survey to 2,868 medical students at three schools in Ohio between January and February 2020 including validated scales for psychological distress, self-stigma, and an exploration of mental health treatment. The authors used multivariable logistic regression to identify factors associated with treatment and qualitative analysis to identify common barriers to care.

RESULTS

Twenty-eight percent (N = 800) of 2,868 students responded to the survey. Fifty-six percent (n = 439) of students reported a perceived need for help, while 34.6% of these respondents (n = 152) did not receive treatment. Among those with perceived need who completed the survey (n = 388), Asian students compared to non-Hispanic white students (adjusted odds ratio [aOR] = 0.45, 95% confidence interval [CI] 0.25-0.82) and those with higher self-stigma (aOR = 0.90, 95% CI 0.87-0.94) had lower odds of service use. Students told by others to seek help (aOR = 2.82, 95% CI 1.71-4.64) were the only group with higher odds of service use. The most common barriers to care were lack of time, difficulty accessing services, and stigma.

CONCLUSIONS

Despite a perceived need for help, many students do not seek care and experience treatment barriers. Schools can encourage help-seeking by identifying students in need, using targeted messaging, fostering a low-stigma environment, and removing barriers.

Postoperative Radiation Therapy in Oral Cavity Verrucous Carcinoma

OBJECTIVES/HYPOTHESIS

We investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) and its effect on overall survival (OS) for patients with oral cavity verrucous carcinoma (VC).

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of the National Cancer Database (NCDB) from 2006 to 2015 was performed. Multivariable logistic regression was used to identify independent predictive factors associated with the use of PORT. Cox Regression survival and propensity score analyses were used to evaluate the effect of PORT on mortality.

RESULTS

A total of 356 adult patients with primary oral cavity VC who underwent definitive surgical resection were identified. A total of 10.7% of patients underwent definitive surgical resection followed by PORT. Variables associated with PORT included distance to the hospital per 10 miles (adjusted odds ratio [aOR], 0.81 [95% confidence interval (CI), 0.70-0.95]) and stage III-IV disease (aOR, 12.13 and 23.92, respectively). Multivariable Cox regression survival analysis indicated no evidence of survival benefit in patients undergoing PORT compared to surgery alone (adjusted hazard ratio 1.50 [0.74-3.05], P = .23). Propensity score analysis also showed no OS benefit with the use of PORT (P = .41).

CONCLUSIONS

Variables associated with the use of PORT on multivariable analysis included closer distance to hospital and stage III-IV disease. No clear survival benefit with PORT was identified on either multivariable survival analysis or propensity score analysis. These results suggest that surgery alone with negative margins may be the optimal treatment for patients with oral cavity VC.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Improving Cardiovascular Health in Black Men Through a 24-Week Community-Based Team Lifestyle Change Intervention: The Black Impact Pilot Study

Background

Higher cardiovascular health scores, using American Heart Association's (AHA) Life's Simple 7 (LS7), have been associated with lower risk of cardiovascular disease, type 2 diabetes, cancer, and mortality among all racial/ethnic groups. Nationally, Black men have the lowest levels of LS7. Thus, a study was conducted to evaluate the impact of a community-based team lifestyle change program on LS7 among Black men.

Methods

Black adult males (n = 74) from a large Midwestern city participated in Black Impact, a 24-week community-based team lifestyle change program adapted from the Diabetes Prevention Program and AHA's Check, Change, Control Blood Pressure Self-Management Program, which incorporates AHA's LS7 framework. The change in a LS7 score (range 0–14) from baseline to 12 and 24 weeks was evaluated using a linear mixed-effects model adjusted for age, education, and income.

Results

The mean age of participants was 52 ± 10 years. The men were sociodemographically diverse, with annual income ranging from <$20,000 (7%) to ≥$75,000 (25%). Twenty-five percent were college graduates, 73% had private insurance, and 84% were employed. In fully adjusted models, LS7 score at baseline was 7.12 and increased 0.67 (95%CI: 0.14, 1.20, p = 0.013) and 0.93 (95%CI: 0.40, 1.46, p<0.001) points at 12 and 24 weeks, respectively, compared to baseline. Sensitivity analysis evaluating 5 components (excluding diet and physical activity) and 6 components (excluding diet) also showed significant increases at 12 and 24 weeks (all p<0.01).

Conclusions

The Black Impact lifestyle change single-arm pilot program showed that a community-based lifestyle intervention has the potential to improve LS7 in Black men. Further randomized studies are urgently needed to improve cardiovascular health and advance cardiovascular health equity in Black men.

Interaction effect of systemic inflammation and modifiable rheumatoid cachexia risk factors on resting energy expenditure in patients with rheumatoid arthritis

Background

In rheumatoid cachexia (RC), high resting energy expenditure (REE) is associated with loss of muscle mass driven by proinflammatory cytokines. The objectives of this study were to investigate parameters associated with RC, and the interaction between systemic inflammation and modifiable risk factors for RC on REE.

Methods

Thirty-five rheumatoid arthritis (RA) and nineteen non-RA controls comparable in age, sex, race and BMI underwent measures of REE by indirect calorimetry. Clinical, dietary, body composition and physical function data were collected. Homeostasis model assessment for insulin resistance (HOMA-IR) and serum interleukin-6 (IL-6) were used as parameters of IR and systemic inflammation, respectively. Regression models tested association between REE and dependent variables, including pre-specified interaction tests involving HOMA-IR and IL-6 and dietary intake of protein per weight (PPW) and IL-6.

Results

RA subjects were mostly women (94%) and had a median age of 54 years (50.5, 70) and BMI of 30.5 kg/m2 (26.1, 36.9). We observed a significant interaction effect between PPW and serum IL-6 on REE among RA subjects in the multiple regression model among RA. The upper tertile of PPW demonstrated a significant negative correlation between REE and IL-6 (β=-19.97, 95% CI [-35.41, -4.54], p=0.01). The lower tertile of PPW demonstrated a significant positive correlation between REE and IL-6 (β=42.24, 95% CI [4.25, 80.23], p=0.03).

Conclusions

While IR can lead to muscle catabolism, IR was not significantly associated with REE in RA individuals. Higher dietary protein intake could attenuate the effect of systemic inflammation on REE in RA patients.

Mortality and Cause of Death Among Youths Previously Incarcerated in the Juvenile Legal System

Importance

More than 50 000 youths are incarcerated in the United States on any given day, and youth incarceration has been linked to lasting adverse outcomes, including early mortality. Improving our understanding of the factors associated with early mortality among incarcerated youths can inform appropriate prevention strategies.

Objective

To examine mortality rates and causes of death among youths previously incarcerated in the juvenile legal system.

Design, Setting, and Participants

This retrospective longitudinal population-based cohort study compared mortality rates between youths aged 11 to 21 years incarcerated from 2010 to 2017 with same-aged nonincarcerated Medicaid-enrolled youths in the state of Ohio. Data from January 2017 to December 2019 were collected from juvenile incarceration, Medicaid, and death certificate information in Ohio.

Exposure

Incarceration in the state of Ohio's juvenile legal system.

Main Outcomes and Measures

Number, characteristics, and causes of deaths. Poisson regression incidence rate ratios (IRRs) compared mortality rates between previously incarcerated and Medicaid-enrolled youths.

Results

Among 3645 incarcerated youths, 3398 (93.2%) were male, 2155 (59.1%) Black, 1307 (35.9%) White, and 183 (5.0%) other race and ethnicity. Overall, 113 youths (3.1%) died during the study period. Homicide was the leading cause of death in formerly incarcerated youths (homicide: 63 [55.8%]; legal intervention [ie, death due to injuries inflicted by law enforcement]: 3 [2.7%]). All-cause mortality rates were significantly higher among previously incarcerated youths than Medicaid-enrolled youths (adjusted IRR [aIRR], 5.91; 95% CI, 4.90-7.13) in every demographic subgroup. Compared with Medicaid-enrolled youths, mortality rates for previously incarcerated youths were highest for homicide (aIRR, 11.02; 95% CI, 8.54-14.22), overdose (aIRR, 4.32; 95% CI, 2.59-7.20), and suicide (aIRR, 4.30; 95% CI, 2.22-8.33). Formerly incarcerated Black youths had a significantly higher risk of homicide (aIRR, 14.24; 95% CI, 4.45-45.63) but a lower risk of suicide (aIRR, 0.18; 95% CI, 0.04-0.89) and overdose (aIRR, 0.31; 95% CI, 0.10-0.99) than White youths who were incarcerated. Previously incarcerated youths aged 15 to 21 years were significantly more likely to die than youths aged 22 to 29 years, irrespective of cause of death (aIRR for youths aged 22-29 years, 0.09; 95% CI, 0.06-0.14).

Conclusions and Relevance

In this study, youths with a history of incarceration were significantly more likely to experience early mortality compared with nonincarcerated Medicaid-enrolled youths. Delinquency and violence prevention strategies that incorporate a culturally informed approach and consider sex and developmental level are critical.

Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis

Little is known about the risk factors for deliberate self-harm (DSH) and suicide among adolescents and young adults with first episode psychosis (FEP) and the longitudinal course of DSH following the initial onset of illness. This study identifies risk factors for DSH and suicide death among Medicaid-covered adolescents and young adults with FEP along with the periods of greatest risk for DSH after diagnosis. A retrospective longitudinal cohort analysis was performed using Medicaid claims data merged with death certificate data for 19 422 adolescents and young adults (aged 15-24 years) diagnosed with the onset of FEP between 2010 and 2017. DSH per 1000 person-years and standardized mortality rates for suicide were determined. Hazard ratios of DSH and suicide were estimated by Cox proportional hazard models. During follow-up, 2148 (11.1%) individuals had at least one self-harm event and 22 (0.1%) died by suicide. The hazards of DSH were significantly higher for those with a previous DSH, suicidal ideation, child abuse and neglect, comorbid medical and psychiatric diagnoses, and prior mental health care. The median follow-up time for those who had DSH was 208.0 days (SD: 526.5 days) in adolescents and 108.0 days (SD: 340.0 days) in young adults. Risk of DSH was highest in the first 3 months following FEP. Individuals with FEP are at high risk for self-harm and suicidal behavior, and recognition of who among these individuals and when following illness onset they are at greatest risk may guide more precise clinical recognition and intervention.

A multistate transition model for statin-induced myopathy and statin discontinuation

The overarching goal of this study was to simultaneously model the dynamic relationships among statin exposure, statin discontinuation, and potentially statin-related myopathic outcomes. We extracted data from the Indiana Network of Patient Care for 134,815 patients who received statin therapy between January 4, 2004, and December 31, 2008. All individuals began statin treatment, some discontinued statin use, and some experienced myopathy and/or rhabdomyolysis while taking the drug or after discontinuation. We developed a militate model to characterize 12 transition probabilities among six different states defined by use or discontinuation of statin and its associated myopathy or rhabdomyolysis. We found that discontinuation of statin therapy was common and frequently early, with 44.4% of patients discontinuing therapy after 1 month, and discontinuation is a strong indicator for statin-induced myopathy (risk ratio, 10.8; p < 0.05). Women more likely than men (p < 0.05) and patients aged 65 years and older had a higher risk than those aged younger than 65 years to discontinue statin use or experience myopathy. In conclusion, we introduce an innovative multistate model that allows clear depiction of the relationship between statin discontinuation and statin-induced myopathy. For the first time, we have successfully demonstrated and quantified the relative risk of myopathy between patients who continued and discontinued statin therapy. Age and sex were two strong risk factors for both statin discontinuation and incident myopathy.

Novel genetic variants associated with mortality after unrelated donor allogeneic hematopoietic cell transplantation

BACKGROUND

Identification of non-human leukocyte antigen (HLA) genetic risk factors could improve survival after allogeneic blood or marrow transplant (BMT) through matching at additional loci or individualizing risk prediction. We hypothesized that non-HLA loci contributed significantly to 1-year overall survival (OS), disease related mortality (DRM) or transplant related mortality (TRM) after unrelated donor (URD)BMT.

METHODS

We performed a genome-wide association study (GWAS) in 2,887 acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) and acute lymphoblastic leukemia (ALL) patients and their ≥8/8 HLA-matched URDs comprising two independent cohorts treated from 2000-2011.

FINDINGS

Using meta-analyses of both cohorts, genome-wide significant associations (p < 5 × 10^-8) were identified in: recipient genomes with OS at MBNL1 (rs9990017, HR = 1.4, 95% CI 1.24-1.56, p = 3.3 × 10^-8) and donor-recipient genotype mismatch with OS at LINC02774 (rs10927108, HR = 1.34, 95% CI 1.21-1.48, p = 2.0 × 10^-8); donor genomes with DRM at PCNX4 (rs79076914, HR = 1.7, 95% CI 1.41-2.05, p = 3.15 × 10^-8), LINC01194 (rs79498125, HR = 1.86, 95% CI 1.49-2.31, p = 2.84 × 10^-8), ARID5B (rs2167710, HR = 1.5, 95% CI 1.31-1.73, p = 6.9 × 10^-9) and CT49 (rs32250, HR = 1.44, 95% CI1.26-1.64, p = 2.6 × 10^-8); recipient genomes at PILRB with TRM (rs141591562, HR = 2.33, 95% CI 1.74-3.12, p = 1.26 × 10^-8) and donor-recipient genotype mismatch between EPGN and MTHF2DL with TRM (rs75868097, HR = 2.66, 95% CI 1.92-3.58, p = 4.6 × 10^-9). Results publicly available at https://fuma.ctglab.nl/browse.

INTERPRETATION

These data provide the first evidence that non-HLA common genetic variation at novel loci with biochemical function significantly impacts 1-year URD-BMT survival. Our findings have implications for donor selection, could guide treatment strategies and provide individualized risk prediction after future validation and functional studies.

FUNDING

This project was funded by grants from the National Institutes of Health, USA.

Association of Adiposity With Incident Diabetes Among Black Adults in the Jackson Heart Study

Background

The prognostic value of anthropometric, adipokine, and computed tomography measures of adiposity to predict diabetes in Black, specifically by normoglycemia versus prediabetes, remains incompletely understood.

Methods and Results

Among Black participants without diabetes in the JHS (Jackson Heart Study), waist circumference [WC], body mass index, adiponectin, leptin, and leptin:adiponectin ratio were standardized in sample 1 (2422 participants at baseline [2000–2004]) and WC, body mass index, visceral adipose tissue (VAT), subcutaneous adipose tissue, and liver attenuation in 1537 participants at examination 2 (2005–2008) (sample 2). Hazard ratios (HRs) for diabetes were estimated using interval‐censored Cox modeling adjusting for traditional risk factors and validated with the C index. Over 5 years, 300 and 122 incident diabetes cases occurred in sample 1 and sample 2, respectively. In sample 1 and sample 2, a 1‐SD higher log‐leptin:adiponectin ratio and VAT had the strongest associations (HR, 1.95 [95% CI, 1.67–2.27] and 1.76 [95% CI, 1.52–2.04]) and discriminatory power (C index 0.68 [95% CI, 0.64–0.71] and C index 0.67 [95% CI, 0.61–0.74]) with diabetes. The normoglycemic compared with the prediabetes group had a 1.3 to 1.9 times greater magnitude of associations with diabetes for WC, liver attenuation, and VAT (P interaction <0.10). In sample 2, C indices for WC (HR, 0.84; 95% CI, 0.73–0.95), VAT (HR, 0.91; 95% CI, 0.85–0.98), and liver attenuation (HR, 0.90; 95% CI, 0.77–1.00) were greater than HbA_1c (HR, 0.74; 95% CI, 0.57–0.90) in normoglycemia, whereas HbA_1c was best in prediabetes (HR, 0.72; 95% CI, 0.66–0.78).

Conclusions

Overall, among Black adults, multiple measures of adiposity were associated with incident diabetes with modest predictive ability. In Black patients with normoglycemia, WC, liver attenuation, and VAT may appropriately identify those at high risk for diabetes, whereas HbA_1c was the best predictor in individuals with prediabetes.

An online Sexual Health and Rehabilitation eClinic (TrueNTH SHAReClinic) for prostate cancer patients: a feasibility study

Purpose

The primary objective was to determine the feasibility of implementing the TrueNTH SHAReClinic as a pan-Canadian sexual health and rehabilitation intervention for patients treated for localized prostate cancer.

Methods

The feasibility study was designed to evaluate the accessibility and acceptability of the intervention. Participants from five institutions across Canada were enrolled to attend one pre-treatment and five follow-up online clinic visits over 1 year following their prostate cancer (PC) treatment.

Results

Sixty-five patients were enrolled in the intervention. Website analytics revealed that 71% completed the intervention in its entirety, including the educational modules, with an additional 10% completing more than half of the intervention. Five thousand eighty-three views of the educational modules were made along with 654 views of the health library items. Over 1500 messages were exchanged between participants and their sexual health coaches. At 12 months, the intervention received an overall average participant rating of 4.1 out of 5 on a single item satisfaction measure.

Conclusion

Results support the TrueNTH SHAReClinic as highly acceptable to participants as defined by intervention adherence and engagement. The TrueNTH SHAReClinic demonstrated promise for being a feasible and potentially resource-efficient approach to effectively improving the sexual well-being of patients after PC treatment.

Stage Migration and Survival Trends in Laryngeal Cancer

BACKGROUND

During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy.

METHODS

From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year.

RESULTS

No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001).

CONCLUSION

Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.

Machine perfusion of kidney allografts affects early but not late graft function

BACKGROUND

Hypothermic machine perfusion (HMP) parameters are influenced by donor variables which further affect recipient outcome. Interplay between these parameters can help to predict kidney performance on pump and the long term outcome.

METHODS

All the kidneys transplanted at our center between May 2013 through November 2017 were included in the study. Donor and recipient data was obtained from internal database. Multiple logistic regression models with backward selection were used to determine significant donor and pump variables.

RESULTS

Donor BMI, KDPI, age and donor sex had a significant association with pump flow. Donor sex, donor type, KDPI and age had significant effect on RI. Diastolic pressure and KDPI were significantly associated with DGF. Duration on pump, KDPI, flow, donor creatinine and type of donor were significantly associated with day 5 creatinine. KDPI was significantly associated with Day 365 creatinine.

CONCLUSION

HMP effects early graft function while the long term function depends on donor parameters.