Eligibility Criteria for Lower Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities.

BACKGROUND: Cost-containment strategies may discourage hospitals from performing surgery for patients with preexisting risk factors such as those with high body mass index (BMI), those with high hemoglobin A1c (HbA1c), or those who smoke cigarettes. Because these risk factors may not appear in equal proportions across the population, using these risk factors as inflexible eligibility criteria for lower extremity joint arthroplasty may exacerbate existing racial-ethnic, gender, and socioeconomic disparities pertaining to access to an operation that can improve health and quality of life. However, any effects on such disparities have not yet been quantified nor have the groups been identified that may be most affected by inflexible eligibility criteria. QUESTIONS/PURPOSES: Does the use of inflexible eligibility criteria related to (1) BMI; (2) HbA1c level; and (3) smoking status potentially decrease the odds of lower extremity joint arthroplasty eligibility for members of racial-ethnic minority groups, women, and those of lower socioeconomic status more than it does for non-Hispanic whites, men, and those of higher socioeconomic status? METHODS: We pooled data from 21,294 adults aged ≥ 50 years from the 1999-2014 National Health and Nutrition Examination Survey (NHANES). NHANES is a nationally administered series of surveys that assess the health and nutritional status of the US population and collect information on many risk factors for diseases. NHANES is uniquely suited to examine our study questions because it includes data from physical examinations and laboratory assessments as well as comprehensive questionnaires, and it is nationally representative. We determined the odds of lower extremity arthroplasty eligibility by running separate multivariable logistic regressions for each criterion (that is, for each dependent variable): (1) BMI < 35 kg/m; (2) BMI < 40 kg/m; (3) HbA1c < 8%; and (4) current nonsmoker status. Independent variables of interest were race-ethnicity, gender, educational level, and annual household income. Each model included all independent variables of interest, age, and survey year. RESULTS: The BMI < 35-kg/m criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks compared with non-Hispanic whites (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.55-0.70; p < 0.001), women versus men (OR, 0.61; 95% CI, 0.55-0.69; p < 0.001), individuals of lower socioeconomic status versus those of higher socioeconomic status (annual household income < USD 45,000 versus ≥ USD 45,000 [OR, 0.81; 95% CI, 0.71-0.93; p = 0.002], and those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.66; 95% CI, 0.57-0.77; p < 0.001). The HbA1c < 8% criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks (OR, 0.44; 95% CI, 0.37-0.53; p < 0.001) and Hispanics (OR, 0.41; 95% CI, 0.33-0.51; p < 0.001) versus non-Hispanic whites, for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.73; 95% CI, 0.56-0.94; p = 0.015), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.58; 95% CI, 0.44-0.77; p < 0.001). Excluding smokers resulted in lower arthroplasty eligibility for non-Hispanic blacks versus non-Hispanic whites (OR, 0.84; 95% CI, 0.73-0.97; p = 0.019), for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.53; 95% CI, 0.47-0.61; p < 0.001), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.29; 95% CI, 0.24-0.35; p < 0.001). CONCLUSIONS: Payment structures and clinical decision-making algorithms that set inflexible cutoffs with respect to BMI, HbA1c, and smoking status disproportionately discourage performing lower extremity arthroplasty for non-Hispanic blacks and individuals of lower socioeconomic status. We do not advocate performing elective surgery for patients with multiple, uncontrolled medical comorbidities. However, ample evidence suggests that many patients whose BMI values are > 35 kg/m (or even > 40 kg/m) may be reasonable candidates for arthroplasty surgery, and BMI is not an easily modifiable risk factor for many patients. We discourage across-the-board cutoff parameters in these domains because such cutoffs will worsen current racial-ethnic, gender-based, and socioeconomic disparities and limit access to an operation that can improve quality of life. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Factors regulating subcutaneous adipose tissue storage, fibrosis, and inflammation may underlie low fatty acid mobilization in insulin-sensitive obese adults.

Although the rate of fatty acid release from adipose tissue into the systemic circulation is very high in most obese adults, some obese adults maintain relatively low rates of fatty acid release, which helps protect them against the development of systemic insulin resistance. The primary aim of this study was to identify factors in adipose tissue that may underlie low vs. high rates of fatty acid mobilization in a relatively homogeneous cohort of obese adults. We measured systemic fatty acid rate of appearance (FA Ra) via 13C-palmitate isotope dilution, and we obtained subcutaneous abdominal adipose tissue samples from 30 obese adults (BMI: 38 ± 1 kg/m2, age: 30 ± 2 yr) after an overnight fast. We then measured insulin sensitivity using a hyperinsulinemic-euglycemic clamp. Confirming our previous work, insulin sensitivity was inversely proportional to FA Ra (R2 = 0.50; P < 0.001). Immunoblot analysis of subcutaneous adipose tissue samples revealed that, compared with obese adults with high FA Ra, those with low FA Ra had lower markers of lipase activation and higher abundance of glycerol-3-phosphate acyltransferase, which is a primary enzyme for fatty acid esterification. Microarray and pathway analysis provided evidence of lower fibrosis and lower SAPK/JNK pathway activation in obese adults with low FA Ra compared with those with high FA Ra. Our findings suggest that alterations in factors regulating triglyceride storage in adipose tissue, along with lower fibrosis and inflammatory pathway activation, may underlie maintenance of a relatively low FA Ra in obesity, which may help protect against the development of insulin resistance.

The perks of being bi+: Positive sexual orientation-related experiences among bisexual, pansexual, and queer male youth.

Previous research on sexual minority health has largely focused on negative experiences related to one's sexual orientation with limited attention to the ways in which being a sexual minority can contribute to positive experiences. This is especially true of bisexual, pansexual, and queer (bi+) male youth, whose experiences have not been represented in the literature. To address these gaps, the goal of the current study was to characterize positive experiences related to one's sexual orientation in a sample of 46 bi+ male youth (ages 14-17) who were interviewed as part of a larger study. Interviews were transcribed and thematically analyzed. Almost all of the participants described at least one positive experience related to their bi+ identity. The positive experiences fell into six categories: (1) experiences with LGBTQ+ people in general; (2) experiences with other bi+ people; (3) experiences in LGBTQ+ environments; (4) experiences disclosing bi+ identities; (5) romantic and sexual experiences; and (6) experiences with allies. Participants described eight reasons for these experiences being positive: (1) feeling a sense of belonging in a community; (2) the normalization, acceptance, and visibility of one's identity or community; (3) providing or receiving support; (4) discussing shared experiences; (5) the promotion of authenticity; (6) celebrating one's identity or community; (7) experiencing personal growth; and (8) not feeling limited by gender when it came to romantic and sexual experiences. In sum, bi+ male youth report a range of positive experiences related to their sexual orientation, which may have important implications for promoting resilience and wellbeing.

Disruption of prepulse inhibition is associated with compulsive behavior severity and nucleus accumbens dopamine receptor changes in Sapap3 knockout mice.

Obsessive compulsive disorder (OCD) is associated with disruption of sensorimotor gating, which may contribute to difficulties inhibiting intrusive thoughts and compulsive rituals. Neural mechanisms underlying these disturbances are unclear; however, striatal dopamine is implicated in regulation of sensorimotor gating and OCD pathophysiology. The goal of this study was to examine the relationships between sensorimotor gating, compulsive behavior, and striatal dopamine receptor levels in Sapap3 knockout mice (KOs), a widely used preclinical model system for OCD research. We found a trend for disruption of sensorimotor gating in Sapap3-KOs using the translational measure prepulse inhibition (PPI); however, there was significant heterogeneity in both PPI and compulsive grooming in KOs. Disruption of PPI was significantly correlated with a more severe compulsive phenotype. In addition, PPI disruption and compulsive grooming severity were associated with reduced dopamine D1 and D2/3 receptor density in the nucleus accumbens core (NAcC). Compulsive grooming progressively worsened in Sapap3-KOs tested longitudinally, but PPI disruption was first detected in high-grooming KOs at 7 months of age. Through detailed characterization of individual differences in OCD-relevant behavioral and neurochemical measures, our findings suggest that NAcC dopamine receptor changes may be involved in disruption of sensorimotor gating and compulsive behavior relevant to OCD.