Search

Lea Jean Claye,1 Swati Sakhuja,1 Ashley Nutt,1 Maung Aung,2 Pauline E Jolly1 1Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA; 2Epidemiology and Research Unit, Western Regional Health Authority, Ministry of Health, Montego Bay, Jamaica Background: Antiretroviral therapy has minimized mother-to-child transmission of HIV and given hope to HIV-positive women considering pregnancy. In Jamaica, 36% of HIV-positive pregnant women enrolled in a pediatric/perinatal HIV/AIDS program had repeat pregnancies. Objective: To describe the epidemiology and identify factors associated with pregnancy after HIV diagnosis among HIV-positive women in Western Jamaica. Methods: A cross-sectional study was designed among HIV-positive women 18–54 years old who either had or did not have at least one pregnancy after HIV-positive diagnosis. A questionnaire was used to collect information on sociodemographic factors and health-seeking, reproductive, and sexual risk behaviors. Results: A total of 219 HIV-positive women participated in this study. Length of time since HIV diagnosis, CD4 count, and birth-control methods used were significant predictors of pregnancy after HIV diagnosis. Women diagnosed with HIV

Saidah Wright,1 Dominique Earland,1 Swati Sakhuja,1 Anna Junkins,1 Sarah Franklin,1 Luz Padilla,1 Maung Aung,2 Pauline E Jolly1 1Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA; 2Western Region Health Authority, Cornwall Regional Hospital, Ministry of Health, Montego Bay, Jamaica Background: Anemia is one of the most prevalent problems in pregnancy. In 2011, 29.9% of all pregnant women in Jamaica were diagnosed with anemia.Objective: The objective of this study was to determine the prevalence and predictors of anemia in pregnancy in Western Jamaica.Methods: A cross-sectional study was conducted among 293 mothers attending post-natal clinics in Western Jamaica. A questionnaire was administered to the mothers, and an abstraction form was used to collect clinical data from the mothers’ records.Results: The prevalence of anemia among the women was 37.6%. Younger mothers (aged 18–24 years) were more likely to be anemic compared to those ≥35 years (odds ratio [OR]: 3.44, 95% CI: 1.07–11.06). Mothers who reported not always washing their hands after using the toilet were almost 10 times more likely to be anemic (OR: 9.7, 95% CI: 1.72–54.78) compared to those who reported always washing their hands. Mothers who attended a public facility for antenatal care were 2.3 times more likely to be anemic (OR: 2.31, 95% CI: 1.03–5.18) compared to those who obtained care at a private facility, and mothers who reported being told that they were anemic by a health care provider (HCP) were almost six times more likely to be anemic compared with those who were not told (OR: 5.58, 95% CI: 1.73–17.93).Conclusion: The results of the study indicate that early identification and treatment of anemia, especially among younger pregnant women, should be a priority. HCP should ensure that women understand the need to be cured of their anemia and to adhere to preventive hygienic practices. Keywords: predictors of anemia, hygienic practices, ANC facilities, Healthcare Providers’ communication

Purpose: Many adults with atherosclerotic cardiovascular disease (ASCVD) who are recommended to take a statin, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) by the 2018 American Heart Association/American College of Cardiology cholesterol guideline do not receive these medications. We estimated the percentage of recurrent ASCVD events potentially prevented with guideline-recommended cholesterol-lowering therapy following a myocardial infarction (MI) hospitalization., Methods: We conducted simulations using data from US adults with government health insurance through Medicare or commercial health insurance in the MarketScan database. We used data from patients with an MI hospitalization in 2018-2019 to estimate the percentage receiving guideline-recommended therapy. We used data from patients with an MI hospitalization in 2013-2016 to estimate the 3-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The low-density lipoprotein cholesterol (LDL-C) reduction with guideline-recommended therapy was derived from trials of statins, ezetimibe and PCSK9i, and the associated ASCVD risk reduction was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration., Results: Among 279,395 patients with an MI hospitalization in 2018-2019 (mean age 75 years, mean LDL-C 92 mg/dL), 27.3% were receiving guideline-recommended cholesterol-lowering therapy. With current cholesterol-lowering therapy use, 25.3% (95%CI: 25.2%-25.4%) of patients had an ASCVD event over 3 years. If all patients were to receive guideline-recommended therapy, 19.8% (95%CI: 19.5%-19.9%) were estimated to have an ASCVD event over 3 years, representing a 21.6% (95%CI: 20.5%-23.6%) relative risk reduction., Conclusion: Implementation of guideline-recommended cholesterol-lowering therapy could prevent a substantial percentage of recurrent ASCVD events., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Initiation of proprotein convertase subtilisin/kexin type 9 monoclonal antibody (PCSK9 mAb) for lipid-lowering following myocardial infarction (MI) is likely affected by patients' prognostic factors, potentially leading to bias when comparing real-world treatment effects., Methods: Using target-trial emulation, we assessed potential confounding when comparing two treatment strategies post-MI: initiation of PCSK9 mAb within 1 year and no initiation of PCSK9 mAb. We identified MI hospitalizations during July 2015-June 2020 for patients aged ≥18 years in Optum's de-identified Clinformatics Data Mart (CDM) and MarketScan, and those aged ≥66 in the US Medicare claims database. We estimated a 3-year counterfactual cumulative risk and risk difference (RD) for 10 negative control outcomes using the clone-censor-weight approach to address time-varying confounding and immortal person-time., Results: PCSK9 mAb initiation within 1-year post-MI was low (0.7% in MarketScan and 0.4% in both CDM and Medicare databases). In CDM, there was a lower risk for cancer (RD = -3.6% [95% CI: -4.3%, -2.9%]), decubitus ulcer (RD = -7.7% [95% CI: -11.8%, -3.7%]), fracture (RD = -8.1% [95% CI: -9.6%, -6.6%]), influenza vaccine (RD = -9.3% [95% CI: -17.5%, -1.1%]), and visual test (RD = -0.6% [95% CI: -0.7%, -0.6%]) under the PCSK9 mAb initiation versus no initiation strategy. Similar differences persisted in the MarketScan and Medicare databases. In each database, ezetimibe and low-density lipoprotein testing were unbalanced between treatment strategies., Conclusion: A comparative effectiveness study of these treatments using the current approach would likely bias results due to the low number of PCSK9 mAb initiators., Competing Interests: R.S. was an employee of Amgen at the time of completion of the study. A.B. was an employee of Target RWE at the time of the study completion. L.D.C. receives research support from Amgen. A.G.A. and Y.Y. are employees of Target RWE. S.S. and N.D. are employees of Amgen. P.M. received research support and consulting fees from Amgen. M.A.B. has served on scientific advisory committees for Amgen, AbbVie, Atara Biosciences, Brigham and Women’s Hospital, NIDDK, and Vertex; and he is a consulting chief scientist and owns equity in Target RWE. No other author reports no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Mean systolic and diastolic blood pressure (SBP and DBP) on ambulatory blood pressure (BP) monitoring (ABPM) are higher among Black compared with White adults. With 48 to 72 BP measurements obtained over 24 h, ABPM can generate parameters other than mean BP that are associated with increased risk for cardiovascular events. There are few data on race differences in ABPM parameters other than mean BP., Methods: To estimate differences between White and Black participants in ABPM parameters, we used pooled data from five US-based studies in which participants completed ABPM (n = 2580). We calculated measures of SBP and DBP level, including mean, load, peak, and measures of SBP and DBP variability, including average real variability (ARV) and peak increase., Results: There were 1513 (58.6%) Black and 1067 (41.4%) White participants with mean ages of 56.1 and 49.0 years, respectively. After multivariable adjustment, asleep SBP and DBP load were 5.7% (95% CI: 3.5-7.9%) and 2.7% (95% CI: 1.1-4.3%) higher, respectively, among Black compared with White participants. Black compared with White participants also had higher awake DBP ARV (0.3 [95%CI: 0.0-0.6] mmHg) and peak increase in DBP (0.4 [95% CI: 0.0-0.8] mmHg). There was no evidence of Black:White differences in awake measures of SBP level, asleep peak SBP or DBP, awake and asleep measures of SBP variability or asleep measures of DBP variability after multivariable adjustment., Conclusion: Asleep SBP load, awake DBP ARV and peak increase in awake DBP were higher in Black compared to White participants, independent of mean BP on ABPM., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Age is the strongest contributor to 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk. Some older adults have a predicted ASCVD risk ≥7.5 %, without established risk factors. We sought to compare ASCVD incidence among adults with predicted ASCVD risk ≥7.5 %, with and without established ASCVD risk factors, to adults with predicted risk <7.5 %., Methods: We analyzed data from REasons for Geographic and Racial Differences in Stroke study participants, 45-79 years old, without ASCVD or diabetes, not taking statins and with low-density lipoprotein cholesterol 70-189 mg/dL. Participants were categorized into 3 groups based on their 10-year predicted ASCVD risk and presence of established risk factors: <7.5 %, ≥7.5 % with established risk factors and ≥7.5 % without established risk factors. Established risk factors included smoking, systolic blood pressure ≥130 mmHg or antihypertensive medication use, total cholesterol ≥200 mg/dL, or high-density lipoprotein cholesterol <50 mg/dL for women (<40 mg/dL for men). Participants were followed for ASCVD events., Results: Among 11,115 participants, 911 incident ASCVD events occurred over a median of 11.1 years. ASCVD incidence rates were 3.6, 12.8, and 9.8 per 1,000 person-years for participants with predicted risk <7.5 %, predicted risk ≥7.5 % with established risk factors and predicted risk ≥7.5 % without established risk factors, respectively. Compared to adults with predicted risk <7.5 %, hazard ratios for incident ASCVD in participants with risk ≥7.5 % with and without established risk factors were 3.58 (95 %CI 3.03 - 4.21) and 2.72 (95 %CI 1.91-3.88), respectively., Conclusions: Adults with a 10-year predicted ASCVD risk ≥7.5 % but without established risk factors had a high ASCVD incidence., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mary Cushman reports financial support was provided by 10.13039/100000065National Institute of Neurological Disorders and Stroke and the 10.13039/100000049National Institute on Aging (NIA), 10.13039/100000002National Institutes of Health, 10.13039/100022173Department of Health and Human Service. Lisandro Colantonio, Paul Muntner, Emily Levitan reports a relationship with Amgen Inc that includes: funding grants., (© 2023 The Authors. Published by Elsevier B.V.)

Background: The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts., Methods: We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment., Results: Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively., Conclusions: Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit., (© The Author(s) 2023. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Aims: Early identification of risk factors for the development of severe fibrosis in children with cystic fibrosis-related liver disease (CFLD) is crucial as promising therapies emerge., Methods: This multi-center cohort study of children with a priori defined CFLD from 1999 to 2016, was designed to evaluate the clinical utility of CF-specific characteristics and liver biomarkers assessed years prior to liver biopsy-proven CFLD to predict risk of developing severe fibrosis (F3-4) over time. Fibrosis was staged by Metavir classification., Results: The overall study cohort of 42 patients (F0-2 (n = 22) and F3-4 (n = 20)) was 57% male (n = 24) with median age of 7.6 years at baseline visit versus 10.3 years at biopsy. Median FEV 1 % predicted was lower in F3-4 participants at baseline versus F0-2 (59% vs. 85%; p = .002), while baseline FIB-4, APRI and GGT were higher in F3-4. Median splits for FIB-4 (≥.13), APRI (≥.36), GPR (≥.09), GGT (≥25.5), and FEV 1 % (<64%) were associated with more rapid progression to F3-4 (p < .01 for all). Using a combination of change/year in FIB-4, APRI, and GPR to predict F3-4, the AUROC was .81 (95% CI, .66, .96; p < .0001). For up to 5.8 years prior, thresholds for GPR were met 6.5-fold more rapidly, and those for APRI and FIB-4 were met 2.5-fold more rapidly, in those who progressed to F3-4 than those that did not., Conclusions: This study suggests mild-moderate pulmonary dysfunction and higher liver biomarker indices at baseline may be associated with faster progression of CFLD., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes., Methods: We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation., Results: Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant., Conclusions: Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients., (© 2022 Wiley Periodicals LLC.)

Issues of the environmental crisis are being addressed by researchers, government, and organizations alike. GHRM is one such field that is receiving lots of research focus since it is targeted at greening the firms and making them eco-friendly. This research reviews 317 articles from the Scopus database published on green human resource management (GHRM) from 2008 to 2021. The study applies text mining, latent semantic analysis (LSA), and network analysis to explore the trends in the research field in GHRM and establish the relationship between the quantitative and qualitative literature of GHRM. The study has been carried out using KNIME and VOSviewer tools. As a result, the research identifies five recent research trends in GHRM using K-mean clustering. Future researchers can work upon these identified trends to solve environmental issues, make the environment eco-friendly, and motivate firms to implement GHRM in their practices., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Jaundice within the first 1-2 weeks of a neonate's life will generally self-resolve; however, if it lasts longer than this time frame it warrants further work up. Direct or conjugated hyperbilirubinemia can suggest neonatal cholestasis, which in turn reflects marked reduction in bile secretion and flow. The differential diagnosis for neonatal cholestasis is broad. Neonatal choledocholithiasis is a rare cause of neonatal cholestasis, but should be considered on the differential diagnosis for patients presenting with elevated conjugated bilirubin., Case Presentation: We describe an infant who presented with neonatal cholestasis. He subsequently underwent work up for biliary atresia, as this is one of the more time-sensitive diagnoses that must be made in neonates with conjugated hyperbilirubinemia. He was ultimately found to have choledocholithiasis on magnetic resonance cholangiopancreatography. He was managed conservatively with optimizing nutrition and ursodeoxycholic acid therapy., Conclusions: We found that conservative management, specifically optimizing nutrition and treating with ursodeoxycholic acid, can be a sufficient approach to facilitating resolution of the choledocholithiasis and conjugated hyperbilirubinemia., (© 2022. The Author(s).)

Background: Maintaining blood pressure (BP) control over time may contribute to lower risk for cardiovascular disease (CVD) among individuals who are taking antihypertensive medication., Methods: The Jackson Heart Study (JHS) enrolled 5,306 African-American adults ≥21 years of age and was used to determine the proportion of African Americans that maintain persistent BP control, identify factors associated with persistent BP control, and determine the association of persistent BP control with CVD events. This analysis included 1,604 participants who were taking antihypertensive medication at Visit 1 and had BP data at Visits 1 (2000-2004), 2 (2005-2008), and 3 (2009-2013). Persistent BP control was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg at all three visits. CVD events were assessed from Visit 3 through December 31, 2016. Hazard ratios (HR) for the association of persistent BP control with CVD outcomes were adjusted for age, sex, systolic BP, smoking, diabetes, and total and high-density lipoprotein cholesterol at Visit 3., Results: At Visit 1, 1,226 of 1,604 participants (76.4%) with hypertension had controlled BP. Overall, 48.9% of participants taking antihypertensive medication at Visit 1 had persistent BP control. After multivariable adjustment for demographic, socioeconomic, clinical, behavioral, and psychosocial factors, and access-to-care, participants were more likely to have persistent BP control if they were <65 years of age, women, had family income ≥$25,000 at each visit, and visited a health professional in the year prior to each visit. The multivariable adjusted HR (95% confidence interval) comparing participants with versus without persistent BP control was 0.71 (0.46-1.10) for CVD, 0.68 (0.34-1.34) for coronary heart disease, 0.65 (0.27-1.52) for stroke, and 0.55 (0.33-0.90) for heart failure., Conclusion: Less than half of JHS participants taking antihypertensive medication had persistent BP control, putting them at increased risk for heart failure., Competing Interests: P. Muntner receives grant funding and consulting fees from Amgen, Inc, unrelated to topic in the current manuscript. The other authors report no conflicts. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Compared with the Seventh Report of the Joint National Committee (JNC7), the 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline uses lower BP thresholds to define hypertension and BP control., Methods: We pooled data from five US-based studies to compare the association of masked hypertension (MHT) and masked uncontrolled hypertension, defined using the 2017 ACC/AHA guideline ( n  = 1653 without high office BP; <130/80 mmHg) versus the JNC7 guideline ( n  = 2451 without high office BP; <140/90 mmHg), with left ventricular hypertrophy (LVH). MHT and masked uncontrolled hypertension were defined using office BP and awake BP alone and awake, asleep, or 24-h BP. LVH was assessed by echocardiography., Results: Among participants without high office BP not taking antihypertensive medication, the prevalence of MHT defined by the JNC7 guideline and the 2017 ACC/AHA BP guideline was 25.0 and 33.5% using awake BP only and 37.1 and 52.0% when using awake, asleep, or 24-h BP. The adjusted prevalence ratios for LVH associated with MHT versus sustained normotension defined by the JNC7 and 2017 ACC/AHA BP guidelines were 1.72 [95% confidence interval (CI): 1.12-2.64] and 1.56 (95% CI: 0.97-2.51), respectively, when using awake BP only and 2.16 (95% CI: 1.36-3.44) and 1.03 (95% CI: 0.58-1.82), respectively, when using awake, asleep or 24-h BP. There was no evidence that masked uncontrolled hypertension was associated with LVH when defined using the BP thresholds in either the JNC7 or the 2017 ACC/AHA BP guideline., Conclusion: The association of MHT with LVH may depend on the BP thresholds used., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: We pooled ambulatory blood pressure monitoring data from 5 US studies, including the Jackson Heart Study (JHS), the Coronary Artery Risk Development in Young Adults (CARDIA) study, the Masked Hypertension Study, the Improving the Detection of Hypertension Study, and the North Carolina Masked Hypertension Study. Using a cross-sectional study design, we estimated differences in the prevalence of masked hypertension by race/ethnicity when out-of-office blood pressure (BP) included awake, asleep, and 24-hour BP vs. awake BP alone., Methods: We restricted the analyses to participants with office systolic BP (SBP) <130 mm Hg and diastolic BP (DBP) <80 mm Hg. High awake BP was defined as mean SBP/DBP ≥130/80 mm Hg, high asleep BP as mean SBP/DBP ≥110/65 mm Hg, and high 24-hour BP as mean SBP/DBP ≥125/75 mm Hg., Results: Among participants not taking antihypertensive medication (n = 1,292), the prevalence of masked hypertension with out-of-office BP defined by awake BP alone or by awake, asleep, or 24-hour BP was 34.5% and 48.7%, respectively, among non-Hispanic White, 39.7% and 67.6% among non-Hispanic Black, and 19.4% and 35.1% among Hispanic participants. After multivariable adjustment, non-Hispanic Black were more likely than non-Hispanic White participants to have masked hypertension by asleep or 24-hour BP but not awake BP (adjusted odds ratio [OR] 2.14 95% confidence interval [CI] 1.45-3.15) and by asleep or 24-hour BP and awake BP (OR 1.61; 95% CI 1.12-2.32) vs. not having masked hypertension., Conclusions: Assessing asleep and 24-hour BP measures increases the prevalence of masked hypertension more among non-Hispanic Black vs. non-Hispanic White individuals., (© The Author(s) 2022. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Study Objectives: Insomnia is common among older adults and associated with an increased risk for falls. Determining if falls are more strongly associated with insomnia or prescribed hypnotic medications could be used to guide interventions to reduce falls risk., Methods: We examined the prospective association of a diagnosis of insomnia and/or prescribed hypnotic medication use with the risk for serious fall injuries among 9087 Reasons for Geographic and Racial Differences in Stroke (REGARDS) study participants aged 65 years or older with Medicare fee-for-service health insurance at baseline (2003-2007). A diagnosis of insomnia was based on ICD-9 codes in Medicare claims and prescribed hypnotic medication use was determined through a pill bottle review. Serious fall injuries were identified by Medicare claims between baseline and December 31, 2018., Results: Over a median of 6.8 years, 1660 (18.3%) participants had a serious fall injury. The incidence rates for a serious fall injury per 1000 person-years were 24.8 (95%CI: 23.5, 26.1), 28.8 (95%CI: 18.6, 38.9), 32.6 (95%CI: 28.2, 37.0), and 46.6 (95%CI: 26.7, 66.5) for participants without insomnia or taking prescribed hypnotic medication (-insomnia/-hypnotics), with insomnia only (+insomnia/-hypnotics), taking prescribed hypnotic medication only (-insomnia/+hypnotics), and with insomnia and taking prescribed hypnotic medication (+insomnia/+hypnotics), respectively. Compared with the -insomnia/-hypnotic group, the multivariable-adjusted hazard ratios for a serious fall injury were 1.13 (95%CI: 0.79, 1.61), 1.29 (95%CI: 1.11, 1.50), and 1.60 (95%CI: 1.01, 2.56) for +insomnia/-hypnotics, -insomnia/+hypnotics, and +insomnia/+hypnotics, respectively., Conclusions: The risk for serious fall injuries was higher for those taking prescribed hypnotic medications but not with an insomnia diagnosis., (© The Author(s) 2022. Published by Oxford University Press on behalf of Sleep Research Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The authors examined the proportion of US adults that would have their high blood pressure (BP) status changed if systolic BP (SBP) and diastolic BP (DBP) were measured with systematic bias and/or random error versus following a standardized protocol. Data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES; n = 5176) were analyzed. BP was measured up to three times using a mercury sphygmomanometer by a trained physician following a standardized protocol and averaged. High BP was defined as SBP ≥130 mm Hg or DBP ≥80 mm Hg. Among US adults not taking antihypertensive medication, 32.0% (95%CI: 29.6%,34.4%) had high BP. If SBP and DBP were measured with systematic bias, 5 mm Hg for SBP and 3.5 mm Hg for DBP higher and lower than in NHANES, the proportion with high BP was estimated to be 44.4% (95%CI: 42.6%,46.2%) and 21.9% (95%CI 19.5%,24.4%). Among US adults taking antihypertensive medication, 60.6% (95%CI: 57.2%,63.9%) had high BP. If SBP and DBP were measured 5 and 3.5 mm Hg higher and lower than in NHANES, the proportion with high BP was estimated to be 71.8% (95%CI: 68.3%,75.0%) and 48.4% (95%CI: 44.6%,52.2%), respectively. If BP was measured with random error, with standard deviations of 15 mm Hg for SBP and 7 mm Hg for DBP, 21.4% (95%CI: 19.8%,23.0%) of US adults not taking antihypertensive medication and 20.5% (95%CI: 17.7%,23.3%) taking antihypertensive medication had their high BP status re-categorized. In conclusions, measuring BP with systematic or random errors may result in the misclassification of high BP for a substantial proportion of US adults., (© 2021 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Background: Not having a healthcare visit in the past year has been associated with a higher likelihood of uncontrolled blood pressure (BP) among individuals with hypertension., Methods: We examined factors associated with not having a healthcare visit in the past year among US adults with hypertension using data from the US National Health and Nutrition Examination Survey 2013-2018 (n = 5,985). Hypertension was defined as systolic BP (SBP) ≥140 mm Hg, diastolic BP (DBP) ≥90 mm Hg, or antihypertensive medication use. Having a healthcare visit in the past year was self-reported., Results: Overall, 7.0% of US adults with hypertension reported not having a healthcare visit in the past year. Those without vs. with a healthcare visit in the past year were less likely to be aware they had hypertension (45.0% vs. 83.9%), to be taking antihypertensive medication (36.7% vs. 91.4%, among those who were aware they had hypertension), and to have controlled BP (SBP/DBP <140/90 mm Hg; 9.1% vs. 51.7%). After multivariable adjustment, not having a healthcare visit in the past year was more common among US adults without health insurance (prevalence ratio [PR]: 2.22; 95% confidence interval [CI] 1.68-2.95), without a usual source of healthcare (PR: 5.65; 95% CI 4.16-7.67), who smoked cigarettes (PR: 1.34; 95% CI 1.02-1.77), and with heavy vs. no alcohol consumption (PR: 1.55; 95% CI 1.16-2.08). Also, not having a healthcare visit in the past year was more common among those without diabetes or a history of atherosclerotic cardiovascular disease, and those not taking a statin., Conclusions: Interventions should be considered to ensure all adults with hypertension have annual healthcare visits., (© American Journal of Hypertension, Ltd 2021. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Aflatoxin suppresses cellular immunity and accentuates HIV-associated changes in T- cell phenotypes and B- cells., Objective: This prospective study was conducted to examine the association of aflatoxin levels with CD4 T-cell count and antiretroviral therapy uptake over time., Methods: Sociodemographic and food data were collected from antiretroviral therapy naïve HIV-infected patients. CD4+ counts were collected from participants' medical records. Plasma samples were tested for aflatoxin B1 albumin adducts, hepatitis B surface antigen, and HIV viral load. Participants were separated into high and low aflatoxin groups based on the median aflatoxin B1 albumin adduct level of 10.4 pg/ml for data analysis., Results: Participants with high aflatoxin B1 albumin adduct levels had lower mean CD4 at baseline and at each follow-up period. Adjusted multivariable logistic regression analysis showed that higher baseline aflatoxin B1 adduct levels were associated with statistically significant lower CD4 counts (est = -66.5, p = 0.043). Not starting ART and low/middle socioeconomic status were associated with higher CD4 counts (est = 152.2, p<0.001) and (est = 86.3, p = 0.027), respectively., Conclusion: Consistent correlations of higher aflatoxin B1 adduct levels with lower CD4 over time indicate that there is an independent early and prolonged effect of aflatoxin on CD4 even with the initiation of antiretroviral therapy. The prospective study design, evaluation of baseline and follow-up measures, extensive control for potential confounders, and utilization of objective measures of aflatoxin exposure and CD4 count provide compelling evidence for a strong epidemiologic association that deserves careful attention in HIV care and treatment programs., Competing Interests: All authors declare that they have no competing interests.

Background: The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication., Methods: We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk., Results: Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively., Conclusion: Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Nocturnal hypertension and nondipping systolic blood pressure (SBP) are associated with increased cardiovascular disease (CVD) risk. Short and long sleep duration (SSD and LSD) are also associated with increased CVD risk and may be risk factors for nocturnal hypertension and nondipping SBP. We examined the association between SSD and LSD with sleep BP, nocturnal hypertension, and nondipping SBP among 647 white and African American Coronary Artery Risk Development in Young Adults (CARDIA) study participants who completed 24-h ambulatory BP monitoring, wrist actigraphy, and sleep diaries in 2015-2016., Methods: The times when participants were asleep and awake were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as sleep BP ≥120/70 mmHg and nondipping SBP as mean sleep-to-awake SBP ratio >0.90. Sleep duration was categorized as SSD (<6 h), normal sleep duration (NSD: 6-8.9 h), and LSD (≥9 h)., Results: The prevalence of SSD and LSD were 13.9 and 21.1%, respectively. Compared to participants with NSD, participants with LSD had higher mean sleep SBP (2.1 mmHg, 95% confidence interval [CI] 0.2, 4.1 mmHg) and diastolic BP (1.7 mmHg, 95% CI 0.5, 3.0 mmHg). Participants with LSD had a higher prevalence of nocturnal hypertension (prevalence ratio [PR]: 1.26, 95% CI 1.03-1.54) and nondipping SBP (PR 1.33, 95% CI 1.03-1.72) compared to participants with NSD. There was no evidence of an association between SSD and sleep SBP or DBP, nocturnal hypertension, or nondipping SBP., Conclusions: These findings suggest that LSD may be associated with nocturnal hypertension and nondipping SBP., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Ambulatory blood pressure (BP) monitoring (ABPM) may cause sleep disturbances. Some home BP monitoring (HBPM) devices obtain a limited number of BP readings during sleep and may be preferred to ABPM. It is unclear how closely a few BP readings approximate a full night of ABPM. We used data from the Jackson Heart (N = 621) and Coronary Artery Risk Development in Young Adults (N = 458) studies to evaluate 74 sampling approaches to estimate BP during sleep. We sampled two to four BP measurements at specific times from a full night of ABPM and computed chance-corrected agreement (i.e., kappa) of nocturnal hypertension (i.e., mean asleep systolic BP ≥ 120 mmHg or diastolic BP ≥ 70 mmHg) defined using the full night of ABPM and subsets of BP readings. Measuring BP at 2, 3, and 4 h after falling asleep, an approach applied by some HBPM devices obtained a kappa of 0.81 (95% confidence interval [CI]: 0.78, 0.85). The highest kappa was obtained by measuring BP at 1, 2, 4, and 5 h after falling asleep: 0.84 (95% CI: 0.81, 0.87). In conclusion, measuring BP three or four times during sleep may have high agreement with nocturnal hypertension status based on a full night of ABPM., (© 2021. The Author(s), under exclusive licence to The Japanese Society of Hypertension.)

[Figure: see text].

[Figure: see text].

[Figure: see text].

Purpose: To examine patterns of de-novo metastases (mets) and association with breast cancer-specific mortality across subtypes and racial groups., Methods: Non-Hispanic (NH) Black and NH-White patients ages 40 years and older with primary breast cancer (BC) between 2010 and 2015 were examined. Multilevel logistic regression and Cox proportional hazards models were used to assess (1) odds of de-novo mets to specific sites by subtype, and (2) association of subtype with risk of BC mortality among patients with de-novo mets by race., Results: A total of 204,941 BC patients were included in analysis. The most common de-novo mets site was to the bone, and overall prevalence of de-novo mets was higher among NH-Black (6.4%) versus NH-White (4.1%) patients. The odds of de-novo mets to any site were lower for TNBC (OR 0.68, 95% CI 0.62-0.73) and HR+/HER2- (OR 0.50, 95% CI 0.47-0.53) subtypes, but higher for HR-/HER2+ (OR 1.16, 95% CI 1.06-1.28) relative to HR+/HER2+ . De-novo mets to the brain only was associated with the highest mortality risk across all subtypes, ranging from a 13-fold increase (hazard ratio 13.45, 95% CI 5.03-35.96) for HR-/HER2+ to a 39-fold increase (hazard ratio 39.04, 95% CI 26.2-58.14) for HR+/HER2-., Conclusion: Site and fatality of de-novo mets vary by subtype and by race. This information may help improve risk stratification and post-diagnostic surveillance to ultimately reduce BC mortality.

Importance: Higher blood pressure (BP) levels in children are associated with an increased risk for hypertension and subclinical cardiovascular disease in adulthood. Identifying trends in BP could inform the need for interventions to lower BP., Objective: To determine whether systolic BP (SBP) and diastolic BP (DBP) levels among US children have changed during the past 20 years., Design, Setting, and Participants: This serial cross-sectional analysis of National Health and Nutrition Examination Survey data included 9117 children aged 8 to 12 years and 10 156 adolescents aged 13 to 17 years, weighted to the US population from 1999-2002 to 2015-2018. Data were collected from March 1999 to December 2018 and analyzed from March 26, 2020, to February 2, 2021., Exposures: Calendar year., Main Outcomes and Measures: The primary outcomes were mean SBP and mean DBP., Results: A total of 19 273 participants were included in the analysis. Among children aged 8 to 12 years in 2015-2018 (mean age, 10.5 [95% CI, 10.5-10.6] years), 48.7% (95% CI, 45.2%-52.2%) were girls and 51.3% (95% CI, 47.8%-54.8%) were boys; 49.7% (95% CI, 42.2%-57.1%) were non-Hispanic White; 13.7% (95% CI, 10.3%-18.1%) were non-Hispanic Black; 25.5% (95% CI, 19.9%-32.0%) were Hispanic; 4.7% (95% CI, 3.2%-6.7%) were non-Hispanic Asian; and 6.5% (95% CI, 4.9%-8.5%) were other non-Hispanic race/ethnicity. Among those aged 13 to 17 years in 2015-2018 (mean age, 15.5 [95% CI, 15.5-15.5] years), 49.1% (95% CI, 46.1%-52.2%) were girls and 50.9% (95% CI, 47.8%-53.9%) were boys; 53.3% (95% CI, 46.4%-60.1%) were non-Hispanic White; 13.9% (95% CI, 10.3%-18.7%) were non-Hispanic Black; 21.9% (95% CI, 16.6%-28.2%) were Hispanic; 4.6% (95% CI, 3.2%-6.5%) were non-Hispanic Asian; and 6.3% (95% CI, 4.7%-8.5%) were other non-Hispanic race/ethnicity. Among children aged 8 to 12 years, age-adjusted mean SBP decreased from 102.4 (95% CI, 101.7-103.1) mm Hg in 1999-2002 to 101.5 (95% CI, 100.8-102.2) mm Hg in 2011-2014 and then increased to 102.5 (95% CI, 101.9-103.2) mm Hg in 2015-2018. Age-adjusted mean DBP decreased from 57.2 (95% CI, 56.5-58.0) mm Hg in 1999-2002 to 51.9 (95% CI, 50.1-53.7) mm Hg in 2011-2014 and increased to 53.2 (95% CI, 52.2-54.1) mm Hg in 2015-2018. Among adolescents aged 13 to 17 years, age-adjusted mean SBP decreased from 109.2 (95% CI, 108.7-109.7) mm Hg in 1999-2002 to 108.4 (95% CI, 107.8-109.1) mm Hg in 2011-2014 and remained unchanged in 2015-2018 (108.4 [95% CI, 107.8-109.1] mm Hg). Mean DBP decreased from 62.6 (95% CI, 61.7-63.5) mm Hg in 1999-2002 to 59.6 (95% CI, 58.2-60.9) mm Hg in 2011-2014 and then increased to 60.8 (95% CI, 59.8-61.7) mm Hg in 2015-2018. Among children aged 8 to 12 years, mean SBP was 3.2 (95% CI, 1.7-4.6) mm Hg higher among those with overweight and 6.8 (95% CI, 5.6-8.1) mm Hg higher among those with obesity compared with normal weight; mean DBP was 3.2 (95% CI, 0.7-5.6) mm Hg higher among those with overweight and 3.5 (95% CI, 1.9- 5.1) mm Hg higher among those with obesity compared with normal weight. Among adolescents aged 13 to 17 years, mean SBP was 3.5 (95% CI 1.9-5.1) mm Hg higher among those with overweight and 6.6 (95% CI, 5.2-8.0) mm Hg higher among those with obesity compared with normal weight, 4.8 (95% CI, 3.8-5.8) mm Hg higher among boys compared with girls, and 3.0 (95% CI, 1.7-4.3) mm Hg higher among non-Hispanic Black compared with non-Hispanic White participants., Conclusions and Relevance: Despite an overall decline in mean SBP and DBP from 1999-2002 to 2015-2018, BP levels among children and adolescents may have increased from 2011-2014 to 2015-2018.

Background: A subset of patients with serology suggesting celiac disease have an initially negative biopsy but subsequently develop histopathologic celiac disease. Here we characterize patients with potential celiac disease who progress to celiac disease., Methods: We performed a retrospective analysis of children (0-18 years of age) with biopsy-confirmed celiac disease seen at St. Louis Children's Hospital between 2013 and 2018., Results: Three hundred sixteen of 327 (96%) children with biopsy-confirmed celiac disease were diagnosed on initial biopsy. The 11 children with potential celiac disease who progressed to celiac disease had lower anti-tissue transglutaminase (anti-TTG IgA) concentrations (2.4 (1.6-5) X upper limit of normal (ULN) vs. 6.41 (3.4-10.5) X ULN) at time of first biopsy. Their median anti-TTG IgA concentrations rose from 2.4 (1.6-5) X ULN to 3.6 (3.1-9.2) X ULN between biopsies., Conclusions: Four percent of biopsy confirmed celiac patients initially had a negative biopsy, but later developed histopathologic celiac disease. This is likely an underestimate as no surveillance algorithm was in place. We recommend repeat assessment in children whose serology suggests celiac disease despite normal small bowel biopsy.

Almost 1 in 5 US adults with hypertension has apparent treatment resistant hypertension (aTRH). Identifying modifiable risk factors for incident aTRH may guide interventions to reduce the need for additional antihypertensive medication. We evaluated the association between cardiovascular health and incident aTRH among participants with hypertension and controlled blood pressure (BP) at baseline in the Jackson Heart Study (N=800) and the Reasons for Geographic and Racial Differences in Stroke study (N=2316). Body mass index, smoking, physical activity, diet, BP, cholesterol and glucose, categorized as ideal, intermediate, or poor according to the American Heart Association's Life's Simple 7 were assessed at baseline and used to define cardiovascular health. Incident aTRH was defined by uncontrolled BP, systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg, while taking ≥3 classes of antihypertensive medication or controlled BP, systolic BP <130 mm Hg and diastolic BP <80 mm Hg, while taking ≥4 classes of antihypertensive medication at a follow-up visit. Over a median 9 years of follow-up, 605 (19.4%) participants developed aTRH. Incident aTRH developed among 25.8%, 18.2%, and 15.7% of participants with 0 to 1, 2, and 3 to 5 ideal Life's Simple 7 components, respectively. No participants had 6 or 7 ideal Life's Simple 7 components at baseline. The multivariable adjusted hazard ratios (95% CIs) for incident aTRH associated with 2 and 3 to 5 versus 0 to 1 ideal components were 0.75 (0.61-0.92) and 0.67 (0.54-0.82), respectively. These findings suggest optimizing cardiovascular health may reduce the pill burden and high cardiovascular risk associated with aTRH among individuals with hypertension.

Colorectal cancer (CRC) and cardiovascular diseases (CVD) share several risk factors. We examined the relationships between CRC screening and CVD history by race/ethnicity and sex. Data from 15 states across the United States with high age-adjusted CVD rates from the 2012-2016 Behavioral Risk Factor Surveillance System were used to examine prevalence of self-reported screening for CRC among 179,276 adults ages 50-75 years with and without history of CVD. Multivariable logistic regression was used to evaluate the association between socio-demographics and CRC screening in the expansion and stable phases of the Affordable Care Act (ACA) era. Prevalence of CRC screening was high among those with history of CVD. After multivariable adjustment, Whites and Hispanics with CVD had 19% (95%[CI]: 1.13-1.26) and 50% (95%[CI]: 1.10-2.06) higher odds for CRC screening, respectively, versus those without CVD. Individuals in both sexes with CVD had higher odds for CRC screening compared those without CVD. Strikingly, the odds for CRC screening in Hispanics with history of CVD were 72% higher in the stable phase of the ACA era for the fully adjusted model. Whites and Hispanics with history of CVD are more likely to undergo CRC screening, perhaps due to greater exposure to the healthcare system due to CVD. This association was not observed in Blacks. Interventions are needed to improve CRC screening rates among Blacks, especially due to their well-documented higher risk of CVD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Published by Elsevier Inc.)

Background: Several atherosclerotic cardiovascular disease (ASCVD) risk factors are associated with awake and nocturnal hypertension., Methods: We assessed the association between a composite ASCVD risk score and awake or nocturnal hypertension using data from participants aged 40-79 years who completed ambulatory blood pressure monitoring at the Year 30 Coronary Artery Risk Development in Young Adults study exam in 2015-2016 (n = 716) and the baseline Jackson Heart Study exam in 2000-2004 (n = 770). Ten-year predicted ASCVD risk was calculated using the Pooled Cohort risk equations. Awake hypertension was defined as mean awake systolic blood pressure (SBP) ≥135 mm Hg or diastolic blood pressure (DBP) ≥85 mm Hg and nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or DBP ≥70 mm Hg., Results: Among participants with a 10-year predicted ASCVD risk <5%, 5% to <7.5%, 7.5% to <10%, and ≥10%, the prevalence of awake or nocturnal hypertension as a composite outcome was 29.5%, 47.8%, 62.2%, and 69.7%, respectively. After multivariable adjustment, higher ASCVD risk was associated with higher prevalence ratios for awake or nocturnal hypertension among participants with clinic-measured SBP/DBP <130/85 mm Hg but not ≥130/85 mm Hg. The C-statistic for discriminating between participants with vs. without awake or nocturnal hypertension was 0.012 (95% confidence interval 0.003, 0.016) higher when comparing a model with ASCVD risk and clinic-measured blood pressure (BP) together vs. clinic-measured BP without ASCVD risk., Conclusions: Using 10-year predicted ASCVD risk in conjunction with clinic BP improves discrimination between individuals with and without awake or nocturnal hypertension., (© American Journal of Hypertension, Ltd 2020. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background Sleep characteristics and disorders are associated with higher blood pressure (BP) when measured in the clinic setting. Methods and Results We tested whether self-reported sleep characteristics and likelihood of obstructive sleep apnea (OSA) were associated with nocturnal hypertension and nondipping systolic BP (SBP) among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who completed 24-hour ambulatory BP monitoring during the year 30 examination. Likelihood of OSA was determined using the STOP-Bang questionnaire. Global sleep quality, habitual sleep duration, sleep efficiency, and midsleep time were obtained from the Pittsburgh Sleep Quality Index. Nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping SBP was defined as a decline in awake-to-asleep SBP <10%. Among 702 participants, the prevalence of nocturnal hypertension and nondipping SBP was 41.3% and 32.5%, respectively. After multivariable adjustment including cardiovascular risk factors, the prevalence ratios (PRs) for nocturnal hypertension and nondipping SBP associated with high versus low likelihood of OSA were 1.32 (95% CI, 1.00-1.75) and 1.31 (95% CI, 1.02-1.68), respectively. The association between likelihood of OSA and nocturnal hypertension was stronger for white participants (PR: 2.09; 95% CI, 1.23-3.48) compared with black participants (PR: 1.11; 95% CI, 0.79-1.56). The PR for nondipping SBP associated with a 1-hour later midsleep time was 0.92 (95% CI, 0.85-0.99). Global sleep quality, habitual sleep duration, and sleep efficiency were not associated with either nocturnal hypertension or nondipping SBP. Conclusions These findings suggest that addressing OSA risk and sleep timing in a clinical trial may improve BP during sleep.

Background Nocturnal hypertension, defined by a mean asleep systolic blood pressure (SBP)/diastolic blood pressure (BP) ≥120/70 mm Hg, and nondipping SBP, defined by an awake-to-asleep decline in SBP <10%, are each associated with increased risk for cardiovascular disease. Methods and Results We developed predictive equations to identify adults with a high probability of having nocturnal hypertension or nondipping SBP using data from the CARDIA (Coronary Artery Risk Development in Young Adults) study (n=787), JHS (Jackson Heart Study) (n=1063), IDH (Improving the Detection of Hypertension) study (n=395), and MHT (Masked Hypertension) study (n=772) who underwent 24-hour ambulatory BP monitoring. Participants were randomized to derivation (n=2511) or validation (n=506) data sets. The prevalence rates of nocturnal hypertension and nondipping SBP were 39.7% and 44.9% in the derivation data set, respectively, and 36.6% and 44.5% in the validation data set, respectively. The predictive equation for nocturnal hypertension included age, race/ethnicity, smoking status, neck circumference, height, high-density lipoprotein cholesterol, albumin/creatinine ratio, and clinic SBP and diastolic BP. The predictive equation for nondipping SBP included age, sex, race/ethnicity, waist circumference, height, alcohol use, high-density lipoprotein cholesterol, and albumin/creatinine ratio. Concordance statistics (95% CI) for nocturnal hypertension and nondipping SBP predictive equations in the validation data set were 0.84 (0.80-0.87) and 0.73 (0.69-0.78), respectively. Compared with reference models including antihypertensive medication use and clinic SBP and diastolic BP as predictors, the continuous net reclassification improvement (95% CI) values for the nocturnal hypertension and nondipping SBP predictive equations were 0.52 (0.35-0.69) and 0.51 (0.34-0.69), respectively. Conclusions These predictive equations can direct ambulatory BP monitoring toward adults with high probability of having nocturnal hypertension and nondipping SBP.

Objective: Recent studies have suggested that prediabetes is associated with an increased risk for cardiovascular disease (CVD) only among individuals with concomitant hypertension., Research Design and Methods: We analyzed the association between prediabetes and CVD by hypertension status among 3,313 black adults in the Jackson Heart Study (JHS) without diabetes or a history of CVD at baseline (2000-2004). Prediabetes was defined as fasting plasma glucose between 100 and 125 mg/dL or hemoglobin A 1c between 5.7 and 6.4% (39 and 46 mmol/mol). Hypertension was defined as systolic/diastolic blood pressure ≥140/90 mmHg and/or self-reported antihypertensive medication use. Participants were followed for incident CVD events and all-cause mortality through 31 December 2014., Results: Overall, 35% of JHS participants did not have prediabetes or hypertension, 18% had prediabetes alone, 22% had hypertension alone, and 25% had both prediabetes and hypertension. Compared with participants without either condition, the multivariable-adjusted hazard ratios for CVD events among participants with prediabetes alone, hypertension alone, and both prediabetes and hypertension were 0.86 (95% CI 0.51, 1.45), 2.09 (1.39, 3.14), and 1.93 (1.28, 2.90), respectively. Among participants with and without hypertension, there was no association between prediabetes and an increased risk for CVD (0.78 [0.46, 1.34] and 0.94 [0.70, 1.26], respectively). No association was present between prediabetes and all-cause mortality among participants with or without hypertension., Conclusions: Regardless of hypertension status, prediabetes was not associated with an increased risk for CVD or all-cause mortality in this cohort of black adults., (© 2019 by the American Diabetes Association.)

Background: Functional limitations may be more common in middle-aged adults than previously recognized. However, there are few published data on the prevalence of activity limitations, and their association with multimorbidity, among adults 50 to 64 years old., Objective: To describe the prevalence of activity limitations and the association with multimorbidity in middle-aged adults., Design: Cross-sectional analysis of US population-based National Health and Nutrition Examination Survey (NHANES) 2011-2016., Participants: The total number of community-dwelling NHANES participants aged 50-64 years old is 4217., Main Measures: Chronic conditions included hypertension, high cholesterol, diabetes mellitus, obesity, chronic kidney disease, cancer, stroke, coronary heart disease, heart failure, chronic obstructive pulmonary disease/asthma, arthritis, and depression. Activity limitations were defined as any difficulty within each of four International Classification of Functioning (ICF) domains: functional limitations (kneeling, carrying, standing, sitting, reaching, grasping, pulling), mobility (walking ¼ mile, climbing 10 steps), basic activities of daily living (BADLs; walking, transferring, eating, dressing), and instrumental activities of daily living (IADLs; finances, chores, cooking). We calculated prevalence ratios for activity limitations using generalized estimating equations., Key Results: The prevalence of functional limitations, mobility limitations, BADL difficulty, and IADL difficulty was 34%, 11%, 15%, and 17%, respectively. Seventy-two percent of participants had two or more chronic conditions; 23% had two, 18% had three, 15% had four, and 16% had five or more. Multivariable adjusted prevalence ratios (95% CI) for functional limitations among those with 2, 3, 4, and 5 or more chronic conditions, compared with 0-1 conditions, were 1.94 (1.43-2.63), 2.50 (1.93-3.23), 3.26 (2.48-4.27), and 4.54 (3.48-5.93), respectively (p trend < 0.001). Larger prevalence ratios at a higher number of chronic conditions were present for mobility limitations, BADL difficulty, and IADL difficulty., Conclusions: Problems with function are not limited to older adults and multimorbidity may be helpful for identifying middle-aged adults with a high prevalence of activity limitations.

Importance: Little is known regarding health outcomes associated with higher blood pressure (BP) levels measured outside the clinic among African American individuals., Objective: To examine whether daytime and nighttime BP levels measured outside the clinic among African American individuals are associated with cardiovascular disease (CVD) and all-cause mortality independent of BP levels measured inside the clinic., Design, Setting, and Participants: This prospective cohort study analyzed data from 1034 African American participants in the Jackson Heart Study who completed ambulatory BP monitoring at baseline (September 26, 2000, to March 31, 2004). Mean daytime and nighttime BPs were calculated based on measurements taken while participants were awake and asleep, respectively. Data were analyzed from July 1, 2017, to April 30, 2019., Main Outcomes and Measures: Cardiovascular disease events, including coronary heart disease and stroke, experienced through December 31, 2014, and all-cause mortality experienced through December 31, 2016, were adjudicated. The associations of daytime BP and nighttime BP, separately, with CVD events and all-cause mortality were determined using Cox proportional hazards regression models., Results: A total of 1034 participants (mean [SD] age, 58.9 [10.9] years; 337 [32.6%] male; and 583 [56.4%] taking antihypertensive medication) were included in the study. The mean daytime systolic BP (SBP)/diastolic BP (DBP) was 129.4/77.6 mm Hg, and the mean nighttime SBP/DBP was 121.3/68.4 mm Hg. During follow-up (median [interquartile range], 12.5 [11.1-13.6] years for CVD and 14.8 [13.7-15.6] years for all-cause mortality), 113 CVD events and 194 deaths occurred. After multivariable adjustment, including in-clinic SBP and DBP, the hazard ratios (HRs) for CVD events for each SD higher level were 1.53 (95% CI, 1.24-1.88) for daytime SBP (per 13.5 mm Hg), 1.48 (95% CI, 1.22-1.80) for nighttime SBP (per 15.5 mm Hg), 1.25 (95% CI, 1.02-1.51) for daytime DBP (per 9.3 mm Hg), and 1.30 (95% CI, 1.06-1.59) for nighttime DBP (per 9.5 mm Hg). Nighttime SBP was associated with all-cause mortality (HR per 1-SD higher level, 1.24; 95% CI, 1.06-1.45), but no association was present for daytime SBP (HR, 1.13; 95% CI, 0.97-1.33) and daytime (HR, 0.95; 95% CI, 0.81-1.10) and nighttime (HR, 1.06; 95% CI, 0.90-1.24) DBP., Conclusions and Relevance: Among African American individuals, higher daytime and nighttime SBPs were associated with an increased risk for CVD events and all-cause mortality independent of BP levels measured in the clinic. Measurement of daytime and nighttime BP using ambulatory monitoring during a 24-hour period may help identify African American individuals who have an increased cardiovascular disease risk.

The 2017 Hypertension Clinical Practice Guidelines recommend out-of-clinic BP monitoring to screen for white coat and masked hypertension among adults not taking antihypertensive medication and white coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. We estimated the percentage of US adults meeting criteria for out-of-clinic BP monitoring by the American College of Cardiology/American Heart Association guideline using the 2011 to 2014 National Health and Nutrition Examination Survey (n=9623). Among US adults not taking antihypertensive medication, 92.6% (95% CI, 90.7%-94.1%) with systolic/diastolic BP ≥130/80 mm Hg met criteria for out-of-clinic BP monitoring to screen for white coat hypertension and 32.8% (95% CI, 30.4%-35.3%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat hypertension were less often met at an older age and did not differ by race/ethnicity or sex. The proportion meeting criteria for out-of-clinic BP monitoring to screen for masked hypertension was higher at an older age, among men versus women and non-Hispanic blacks and whites versus non-Hispanic Asians or Hispanics. Among US adults taking antihypertensive medication, 12.5% (95% CI, 10.5%-14.9%) with systolic/diastolic BP ≥130/80 mm Hg met criteria to screen for white coat effect and 57.4% (95% CI, 52.7%-62.1%) with systolic/diastolic BP<130/80 mm Hg met criteria to screen for masked uncontrolled hypertension. Criteria for out-of-clinic BP monitoring to screen for white coat effect was more commonly met at an older age and among non-Hispanic blacks than non-Hispanic whites and to screen for masked uncontrolled hypertension in older adults and men. In conclusion, ≈103.8 million US adults (45.8%) met the 2017 Hypertension Clinical Practice Guidelines criteria for out-of-clinic BP monitoring.

Background: Several health behaviors have been associated with hypertension based on clinic blood pressure (BP). Data on the association of health behaviors with nocturnal hypertension and non-dipping systolic BP (SBP) are limited., Methods: We analyzed data for participants with ambulatory BP monitoring at the Year 30 Coronary Artery Risk Development in Young Adults (CARDIA) study exam in 2015-2016 (n = 781) and the baseline Jackson Heart Study (JHS) exam in 2000-2004 (n = 1,046). Health behaviors (i.e., body mass index, physical activity, smoking, and alcohol intake) were categorized as good, fair, and poor and assigned scores of 2, 1, and 0, respectively. A composite health behavior score was calculated as their sum and categorized as very good (score range = 6-8), good (5), fair (4), and poor (0-3). Nocturnal hypertension was defined as mean asleep SBP ≥ 120 mm Hg or mean asleep diastolic BP ≥ 70 mm Hg and non-dipping SBP as < 10% awake-to-asleep decline in SBP., Results: Among CARDIA study and JHS participants, 41.1% and 56.9% had nocturnal hypertension, respectively, and 32.4% and 72.8% had non-dipping SBP, respectively. The multivariable-adjusted prevalence ratios (95% confidence interval) for nocturnal hypertension associated with good, fair, and poor vs. very good health behavior scores were 1.03 (0.82-1.29), 0.98 (0.79-1.22), and 0.96 (0.77-1.20), respectively in CARDIA study and 0.98 (0.87-1.10), 0.96 (0.86-1.09), and 0.86 (0.74-1.00), respectively in JHS. The health behavior score was not associated non-dipping SBP in CARDIA study or JHS after multivariable adjustment., Conclusions: A health behavior score was not associated with nocturnal hypertension or non-dipping SBP., (© American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline lowered the BP thresholds for defining hypertension compared with the Seventh Report of the Joint National Committee (JNC7) guideline., Methods: We analyzed clinic and ambulatory BP monitoring data from 717 Coronary Artery Risk Development in Young Adults study participants and compared the prevalence of clinic and out-of-clinic BP phenotypes using thresholds from the 2017 ACC/AHA and JNC7 guidelines., Results: Among participants not taking antihypertensive medication and according to the JNC7 and 2017 ACC/AHA guidelines, 11.1 and 30.1% of participants had clinic hypertension, 37.5 and 57.9% had awake hypertension, 35.7 and 58.1% had asleep hypertension, and 35.7 and 58.6% had 24-h hypertension, respectively. According to the JNC7 and 2017 ACC/AHA guideline definitions, 1.9 and 3.2% had white-coat hypertension, 28.2 and 31.0% had masked hypertension and 9.3 and 26.9% had sustained hypertension, respectively. Among participants taking antihypertensive medication and when defined using the JNC7 and 2017 ACC/AHA guideline BP thresholds, 18.6 and 45.3% had uncontrolled clinic BP, 48.1 and 62.5% had uncontrolled awake BP, 48.1 and 70.2% had uncontrolled asleep BP and, 47.7 and 65.3% had uncontrolled 24-h BP, respectively. Using JNC7 and 2017 ACC/AHA guideline BP thresholds, the prevalence was 1.4 and 5.2% for white-coat effect, 30.9 and 22.5% for masked uncontrolled hypertension, and 17.2 and 40.0% for sustained uncontrolled BP, respectively., Conclusion: The 2017 ACC/AHA guideline results in a substantially higher prevalence of awake, asleep, 24-h, and sustained hypertension.

In 2018, the American Heart Association published a Scientific Statement on resistant hypertension. We compared the prevalence of apparent treatment-resistant hypertension (aTRH) among US adults as defined in the 2018 and 2008 American Heart Association Scientific Statements using data from 4158 participants with hypertension, taking antihypertensive medication in the 2009 to 2014 National Health and Nutrition Examination Survey. Blood pressure (BP) was measured 3 times, and antihypertensive medication classes were identified through a pill bottle review. In both Scientific Statements, aTRH was defined as uncontrolled BP while taking ≥3 classes of antihypertensive medication or taking ≥4 classes of antihypertensive medication regardless of BP level. Uncontrolled BP was defined as systolic/diastolic BP ≥140/90 mm Hg (≥130/80 mm Hg for those with diabetes mellitus or chronic kidney disease) in the 2008 Scientific Statement and systolic/diastolic BP ≥130/80 mm Hg (systolic BP ≥130 mm Hg only for low-risk adults ≥65 years of age) in the 2018 Scientific Statement. The prevalence of aTRH was 17.7% and 19.7% according to the 2008 and 2018 Scientific Statement definitions, respectively (Δ=2.0%; 95% CI, 1.5%-2.7%). Overall, 10.3 million US adults had aTRH according to the 2018 Scientific Statement. The most common 3-drug combination taken included an angiotensin-converting enzyme inhibitor, β-blocker, and thiazide diuretic. Using the 2018 definition, 3.2% of US adults with aTRH were taking a thiazide-like diuretic (chlorthalidone or indapamide), and 9.0% were taking a mineralocorticoid receptor blocker (spironolactone or eplerenone). In conclusion, the prevalence of aTRH is only modestly higher using the definition in the 2018 versus 2008 resistant hypertension Scientific Statement.

Racial disparities in cancer mortality still exist despite improvements in treatment strategies leading to improved survival for many cancer types. In this study, we described race/ethnic differences in patterns of de novo metastasis and evaluated the association between site of de novo metastasis and breast, prostate, and colorectal cancer mortality. Data were obtained from the Surveillance Epidemiology and Ends Results (SEER) database from 2010 to 2013 and included 520,147 patients ages ≥40 years with primary diagnosis of breast, colorectal, or prostate cancer. Site and frequency of de novo metastases to four sites (bone, brain, liver, and lung) were compared by race/ethnicity using descriptive statistics, and survival differences examined using extended Cox regression models in SAS 9.4. Overall, non-Hispanic (NH) Blacks (11%) were more likely to present with de novo metastasis compared with NH-Whites (9%) or Hispanics (10%). Among patients with breast cancer, NH-Blacks were more likely to have metastasis to the bone, (OR: 1.25, 95% CI: 1.15-1.37), brain (OR: 2.26, 95% CI: 1.57-3.25), or liver (OR: 1.62, 95% CI: 1.35-1.93), while Hispanics were less likely to have metastasis to the liver (OR: 0.76, 95% CI: 0.60-0.97) compared with NH-Whites. Among patients with prostate cancer, NH-Blacks (1.39, 95% CI: 1.31-1.48) and Hispanics (1.39, 95% CI: 1.29-1.49) were more likely to have metastasis to the bone. Metastasis to any of the four sites evaluated increased overall mortality by threefold (for breast cancer and metastasis to bone) to 17-fold (for prostate cancer and metastasis to liver). Racial disparities in mortality remained after adjusting for metastasis site in all cancer types evaluated. De novo metastasis is a major contributor to cancer mortality in USA with racial differences in the site, frequency, and associated survival., (© 2018 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Metabolic syndrome (MetS) is an important etiologic and prognostic factor for cancer, but few studies have assessed hospitalization outcomes among patients with both conditions., Methods: Data was obtained from the Healthcare Cost and Utilization project Nationwide Inpatient Sample (HCUP-NIS). Study variables were assessed using ICD-9 codes on adults aged 40 years and over admitted to a US hospital between 2007 and 2011 with primary diagnosis of either breast, colorectal, or prostate cancer. We examined in-hospital mortality, post-surgical complications, and discharge disposition among cancer patients with MetS and compared with non-MetS patients., Results: Hospitalized breast (OR: 0.31, 95% CI: 0.20-0.46), colorectal (OR: 0.41, 95% CI: 0.35-0.49), and prostate (OR: 0.28, 95% CI: 0.16-0.49) cancer patients with MetS had significantly reduced odds of in-hospital mortality. The odds of post-surgical complications among breast (OR: 1.20, 95% CI: 1.03-1.39) and prostate (OR: 1.22, 95% CI: 1.09-1.37) cancer patients with MetS were higher, but lower by 7% among colorectal cancer patients with MetS. Additionally, breast (OR: 1.21, 95% CI: 1.11-1.32) and colorectal (OR: 1.06, 95% CI: 1.01-1.11) cancer patients with MetS had significantly higher odds for discharge to a skilled nursing facility compared with those without MetS, but this was not statistically significant among prostate cancer patients., Conclusions: Adverse health outcomes were significantly higher among hospitalized patients with a primary diagnosis of cancer and MetS. Future studies are needed to identify clinical strategies for detecting and managing patients with MetS to reduce the likelihood of poor inpatient outcomes.

Aims: Metabolic Syndrome (MetS) is an important etiologic and prognostic factor for pancreatic cancer, but few studies have assessed health outcomes among hospitalized pancreatic cancer patients. We examined the associations between MetS and in-hospital outcomes, i.e. pancreatic resection, post-surgery complications, in-hospital mortality and discharge disposition among hospitalized patients with pancreatic cancer., Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) dataset from 2007 to 2011, we obtained data on 47,386 patients hospitalized with a primary diagnosis of pancreatic cancer. Descriptive statistics and multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals adjusting for age, race/ethnicity, and socioeconomic status., Results: Pancreatic cancer patients with MetS were more likely to undergo pancreatic resection (OR: 1.14, 95% CI: 1.04-1.25) compared to those without MetS. However they were less likely to experience post-surgical complications (OR: 0.90, 95% CI: 0.81-0.99), discharge to a skilled nursing facility (OR: 0.90, 95% CI: 0.83-0.93), and less likely to experience in-hospital mortality (OR: 0.52, 95% CI: 0.44-0.61) compared to those without MetS., Conclusion: Hospitalized pancreatic cancer patients with a clinical diagnosis of MetS were more likely to receive pancreatic resection, and had reduced odds of post-surgical complications and in-hospital mortality. If confirmed in future studies, then better understanding of the biological mechanisms underlying this association will be needed, potentially leading to the development of clinical and/or molecular biomarkers to improve early diagnosis of pancreatic cancer and identify patients that may benefit from pancreatic resection., (Copyright © 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study is to examine whether racial disparities in epithelial ovarian cancer stage at diagnosis and survival may be explained by geographic availability of healthcare resources among Blacks and Whites., Methods: Data from the Surveillance, Epidemiology and End Results (SEER) database was used to identify White and Black women ages 40 years and above diagnosed with epithelial ovarian cancer between 2000 and 2010. Data on county-level availability of healthcare resources was obtained from the Area Resource File. Multi-level regression models, overall and stratified by race and age, were used to examine the associations of health care access (HCA) and socioeconomic status (SES) with stage at diagnosis while Cox proportional hazards models were used to examine the association with survival., Results: Among 46,423 women diagnosed with epithelial ovarian cancer, Blacks were more likely to reside in counties with fewer average number of oncology hospitals (p < 0.05) and hospitals with ultrasound (p < 0.001), but higher number of medical doctors (p < 0.0001) and Ob/Gyn (p < 0.001). Black patients had higher odds of late stage diagnosis of epithelial ovarian cancer (OR: 1.13, 95% CI: 1.04-1.25) and higher risk of epithelial ovarian cancer mortality (HR: 1.25, 95% CI: 1.19-1.32) compared with White patients after accounting for differential availability of healthcare resources. Among Black patients, residing in counties with fewer medical doctors was associated with increased odds of late stage diagnosis (OR: 1.86, 95% CI: 1.10-3.13), and the racial disparity in late stage diagnosis and mortality was larger among patients ages <65 years compared with older patients., Conclusion: Racial disparities in availability and utilization of healthcare resources likely contributes to adverse epithelial ovarian cancer outcomes among Black women in the US.