Longitudinal Predictors of Pain in Pediatric Sickle Cell Disease.

OBJECTIVE: Despite the identified pathophysiology of vaso-occlusive pain in sickle cell disease (SCD), predictors of pain in youth with SCD remain elusive. In this study, we measured changes in pain frequency, intensity, and interference over 1 year and examined biopsychosocial risk factors (SCD disease severity, age, female, depression, and sleep quality) as possible longitudinal predictors. METHODS: Medical history was obtained from retrospective chart review for 79 children with SCD (ages 2-18 years; 48.1% female; 100% Black/African American; 83.5% SCD, SS genotype). As part of a clinical screening protocol, caregivers (n = 79) and youth 8-18 years (n = 43) completed psychosocial questionnaires approximately 1 year apart (M = 15.52 months, SD = 5.69). Zero-order correlations, paired t-tests, and hierarchical linear models examined longitudinal predictors of pain. The longitudinal bidirectional relationship between pain and sleep was also examined. RESULTS: The rate of severe SCD disease increased from 41.8% to 55.7% across the year, while most hematologic medical parameters remained stable. Increased depression and pain interference at survey 1 significantly predicted increased pain interference at survey 2. Poor sleep quality and increased pain frequency at survey 1 predicted increased pain frequency at survey 2. Finally, increased pain interference at survey 1 predicted poor sleep quality at survey 2. DISCUSSION: History of pain, depression, and sleep quality were longitudinal predictors of pain over 1 year in youth with SCD. Identifying longitudinal predictors of pain may lead to earlier identification of patients with a high-risk SCD pain phenotype and earlier medical, psychological, and behavioral interventions.

Long-Term Air Pollution and Blood Pressure in an African American Cohort: the Jackson Heart Study.

INTRODUCTION: African Americans are disproportionately affected by high blood pressure, which may be associated with exposure to air pollutants, such as fine particulate matter and ozone. METHODS: Among African American Jackson Heart Study participants, this study examined associations between 1-year and 3-year mean fine particulate matter and ozone concentrations with prevalent and incident hypertension at Visits 1 (2000-2004, n=5,191) and 2 (2005-2008, n=4,105) using log binomial regression. Investigators examined associations with systolic blood pressure, diastolic blood pressure, pulse pressure, and mean arterial pressure using linear regression and hierarchical linear models, adjusting for sociodemographic, behavioral, and clinical characteristics. Analyses were conducted in 2017-2019. RESULTS: No associations were observed between fine particulate matter or ozone concentration and prevalent or incident hypertension. In linear models, an IQR increase in 1-year ozone concentration was associated with 0.67 mmHg higher systolic blood pressure (95% CI=0.27, 1.06), 0.42 mmHg higher diastolic blood pressure (95% CI=0.20, 0.63), and 0.50 mmHg higher mean arterial pressure (95% CI=0.26, 0.74). In hierarchical models, fine particulate matter was inversely associated with systolic blood pressure (-0.72, 95% CI= -1.31, -0.13), diastolic blood pressure (-0.69, 95% CI= -1.02, -0.36), and mean arterial pressure (-0.71, 95% CI= -1.08, -0.33). Attenuated associations were observed with 1-year concentrations and at Visit 1. CONCLUSIONS: Positive associations were observed between ozone and systolic blood pressure, diastolic blood pressure, and mean arterial pressure, and inverse associations between fine particulate matter and systolic blood pressure, diastolic blood pressure, and mean arterial pressure in an African American population with high (56%) prevalence of hypertension. Effect sizes were small and may not be clinically relevant.

Association of Sickle Cell Trait With Incidence of Coronary Heart Disease Among African American Individuals.

Importance: The incidence of and mortality from coronary heart disease (CHD) are substantially higher among African American individuals compared with non-Hispanic White individuals, even after adjusting for traditional factors associated with CHD. The unexplained excess risk might be due to genetic factors related to African ancestry that are associated with a higher risk of CHD, such as the heterozygous state for the sickle cell variant or sickle cell trait (SCT). Objective: To evaluate whether there is an association between SCT and the incidence of myocardial infarction (MI) or composite CHD outcomes in African American individuals. Design, Setting, and Participants: This cohort study included 5 large, prospective, population-based cohorts of African American individuals in the Women's Health Initiative (WHI) study, the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, the Multi-Ethnic Study of Atherosclerosis (MESA), the Jackson Heart Study (JHS), and the Atherosclerosis Risk in Communities (ARIC) study. The follow-up periods included in this study were 1993 and 1998 to 2014 for the WHI study, 2003 to 2014 for the REGARDS study, 2002 to 2016 for the MESA, 2002 to 2015 for the JHS, and 1987 to 2016 for the ARIC study. Data analysis began in October 2013 and was completed in October 2020. Exposures: Sickle cell trait status was evaluated by either direct genotyping or high-quality imputation of rs334 (the sickle cell variant). Participants with sickle cell disease and those with a history of CHD were excluded from the analyses. Main Outcomes and Measures: Incident MI, defined as adjudicated nonfatal or fatal MI, and incident CHD, defined as adjudicated nonfatal MI, fatal MI, coronary revascularization procedures, or death due to CHD. Cox proportional hazards regression models were used to estimate the hazard ratio for incident MI or CHD comparing SCT carriers with noncarriers. Models were adjusted for age, sex (except for the WHI study), study site or region of residence, hypertension status or systolic blood pressure, type 1 or 2 diabetes, serum high-density lipoprotein level, total cholesterol level, and global ancestry (estimated from principal components analysis). Results: A total of 23 197 African American men (29.8%) and women (70.2%) were included in the combined sample, of whom 1781 had SCT (7.7% prevalence). Mean (SD) ages at baseline were 61.2 (6.9) years in the WHI study (n = 5904), 64.0 (9.3) years in the REGARDS study (n = 10 714), 62.0 (10.0) years in the MESA (n = 1556), 50.3 (12.0) years in the JHS (n = 2175), and 53.2 (5.8) years in the ARIC study (n = 2848). There were no significant differences in the distribution of traditional factors associated with cardiovascular disease by SCT status within cohorts. A combined total of 1034 participants (76 with SCT) had incident MI, and 1714 (137 with SCT) had the composite CHD outcome. The meta-analyzed crude incidence rate of MI did not differ by SCT status and was 3.8 per 1000 person-years (95% CI, 3.3-4.5 per 1000 person-years) among those with SCT and 3.6 per 1000 person-years (95% CI, 2.7-5.1 per 1000 person-years) among those without SCT. For the composite CHD outcome, these rates were 7.3 per 1000 person-years (95% CI, 5.5-9.7 per 1000 person-years) among those with SCT and 6.0 per 1000 person-years (95% CI, 4.9-7.4 per 1000 person-years) among those without SCT. Meta-analysis of the 5 study results showed that SCT status was not significantly associated with MI (hazard ratio, 1.03; 95% CI, 0.81-1.32) or the composite CHD outcome (hazard ratio, 1.16; 95% CI, 0.92-1.47). Conclusions and Relevance: In this cohort study, there was not an association between SCT and increased risk of MI or CHD in African American individuals. These disorders may not be associated with sickle cell trait-related sudden death in this population.

Human Papilloma Virus Vaccination Compliance in a Military Aviation Training Community.

INTRODUCTION: Human Papilloma Virus (HPV) vaccination compliance as reported by the CDC in 2011 falls short of a national goal to have 80% of adolescents vaccine-complete by 2020. The Naval Aviation Schools Command, Pensacola, Florida offers a single point of contact for military aviation trainees offering near-complete capture of an HPV vaccine target population. The purpose of this study is to identify baseline HPV vaccination rates among military aviation trainees and whether or not the provision of educational materials at the start of aviation training would increase future HPV vaccination compliance. MATERIALS AND METHODS: Approval to conduct this study was obtained from the Institutional Review Board of Naval Medical Center Portsmouth, Virginia. Our population of interest consisted of US Navy and Marine Corps student naval aviators, student naval flight officers (officers), and student enlisted air crew (enlisted) reporting for aviation related duty. A convenience sampling of officer and enlisted student classes checking in for training was performed over a period of 6 months. The first 3 months of students were assigned as the intervention group and the remaining 3 months of students were assigned to the control group. This study was conducted in two parts: (1) an anonymous survey captured cross-sectional data of self-reported HPV vaccine use, and (2) prospective analysis of service members' HPV vaccine rates before and after educational intervention as documented within the military's electronic health record system, Armed Forces Health Longitudinal Technology Application (AHLTA). RESULTS: AHLTA immunization status was evaluated for 1,164 personnel; 114 (9.8%) were excluded for missing basic vaccination information. Of the remaining 1,050, another 199 (19%) members were excluded as already vaccine complete (evidenced by three shots documented) prior to entry into the study. Within the 199 service members with documented baseline HPV vaccination completion, 197/199 (99%) were officers and 2/199 (0.1%) were enlisted. A total of 851 personnel were included for prospective analysis. Person-time of 100 person years was used and the vaccination rate translates to 16.62/100 person years (95% CI 11.29, 23.59) within intervention vs. 2.96/100 person years (95% CI 0.80, 7.58) within control groups and are significantly different (P = 0.0001). Comparing intervention and control groups, rate ratios = 5.61 (95% CI 2.14, 18.64) and rate differences = 13.66 (95% CI 7.13, 20.19). Among intervention group survey responders who previously reported nonvaccine use, 50.5% reported a change in opinion about obtaining the vaccination, with a higher proportion of enlisted members reporting a change in opinion (62.8% vs. 39.7%, P = 0.0053). CONCLUSIONS: Electronic health records immunizations review noted a baseline vaccine completion rate of 19%. Our study showed a health inequity between enlisted and officers, with officers having 99% of the documented baseline completion rates per AHLTA data. Our prospective analysis noted statistically significant rate differences of 13.66% and rate ratios of 5.61 between intervention and control groups. This analysis of AHLTA data combined with survey response of 50.5% indicating a change in opinion about HPV vaccine use among those who had not yet started vaccine series suggests targeted education would be a low-cost intervention to improve HPV vaccine use rates.

Adherence and retention of African Americans in a randomized controlled trial with a yoga-based intervention: the effects of health promoting programs on cardiovascular disease risk study.

Objectives: Sedentary lifestyle is a risk factor for cardiovascular disease (CVD). Few alternative lifestyle interventions, such as yoga practice, focus on African Americans (AA), the population most vulnerable to CVD. Our objective is to compare the retention and adherence rates between yoga, walking, and health education interventions while providing information about the acceptance of various yoga regimens. Design: Three hundred seventy-five AA participants were recruited exclusively from an active cohort study and randomized into a 48-week study (24 weeks intervention, 24 weeks follow-up) with 5 health promotion interventions: high frequency yoga, moderate frequency yoga, low frequency yoga, guided walking, and health education. In addition to examining the separate yoga interventions, a pooled yoga intervention is considered for comparison to guided walking and health education. Participant retention, adherence, and vitals were monitored at each intervention session. Participants were also scheduled for four clinic visits throughout the study where blood panels, health behavior, and medication surveys were administered. Results: Of the 375 participants recruited, 31.7% did not complete the study. At baseline, in both the guided walking group and the high frequency yoga group, there were significant differences between those who completed the study and those who did not. Although intervention retention in the pooled yoga program (78.3%) was higher compared to the walking (60%) and education programs (74.3%) (p = 0.007), differences in post-intervention retention was not significant. Median adherence rates for the pooled yoga program exceeded rates for guided walking and education with moderate frequency yoga out performing high and low frequency yoga. Conclusion: Study-defined retention success rates were not reached by all health promotion programs. However, retention and adherence rates for the pooled yoga program show that older African Americans are receptive to participating in yoga-based health promotion practices.

Recruitment and enrollment of African Americans into health promoting programs: the effects of health promoting programs on cardiovascular disease risk study.

Objectives: Randomized controlled trials (RCT) often employ multiple recruitment methods to attract participants, however, special care must be taken to be inclusive of under-represented populations. We examine how recruiting from an existing observational study affected the recruitment of African Americans into a RCT that included yoga-based interventions. In particular, we report the recruitment success of The Effects of Health Promoting Programs (HPP) on Cardiovascular Disease Risk (NCT02019953), the first yoga-based clinical trial to focus only on African Americans. Design: To recruit participants, a multifaceted recruitment strategy was implemented exclusively in the Jackson Heart Study (JHS) cohort. The HPP recruited from the JHS cohort using direct mailings, signs and flyers placed around JHS study facilities, and through JHS annual follow-up interviews. Results: Enrollment into HPP was open to all active JHS participants that were eligible to return for the third clinic exam (n = 4644). The target sample size was 375 JHS participants over a 24 month recruitment and enrollment period. From the active members of the JHS cohort, 503 were pre-screened for eligibility in HPP. More than 90% of those pre-screened were provisionally eligible for the study. The enrollment goal of 375 was completed after a 16-month enrollment period with over 25% (n = 97) of the required sample size enrolling during the second month of recruitment. Conclusions: The findings show that participants in observational studies can be successfully recruited into RCT. Observational studies provide researchers with a well-defined population that may be of interest when designing clinical trials. This is particularly useful in the recruitment of a high-risk, traditionally underrepresented populations for non-pharmacological clinical trials where traditional recruitment methods may prolong enrollment periods and extend study budgets.

Physical Activity and Pain in Youth With Sickle Cell Disease.

Study objectives were to examine the relationships between physical activity, pain, and psychological distress in youth 8 to 17 years of age with sickle cell disease. Participants were 206 youth with sickle cell disease (M = 11.73 years, 54.9% female, 99.5% African American). Caregivers and youth completed a clinical psychosocial screening battery. Results revealed frequent pain (37.6%), moderate median pain intensity, and elevated median pain interference in youth. Lower caregiver-reported physical activity was associated with worse pain outcomes. Increased anxiety was also associated with worse pain outcomes. A better understanding of the relationship between physical activity/inactivity and pain will guide multifactorial treatment interventions.

Does intravenous acetaminophen reduce perioperative opioid use in pediatric tonsillectomy?

OBJECTIVE: Postoperative pain control is of significant interest in pediatric otolaryngology given the safety concerns with opioid use. We sought to determine if addition of intraoperative intravenous acetaminophen decreases perioperative morphine use in pediatric tonsillectomy. METHODS: This study is a retrospective cohort study performed at a tertiary care academic children's hospital. 166 pediatric patients (aged 1-16 years) who underwent tonsillectomy with or without adenoidectomy were for review. Seventy-four patients received intraoperative intravenous acetaminophen (intervention cohort), while ninety-two patients served as our control and did not receive any intraoperative intravenous acetaminophen. Perioperative (intraoperative and postoperative) morphine use was our primary outcome measure. Rate of adverse events in the post anesthesia care unit and time for discharge readiness were secondary outcome measures. Wilcoxon two-sample t-test approximation and Fisher's exact test were used for data analyses. RESULTS: Patients in the intravenous acetaminophen cohort received less morphine (mg/kg) intraoperatively (0.058 versus 0.070, p = 0.089) and in the post anesthesia care unit (0.034 versus 0.051, p = 0.034) than the control cohort. The median time to discharge readiness for the intravenous acetaminophen and control groups was 108.5 versus 105 min (p = 0.018). There was no adverse respiratory event (oxygen desaturation <92% lasting more than a minute, requiring bag mask ventilation or reintubation) in either group in the post anesthesia care unit. There were 5 (7%) episodes of postoperative vomiting in the IV APAP, while 2 (2%) were recorded in the control cohort (p = 0.244). CONCLUSION: Our findings suggest intraoperative intravenous acetaminophen use in pediatric tonsillectomy can decrease the perioperative use of opioid for optimal pain management.

Association of Daytime and Nighttime Blood Pressure With Cardiovascular Disease Events Among African American Individuals.

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.

Calibration of blood pressure measurements in the Jackson Heart Study.

BACKGROUND: In longitudinal research studies with follow-up examinations, the devices used to measure phenotypes may change over time. When a device change occurs, the two devices should be calibrated to each other to ensure that measurements are comparable. This paper details the Jackson Heart Study (JHS) blood pressure (BP) comparability study. PARTICIPANTS AND METHODS: During its second clinic exam (2005-2008), the JHS switched from a random-zero sphygmomanometer (RZS) BP measurement device to an oscillometric device (OD). During this exam, BP measurements from both an RZS and an OD were taken simultaneously in 2117 participants for the purpose of calibration. Five methods for calibrating systolic BP (SBP) and diastolic BP (DBP) were considered: ignoring the change, ordinary least squares regression, adding the average difference, Deming regression, and robust regression. RESULTS: Using the RZS and OD, the mean (SD) SBP was 125.5 (19.2) and 126.5 (19.9), respectively, and the mean (SD) DBP was 76.4 (10.6) and 74.0 (11.0), respectively. The correlation between RZS and the OD was 0.90 for SBP and 0.80 for DBP. The prevalence of high BP and hypertension and associations with albuminuria were similar when applying each of the five calibration methods. Robust regression was chosen for calibration, giving the following equations:(Equation is included in full-text article.)These equations had a higher R statistic than using calibration equations from the Coronary Artery Risk Development in Young Adults Study and the Heinz Nixdorf Recall Study. CONCLUSIONS: The JHS BP data have been calibrated using the above equations for use in future analyses.

Audiologic profile of the jackson heart study cohort and comparison to other cohorts.

OBJECTIVES/HYPOTHESIS: The objective of this study was to determine the audiological profile of an African American cohort, identify related factors, and compare them to other datasets. STUDY DESIGN: Cross-sectional, longitudinal cohort study. METHODS: The Jackson Heart Study (JHS) is a longitudinal cohort study of 5,306 African Americans living in the metropolitan Jackson, Mississippi area, with a focus on cardiometabolic health. The JHS Hearing Study (n = 1,314) was implemented to measure the prevalence of hearing, tinnitus, and balance outcomes and relationship to predictor variables. Here we present prevalence and covariate relationships in comparison to the Epidemiology of Hearing Loss Study and the National Health and Nutrition Examination Survey. RESULTS: The prevalence of self-reported hearing difficulty was 38.1% (n = 500). The prevalence of hearing loss based on audiometric pure tone threshold average (0.5, 1.0, 2.0, 4.0 kHz) of the better ear was 19.8% (n = 260) and for the worse ear 29.8% (n = 392). The prevalence of tinnitus was 29.5% (n = 388) and balance dysfunction 24.1% (n = 317). Relationships of hearing loss to demographic, cardiometabolic, and audiologic variables are presented. CONCLUSIONS: These results demonstrate that hearing loss, tinnitus, and balance dysfunction are common issues affecting adult African Americans, and that hearing loss is related to numerous modifiable and nonmodifiable risk factors. Furthermore, our findings are consistent with lower prevalence of hearing loss in African Americans compared to the non-African American populations. However, despite the lower audiometric evidence of hearing loss, nearly 40% of participants reported hearing difficulty. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:2391-2397, 2019.

Impact of Race and Socioeconomic Status on Psychologic Outcomes in Childhood Cancer Patients and Caregivers.

Complex relationships between race and socioeconomic status have a poorly understood influence on psychologic outcomes in pediatric oncology. The Family Symptom Inventory was used to assess symptoms of depression and anxiety in pediatric patients with cancer and their caregivers. Separate hierarchical linear regression models examined the relationship between demographic variables, cancer characteristics, socioeconomic status, and access to care and patient or caregiver depression/anxiety. Participants included 196 pediatric patients with cancer (mean age, 11.21 y; 49% African American) and their caregivers. On average, caregivers reported low levels of depression/anxiety. Symptoms of depression and anxiety in patients were correlated with poorer mental health in caregivers (r=0.62; P<0.01). Self-reported financial difficulty (ß=0.49; P<0.001) and brain cancer diagnosis for their child (ß=0.42; P=0.008) were significantly associated with depression and anxiety in caregivers. Analysis did not reveal significant associations between race, household income, or access to care and patient or caregiver depression/anxiety. Perception of financial hardship can adversely impact mental health in caregivers of children with cancer. Psychosocial assessment and interventions may be especially important for caregivers of patients with brain tumors and caregivers who report feeling financial difficulty.

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

OBJECTIVE: To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population. STUDY DESIGN: Retrospective study. METHODS: 1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort. RESULTS: The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028). CONCLUSION: The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding. LEVEL OF EVIDENCE: 4.

Association of Sickle Cell Trait With Ischemic Stroke Among African Americans: A Meta-analysis.

Importance: African Americans and individuals of African ancestry have a higher risk of stroke compared with non-Hispanic white individuals. Identifying the source of this disparity could provide an opportunity for clinical stroke risk stratification and more targeted therapy. Whether sickle cell trait (SCT) is an indicator of increased risk of ischemic stroke among African Americans is still unclear. Objective: To examine whether SCT is associated with a higher risk of incident ischemic stroke among African Americans. Design, Setting, and Participants: This meta-analysis assessed the association of SCT with the risk of incident ischemic stroke. Four large, prospective, population-based studies with African American cohorts were assessed: Jackson Heart Study (September 1, 2005, through December 31, 2012), Multi-Ethnic Study of Atherosclerosis (July 1, 2002, through December 31, 2012), Reasons for Geographic and Racial Differences in Stroke (January 1, 2003, through December 31, 2014), and Women's Health Initiative (October 1, 1998, through December 31, 2012). Using a Cox proportional hazards regression model adjusted for major stroke risk factors, this study estimated the hazard ratio for incident ischemic stroke associated with SCT. Data analysis was performed from July 10, 2016, to February 2, 2017. Interventions or Exposures: Participants' SCT status determined by polymerase chain reaction assay genotyping or a combination of whole-exome sequencing and imputation. Main Outcomes and Measures: Incident ischemic stroke. Results: This meta-analysis included 19 464 African American individuals (1520 with SCT, 17 944 without SCT, and 620 with ischemic stroke) from 4 studies, with a mean (SD) age of 60.0 (13.0) years (5257 [27.0%] men and 14 207 [73.0%] women). No differences were found in the distribution of risk factors for ischemic stroke comparing participants with and those without SCT at study visit 1 in each cohort. The crude incidence of ischemic stroke was 2.9 per 1000 person-years (95% CI, 2.2-4.0 per 1000 person-years) among those with SCT and 3.2 per 1000 person-years (95% CI, 2.7-3.8 per 1000 person-years) among those without SCT. After stroke risk factors were adjusted for, the hazard ratio of incident ischemic stroke independently associated with SCT in the meta-analysis of all 4 cohorts was 0.80 (95% CI, 0.47-1.35; P = .82). The results of the meta-analysis were similar to those of individual cohorts, in which the results were also similar. Conclusions and Relevance: Sickle cell trait may not be associated with incidence of ischemic stroke among African Americans. The results of this study suggest performing a more thorough clinical evaluation of a stroke patient with SCT rather than assuming that SCT is the etiologic factor for the stroke.

Evaluating different criteria for defining a complete ambulatory blood pressure monitoring recording: data from the Jackson Heart Study.

OBJECTIVE: We determined differences in the prevalence of blood pressure (BP) phenotypes and the association of these phenotypes with left ventricular hypertrophy (LVH) for individuals who fulfilled and did not fulfill various criteria used for defining a complete ambulatory blood pressure monitoring (ABPM) recording. METHODS: We analyzed data for 1141 participants from the Jackson Heart Study. Criteria evaluated included having greater than or equal to 80% of planned readings with more than or equal to one reading per hour (Spanish ABPM Registry criteria), more than or equal to 70% of planned readings with a minimum of 20 daytime and seven nighttime readings (2013 European Society of Hypertension criteria), greater than or equal to 14 daytime and greater than or equal to seven nighttime readings (2003 European Society of Hypertension criteria), more than or equal to 10 daytime and more than or equal to 5 nighttime readings (International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome criteria), and greater than or equal to 14 daytime readings (UK National Institute of Health and Clinical Excellence criteria). RESULTS: Between 45.0% (Spanish ABPM Registry) and 91.8% (UK National Institute of Health and Clinical Excellence) of the participants fulfilled the different criteria for a complete ABPM recording. Across the various criteria evaluated, 55.5-57.8% of participants had nocturnal hypertension and 62.8-66.8% had nondipping systolic BP. Among participants with clinic-measured systolic/diastolic BP of more than or equal to 140/90 mmHg, 22.9-26.5% had white-coat hypertension. The prevalence of daytime, 24-h, sustained, and masked hypertension differed by up to 2% for participants fulfilling each criterion. The association of BP phenotypes with LVH was similar for participants who fulfilled versus those who did not fulfill different criteria (each P>0.05). CONCLUSION: Irrespective of the criteria used for defining a complete ABPM recording, the prevalence of BP phenotypes and their association with LVH were similar.

Chronic kidney disease and incident apparent treatment-resistant hypertension among blacks: Data from the Jackson Heart Study.

It is unclear whether black patients with chronic kidney disease (CKD) vs those without CKD who take antihypertensive medication have an increased risk for apparent treatment-resistant hypertension (aTRH). The authors analyzed 1741 Jackson Heart Study participants without aTRH taking antihypertensive medication at baseline. aTRH was defined as uncontrolled blood pressure while taking three antihypertensive medication classes or taking four or more antihypertensive medication classes, regardless of blood pressure level. CKD was defined as an albumin to creatinine ratio ≥30 mg/g or estimated glomerular filtration rate <60 mL/min/1.73 m2 . Over 8 years, 20.1% of participants without CKD and 30.5% with CKD developed aTRH. The multivariable-adjusted hazard ratio for aTRH comparing participants with CKD vs those without CKD was 1.45 (95% CI, 1.12-1.86). Participants with an albumin to creatinine ratio ≥30 vs <30 mg/g (hazard ratio, 1.44; 95% CI, 1.04-2.00) and estimated glomerular filtration rate of 45 to 59 mL/min/1.73 m2 and <45 vs ≥60mL/min/1.73 m2 (hazard ratio, 1.60 [95% CI, 1.16-2.20] and 2.05 [95% CI, 1.28-3.26], respectively) were more likely to develop aTRH.

Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg.

BACKGROUND: Data from before the 2000s indicate that the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP) ≥140/90 mm Hg. Over the past several decades, BP has declined and hypertension control has improved. METHODS: We estimated the percentage of incident CVD events that occur at SBP/DBP <140/90 mm Hg in a pooled analysis of 3 contemporary US cohorts: the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), the MESA (Multi-Ethnic Study of Atherosclerosis), and the JHS (Jackson Heart Study) (n=31 856; REGARDS=21 208; MESA=6779; JHS=3869). Baseline study visits were conducted in 2003 to 2007 for REGARDS, 2000 to 2002 for MESA, and 2000 to 2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or nonfatal stroke, nonfatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. RESULTS: Over a mean follow-up of 7.7 years, 2584 participants had incident CVD events. Overall, 63.0% (95% confidence interval [CI], 54.9-71.1) of events occurred in participants with SBP/DBP <140/90 mm Hg; 58.4% (95% CI, 47.7-69.2) and 68.1% (95% CI, 60.1-76.0) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP <140/90 mm Hg among those <65 years of age (66.7%; 95% CI, 60.5-73.0) and ≥65 years of age (60.3%; 95% CI, 51.0-69.5), women (61.4%; 95% CI, 49.9-72.9) and men (63.8%; 95% CI, 58.4-69.1), and for whites (68.7%; 95% CI, 66.1-71.3), blacks (59.0%; 95% CI, 49.5-68.6), Hispanics (52.7%; 95% CI, 45.1-60.4), and Chinese-Americans (58.5%; 95% CI, 45.2-71.8). Among participants taking antihypertensive medication with SBP/DBP <140/90 mm Hg, 76.6% (95% CI, 75.8-77.5) were eligible for statin treatment, but only 33.2% (95% CI, 32.1-34.3) were taking one, and 19.5% (95% CI, 18.5-20.5) met the SPRINT (Systolic Blood Pressure Intervention Trial) eligibility criteria and may benefit from a SBP target goal of 120 mm Hg. CONCLUSIONS: Although higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP <140/90 mm Hg. While absolute risk and cost-effectiveness should be considered, additional CVD risk-reduction measures for adults with SBP/DBP <140/90 mm Hg at high risk for CVD may be warranted.

Relational Intimacy Mediates Sexual Outcomes Associated With Impaired Sexual Function: Examination in a Clinical Sample.

BACKGROUND: Relational intimacy is hypothesized to underlie the association between female sexual functioning and various sexual outcomes, and married women and women with sexual dysfunction have been generally absent from prior studies investigating these associations, thus restricting generalizability. AIM: To investigate whether relational intimacy mediates sexual outcomes (sexual satisfaction, coital frequency, and sexual distress) in a sample of married women with and without impaired sexual functioning presenting in clinical settings. METHODS: Using a cross-sectional design, 64 heterosexual married women with (n = 44) and without (n = 20) impaired sexual functioning completed a battery of validated measurements assessing relational intimacy, sexual dysfunction, sexual frequency, satisfaction, and distress. Intimacy measurements were combined using latent factor scores before analysis. Bias-corrected mediation models of the indirect effect were used to test mediation effects. Moderated mediation models examined whether indirect effects were influenced by age and marital duration. OUTCOMES: Patients completed the Female Sexual Function Index, the Couple's Satisfaction Index, the Sexual Satisfaction Scale for Women, the Inclusion of the Other in the Self Scale, and the Miller Social Intimacy Test. RESULTS: Mediation models showed that impaired sexual functioning is associated with all sexual outcomes directly and indirectly through relational intimacy. Results were predominantly independent of age and marital duration. CLINICAL IMPLICATIONS: Findings have important treatment implications for modifying interventions to focus on enhancing relational intimacy to improve the sexual functioning of women with impaired sexual functioning. STRENGTHS AND LIMITATIONS: The importance of the role relational intimacy plays in broad sexual outcomes of women with impaired sexual functioning is supported in clinically referred and married women. Latent factor scores to improve estimation of study constructs and the use of contemporary mediation analysis also are strengths. The cross-sectional design precludes any causal conclusions and it is unknown whether the results generalize to male partners, partners within other relationship structures, and non-heterosexual couples. CONCLUSION: Greater relational intimacy mitigates the adverse impact of impaired sexual functioning on sexual behavior and satisfaction in women. Witherow MP, Chandraiah S, Seals SR, et al. Relational Intimacy Mediates Sexual Outcomes Associated With Impaired Sexual Function: Examination in a Clinical Sample. J Sex Med 2017;14:843-851.

Microcirculatory Effects of Botulinum Toxin A in the Rat: Acute and Chronic Vasodilation.

BACKGROUND: Botulinum toxin-A (BTX) has numerous cosmetic and therapeutic applications. Our previous studies have found that BTX augments pedicled flap survival through both vasodilatory effects and attenuation of the inflammatory response to ischemia in the rat. This study examines the effect of chronic BTX on microcirculatory vascular tone and its response to acute topical vasodilators in muscle flaps. METHODS: The spinotrapezius muscle of Sprague-Dawley rats underwent a single 2-week pretreatment of 0.2 mL saline either with (n = 5) or without (n = 5) 2u BTX. After surgical elevation, an arcade arteriole was observed using a video caliper device. Vessel diameter was measured at 30-second intervals after sequential superfusion of nitroglycerin (100 and 200 µg/mL), multiple concentrations of lidocaine, and a combination of adenosine (10 µM) and nitroprusside (10 µM) to induce maximum dilation. RESULTS: Baseline and dilation diameters were expressed as ratios of pharmacologically induced maximum dilation, whereas percent dilation was defined as the change in diameter over baseline diameter. We found a significant increase in resting diameter with BTX pretreatment (P = 0.0028). Compared with the control group, mean baseline diameter was 15% greater, and percent dilation was 25% less in BTX-pretreated flaps. There was no significant relationship between BTX pretreatment and dilation diameter (P = 0.2895) after adjusting for the effect of acute vasodilators. CONCLUSIONS: Pretreatment with BTX may induce the arteriolar resting diameter to be closer to their maximum potential diameter. Additionally, BTX does not display a synergistic effect with topical vasodilators on vasodilation.

Clinic and ambulatory blood pressure in a population-based sample of African Americans: the Jackson Heart Study.

Blood pressure (BP) can differ substantially when measured in the clinic versus outside of the clinic setting. Few population-based studies with ambulatory blood pressure monitoring (ABPM) include African Americans. We calculated the prevalence of clinic hypertension and ABPM phenotypes among 1016 participants in the population-based Jackson Heart Study, an exclusively African-American cohort. Mean daytime systolic BP was higher than mean clinic systolic BP among participants not taking antihypertensive medication (127.1[standard deviation 12.8] vs. 124.5[15.7] mm Hg, respectively) and taking antihypertensive medication (131.2[13.6] vs. 130.0[15.6] mm Hg, respectively). Mean daytime diastolic BP was higher than clinic diastolic BP among participants not taking antihypertensive medication (78.2[standard deviation 8.9] vs. 74.6[8.4] mm Hg, respectively) and taking antihypertensive medication (77.6[9.4] vs. 74.3[8.5] mm Hg, respectively). The prevalence of daytime hypertension was higher than clinic hypertension for participants not taking antihypertensive medication (31.8% vs. 14.3%) and taking antihypertensive medication (43.0% vs. 23.1%). A high percentage of participants not taking and taking antihypertensive medication had nocturnal hypertension (49.4% and 61.7%, respectively), white-coat hypertension (30.2% and 29.3%, respectively), masked hypertension (25.4% and 34.6%, respectively), and a nondipping BP pattern (62.4% and 69.6%, respectively). In conclusion, these data suggest hypertension may be misdiagnosed among African Americans without using ABPM.