Jacobs Institute of Women's Health
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Cardiovascular autonomic neuropathy defined by indices of heart rate variability is associated with cardiovascular disease: a longitudinal cohort study of participants with type 1 diabetes
No full textBACKGROUND: To describe longitudinal prevalence and risk factors associated with cardiovascular autonomic neuropathy (CAN), defined by heart rate variability (HRV) indices, and evaluate the impact of CAN on cardiovascular disease (CVD), in adults with type 1 diabetes (T1D) from the Epidemiology of Diabetes Interventions and Complications (EDIC) study. METHODS: Standard resting electrocardiogram (ECG) recordings were obtained annually in 997 participants (mean ± SD age 56.2 ± 6.8 years; T1D duration 34.7 ± 7.9 years; 48% female) between 2015 and 2022. The standard deviation of normally conducted R-R intervals (SDNN) and root mean square of successive differences between normal-to-normal R-R intervals (rMSSD) were used to define CAN using previously validated cut-offs in this cohort from gold-standard cardiovascular reflex tests (CARTs). Generalized estimating equation models were used to evaluate the association of ECG-derived CAN with individual risk factors over repeated time points. Kaplan-Meier estimates were used to describe the cumulative incidence of the first occurrence of any-CVD and of MACE by ECG-derived CAN status, and Cox proportional hazards regression models were used to estimate the effect of ECG-derived CAN adjusted for age and HbA1c. RESULTS: The prevalence of ECG-derived CAN (~ 64%) was stable. Higher pulse rate (OR [95% CI] 1.08 [1.07,1.10] per 1 bpm) and HbA1c (1.43 [1.29,1.58] per 1%) were the most significant risk factors for CAN, followed by older age, male sex, higher albumin excretion rate, and hypertension history. The cumulative incidence of first occurrence of any-CVD over 7 years of follow-up was significantly higher in participants with vs. without CAN (HR [95% CI] any-CVD 2.37 [1.43,3.94]), which remained significant adjusting for mean HbA1c and age, but was attenuated with further adjustment for other factors. CONCLUSIONS: The prevalence of and risk factors for standard resting ECG-derived CAN were similar to previously reported estimates from CARTs. CVD risk was significantly higher in those with vs. without CAN. These data support future studies examining the diagnostic utility of HRV indices at the point of care for risk stratification. TRIAL REGISTRATION: clinicaltrials.gov NCT00360815 and NCT00360893
Cardiovascular Health During Menopause Transition: The Role of Traditional and Nontraditional Risk Factors
No full textPerimenopause, or menopause transition (MT), is a critical life stage that encompasses significant physiological, emotional, and psychosocial changes that impact women\u27s cardiovascular health and quality of life. The decline in estrogen during MT induces adverse metabolic changes that increase the risk of dyslipidemia, obesity, insulin resistance, atherogenesis, and poor downstream outcomes such as diabetes, hypertension, stroke, and other adverse changes. Concurrently, stress plays an important role in shaping overall cardiovascular well-being during MT and long-term heart health post-menopause. In addition, nontraditional risk factors-particularly social determinants of health (SDoH) such as economic well-being, access to health care, built environment, social support, and others-are key upstream determinants of cardiovascular disease in women during perimenopause. Coordinated efforts are needed to screen, identify, and address the primary SDoH for optimal heart health in the clinically vulnerable MT patient population. Patient-centered care pathways that focus on assessing social needs and connecting socially vulnerable patients with available community resources are much needed for holistically addressing patient needs. Community-centered efforts are key to addressing persistent inequities in women\u27s cardiovascular health via navigation and connection to community resources that may help address SDoH barriers
Utilizing Modified Barium Swallow Impairment Profile (MBSImP) to Characterize Swallowing Function Following Total Laryngectomy
No full textOBJECTIVE: We aim to determine the frequency of altered swallowing physiology for ratable components of the 17-component grading system, the Modified Barium Swallow Impairment Profile (MBSImp), in its current validated state for a cohort of patients post total laryngectomy (TL). STUDY DESIGN: Retrospective study. SETTING: Otolaryngology Head & Neck Surgery, The George Washington University Hospital and George Washington University Medical Faculty Associates. METHODS: All participants received a VFSS as part of standard care, which was scored post hoc using the MBSImP protocol and scoring metric by two blinded speech-language pathologists. RESULTS: Due to anatomical changes post-TL, Components 6, 8, 9, 10, and 11 of the MBSImP were not rated. Efficiency concerns were most prevalent with functional deficits noted for: pharyngeal stripping wave, pharyngoesophageal segment opening, tongue base retraction, pharyngeal residue, and esophageal clearance. CONCLUSIONS: Our work aims to provide further insight into the swallowing characteristics of TL as measured using the MBSImP. A high frequency of biomechanical impairment was identified in this cohort of patients. Although the MBSImP is a validated tool its application to the reconstructed anatomy following TL is not precise and should be regarded with caution in clinical settings. Further work is needed to modify definitions of the MBSImP components and inclusion of additional features that can more accurately describe post-TL dysphagia
Factors associated with lateralized cognitive dysfunction using the Cognitive Lateralization Rating Index in pediatric epilepsy
No full textINTRODUCTION: Optimizing cognitive outcomes of pediatric epilepsy surgery requires understanding of risk for change in function, typically based on hemispheric lateralization of language skills. Identification of cognitive lateralization in children is complicated by disease in the setting of ongoing functional development. A quantitative method for assessing lateralization, the Cognitive Lateralization Rating Index (CLRI), was used as a systematic way to assess lateralized cognitive dysfunction in a sample of pediatric epilepsy surgery candidates. METHOD: The current study examined demographic and clinical variables in relation to the CLRI in 179 patients evaluated prior to epilepsy surgery from a national multi-site cohort. RESULTS: The sample was comprised of 179 patients (43.3% female; 76.3% White, 83.6% not Hispanic/Latino; age of seizure onset M 6.58 years; seizure type: 84.7% focal; side of seizure onset: 51.3% left hemisphere, 38.1% right hemisphere). Results demonstrated that lateralization of cognitive dysfunction in a pediatric sample, as well as characterization of presumed atypical functional organization, is possible with the CLRI. There was no significant association of demographic variables on lateralization. Age of seizure onset was not significantly related to the CLRI. Children with focal epilepsy were more likely to have lateralized cognitive profiles than children with generalized seizures, though this relationship was not significant. Additionally, analyses demonstrated those with left hemisphere seizures were significantly more likely to have dominant hemisphere dysfunction or presumed atypical organization on the CLRI. CONCLUSIONS: Results establish the CLRI as a potentially useful tool for both research and clinical care to quantitively stratify cognitive risk profiles for pediatric epilepsy surgery evaluations
Sex-dependent epigenetic disruption of YY1 binding by prenatal BPA exposure downregulates Matr3 and alters Agap1 splicing in the offspring hippocampus
No full textChallenges to Adolescent Pre-exposure Prophylaxis (PrEP) Uptake: an Exploration of Black and Latino American Parents\u27 Beliefs, Attitudes, and Receptivity to PrEP
No full textBACKGROUND: Pre-exposure prophylaxis (PrEP) uptake among adolescents has been slow. This has been attributed to factors such as stigma, lack of PrEP awareness, financial burdens, and provider apprehension about prescribing PrEP. In this study, we sought to understand the impact of familial factors on PrEP uptake among youth. METHODS: We conducted three focus groups with parents of Black and Latino adolescents to gather insights about attitudes, beliefs and receptivity to PrEP uptake among adolescents. Parents were recruited through a teen health clinic in New York City. Data were transcribed, codes were developed, data were coded, and an inductive and deductive analytical approach was employed. RESULTS: We recruited 26 parents. Most participants were female (85%), Black (63%), and an average age of 41 years old. Emergent themes included adherence skepticism, preference for parental consent for PrEP, increased sexual risk-taking concerns, PrEP scientific merit skepticism, and medical mistrust. Subcategories of medical mistrust included historical precedence, governmental genocide conspiracies, and classism. CONCLUSION: Parents of Black and Latino adolescents have reservations about PrEP. Attitudes, beliefs, and receptivity to PrEP may have a significant impact on youth seeking and accessing PrEP. Increasing PrEP uptake may include trust-building within minoritized communities to assure parents and youth of just and safe health practices and including parents in HIV prevention initiatives, with special consideration to Black and Latino communities and families
dd-cfDNA Significantly Improves Rejection Yield in Kidney Transplant Biopsies
No full textDonor-derived cell-free DNA (dd-cfDNA) is a biomarker that enables the early detection of immune-mediated graft injury. This study evaluated the clinical utility of dd-cfDNA in predicting the presence of biopsy-proven rejection (BPAR). We analyzed 1,070 biopsies from 1,743 kidney transplant recipients enrolled in the prospective, multicenter Kidney Allograft Outcomes AlloSure Registry (KOAR). Biopsies were grouped into surveillance or for-cause groups and stratified by dd-cfDNA status: elevated, non-elevated, or not tested. Rejection yield was significantly higher when dd-cfDNA was elevated: 39% vs. 7% in the surveillance group and 47% vs. 12% in the for-cause group (p\u3c0.0001). Biopsies with elevated dd-cfDNA and rejection diagnoses more frequently demonstrated ABMR and mixed rejection, whereas biopsies performed with non-elevated dd-cfDNA most often showed no rejection, borderline, or TCMR 1A. The AUROC for BPAR detection was 0.789. These findings demonstrate dd-cfDNA levels can improve the pre-test probability of BPAR in both surveillance and for-cause settings. Therefore, dd-cfDNA can optimize biopsy utilization by identifying renal transplant patients who are most likely to have histological rejection
Recommendations to Enhance the Residency Interview Experience for Programs, Applicants, and Clinical Education Sites
No full textBACKGROUND AND PURPOSE: Many physical therapist students seek to continue their education through residency programs. The application process for residency programs frequently requires an interview that often coincides with the timing of terminal clinical education experiences (CEEs). Because the interview process may impact clinical education, a work group was established comprising directors of clinical education and residency program directors from across the country. The intent of this group was to provide concrete recommendations to facilitate post-professional physical therapy education while decreasing any negative impacts related to the residency interview process. POSITION AND RATIONALE: Based on a survey conducted by the work group among residency program directors, student applicants for residency education will most likely be pulled away from their CEEs for up to 3 days to participate in interviews, missing critical opportunities for CEEs. The work group provided recommendations for specialty academies, academic programs, residency programs, and students that would support residency education while minimizing the impact of interviews on terminal CEEs. Recommendations include improving access to centralized information, promoting intentional application practices, and encouraging proactive communication among all groups. DISCUSSION AND CONCLUSION: The residency application process often requires an interview, which poses several implications for the applicant, one of which is time away from CEEs. Adherence to the work group\u27s recommendations has the potential to minimize the impact of residency interviews on CEEs while still supporting the pursuit of residency training
Developing A Novel Algorithm to Identify Incident and Prevalent Dementia in Medicare Claims. The ARIC Study
No full textThere is an urgent need to improve dementia ascertainment robustness in real-world studies assessing drug effects on dementia risk. We developed algorithms to dementia identification algorithms using Medicare claims (inpatient/outpatient/prescription) from 3,318 Visit 5 (2011-2013) and 1,828 Visit 6 (2016-2017) participants of the Atherosclerosis Risk in Communities (ARIC) Study, validated against ARIC\u27s rigorous syndromic dementia classification. Algorithm performance was compared to existing algorithms (Jain, Bynum, Lee). We further evaluated algorithms effectiveness in a 20% random Medicare sample aged ≥70 who initiating liraglutide or dipeptidyl peptidase 4 inhibitors (DPP4i) to assess 3-year adjusted risk difference (aRD) for dementia. Our incident dementia algorithm required two dementia diagnostic codes within 1-year, or one dementia code plus a new dementia prescription within 90-days. It achieved a positive predictive value (PPV) of 69.2%, specificity of 99.0%, and sensitivity of 34.6% (population prevalence: 8.8%), comparable to extant algorithms (PPV 58.7~68.6%; sensitivity 25.5~40.4%). Prevalent dementia algorithm (without requiring incident diagnoses/prescriptions) demonstrated similar performance. In the Medicare sample, dementia risk ranged from 3.0%-12.5%, aRD comparing liraglutide to DPP4i varied -1.2% to -3.6%, with our algorithm closely matching the Bynum algorithm. Algorithm selection significantly impacts treatment effect estimates, highlighting its importance in in pharmacoepidemiologic research
Outcomes of THA versus ORIF for Acetabular Fractures in Older Adults
No full textOBJECTIVES: To compare outcomes of total hip arthroplasty (THA) versus open reduction internal fixation (ORIF) for acetabular fractures in older adults using a large national database. METHODS: Design: Retrospective cohort study using the Medicare Limited Data set. SETTING: 798 acute short-stay hospitals. PATIENT SELECTION CRITERIA: Fee-for-service Medicare beneficiaries aged 65+ who underwent inpatient ORIF or THA for acetabular fractures (OTA/AO 62) (without associated femoral fractures) from January 2013 to December 2020 were included. OUTCOME MEASURES AND COMPARISONS: To minimize confounding, 1 THA patient was matched with up to 2 ORIF patients based on sociodemographic factors, comorbidities, and surgery year using a propensity score approach. Multivariable generalized linear models identified adjusted associations between surgery type and outcomes; adjusted odds ratios (ORs) or mean differences with 95% confidence intervals (CI) were reported. RESULTS: Among 5,656 eligible procedures, the matched cohort included 2,879 patients (1,027 THA, mean age 78.6, 42.3% male; 1,852 ORIF, mean age 78.6, 42.4% male). THA (versus ORIF) patients had an increased odds of 30-day and 90-day hospital returns (30-day: OR=1.54, P\u3c0.001; 90-day: OR=1.25, P=0.01) as well as 90-day and 1-year infection (90-day: OR=1.92, P\u3c0.001; 1-year: OR=1.74, P\u3c0.001). THA was also associated with higher odds of 90-day reoperation (OR=2.47, P\u3c0.001) but not 1-year reoperation (OR=0.84, P=0.16). No significant associations were observed for hospital length of stay (P=0.42), discharge disposition (P=0.93), use of 90-day home health services (P=0.13), 90-day venous thromboembolism (P=0.75), or 1-year mortality (P=0.65). CONCLUSIONS: Patients who underwent THA for acetabular fractures were more likely to return to the hospital within 30 and 90 days post-surgery, have an infection in the year after surgery, and undergo a reoperation in the 90-day postoperative period compared to those who underwent ORIF. Further investigation of the mechanisms of the observed associations is necessary to understand which surgical approach provides optimal outcomes. LEVEL OF EVIDENCE: Level III