Post-natal steroid exposure in very low birthweight neonates and associations with acute kidney injury.

OBJECTIVE: The relationship between adrenal insufficiency (AI), post-natal steroids (PNS) and neonatal acute kidney injury (AKI) remains understudied. We investigated associations between PNS and AKI in very low birthweight (VLBW) neonates, hypothesizing PNS is associated with reduced AKI. STUDY DESIGN: We conducted a single-center retrospective review of VLBW infants comparing those with and without PNS exposure. Associations between PNS exposure and AKI were evaluated using generalized linear mixed-modeling adjusted for confounders. RESULT: Of 567 neonates, 97 (17.1%) were exposed to PNS and 130 (22.9%) experienced AKI. Infants with PNS had lower gestational age, birthweight, Apgar scores, and experienced more AI versus those without PNS (all p < 0.05). PNS was associated with AKI (aRR 1.72, 95% CI 1.09-2.72) though hydrocortisone alone was not. CONCLUSION: PNS exposure, but not hydrocortisone alone, is associated with increased AKI in VLBW neonates. Further analysis is needed to investigate the role of AI and AKI.

Narcissism Is Not Associated With Success in U.S. Army Soldier Training.

INTRODUCTION: Narcissism has been studied for its role in leadership using various versions of the Narcissistic Personality Inventory (NPI). Narcissism is described as having a "dark and negative" side as well as a "positive or bright" side. The bright side of narcissism, in particular, has been studied for its role in leadership. In studies among military personnel in Finland and Hungary, the NPI has been associated with positive leadership traits. We assessed if measures of narcissistic personality were predictive of entrance to and graduation from the Army Ranger Course among United States (U.S.) Army personnel. MATERIALS AND METHODS: We included the NPI as one of the measures in the Ranger Resilience and Improved Performance on Phospholipid-bound Omega-3's (RRIPP-3) study. RRIPP-3 was a double-blind, placebo-controlled dietary supplement intervention trial at Fort Benning, GA, that enrolled 555 officers when they entered the U.S. Army Infantry Basic Officer Leadership Course (IBOLC) with the intention to complete the U.S. Ranger School. RRIPP-3 volunteer participants consumed eight dietary supplements daily containing 2.3 g of omega-3 (krill oil) or macadamia nut oil (control) over a 20-week period. Blood spot samples were collected to monitor intake compliance. Cognitive functioning, resilience, and mood were assessed at approximately 14 and 16 weeks. Dietary intake was also assessed. The 40-item, forced-choice NPI was included to assess if three factors of narcissism: Leadership/Authority, Grandiose/Exhibitionism, and Entitlement/Exploitativeness measures of narcissistic personality were associated with entrance to and graduation from the Army Ranger Course. RESULTS: Of the 555 soldiers enrolled in RRIPP-3, there were no statistically significant differences in the total NPI scores comparing U.S. Army IBOLC officers who enrolled (n = 225) versus did not enroll (n = 330, p = .649) or graduated (n = 95; versus did not graduate [n = 460, p = .451]) from the Ranger Course. None of the three-factor NPI subscales differed statistically comparing either enrollment in (p = .442, .510, and .589, respectively) or graduation from the Ranger Course (p = .814, .508, and .813, respectively). CONCLUSIONS: Although narcissism has been positively associated with military trainee success in other countries, we did not find an association between narcissism and trainee success among U.S. Army trainees, and accordingly the level of narcissism did not predict trainee success or failure.

Recurrent neonatal acute kidney injury: incidence, predictors, and outcomes in the neonatal intensive care unit.

OBJECTIVE: Determine recurrent neonatal acute kidney injury (rAKI) incidence, risk factors, and associated outcomes. STUDY DESIGN: Single-center retrospective cohort of neonates admitted to the NICU 1/1/20-6/30/21. Comparisons were made between those with no AKI, single AKI episode (sAKI), and rAKI. Multivariable linear and logistic regression models were used to assess associations between rAKI and length of mechanical ventilation (LMV), length of hospitalization stay (LOS), mortality, and hypertension (HTN) at discharge. RESULTS: The incidence of AKI in the cohort of 869 infants was 19%: 705 (81%) no AKI, 100 (12%) sAKI, 64 (7%) rAKI. Both sAKI and rAKI were independently associated with longer LMV and LOS. sAKI was independently associated with almost 4x higher odds of mortality than rAKI. CONCLUSION: In this single center cohort of neonates, sAKI independently predicts mortality, however rAKI is independently associated with increased LMV and LOS suggesting rAKI is clinically important and warrants further study.

Poor effort on cognitive testing in voluntary research predicts failure in US Army Ranger School: Implications for clinical trial design.

INTRODUCTION: Failure to provide effortful performance on cognitive testing is not uncommon for participants in clinical trials and can significantly impact sensitivity to treatment effect. Whether poor effort on cognitive testing might relate to other behaviors of interest is unknown. In the current investigation, we examined whether effort on baseline cognitive testing in a randomized controlled trial to enhance resiliency in US Army Officers predicted subsequent success in Ranger school. METHODS: Baseline data on six cognitive tests were obtained from 237 US Army Officers entering a military training program prior to attempting Ranger School. Participation was voluntary and the Army was not informed of test scores. "Poor effort" was defined by chance-level accuracy or extreme outlier scores. Logistic regression examined likelihood of Ranger success according to the number of tests with poor effort. RESULTS: Overall, 170 (72%) participants provided good effort on all tests. For these participants, 47% were successful in Ranger, versus 32% with poor effort on one test and 14% with poor effort on two tests. Logistic regression analysis found poor effort on baseline testing predicted reduced likelihood of Ranger success, ß =-.486, p = .005. DISCUSSION: A substantial number of participants exhibited poor effort on testing, and poor effort was predictive of failure in Ranger school. Findings highlight the importance of assessing effort in clinical trials involving cognitive outcomes and suggest application of cognitive effort testing in trials where other motivated behavior is targeted. REGISTRATION: Clinical Trials.gov NCT02908932.

Latency of late preterm steroid administration to delivery and risk of neonatal hypoglycemia.

BACKGROUND: Late preterm antenatal corticosteroid administration has been associated with an increased risk of neonatal hypoglycemia. The mechanism is thought to be secondary to transient fetal hyperinsulinemia, which may be more likely if delivery occurs during peak antenatal corticosteroid levels. OBJECTIVE: This study aimed to investigate whether there is a latency interval between antenatal corticosteroid administration and delivery that places neonates at the greatest risk of hypoglycemia. STUDY DESIGN: This was a retrospective matched cohort study of pregnant women who received antenatal corticosteroid vs unexposed women between 34 0/7 and 36 6/7 weeks of gestation from 2016 to 2019. Unexposed women were those who did not receive antenatal corticosteroid matched according to gestational age at delivery, diabetes mellitus status, and maternal body mass index from 2010 to 2015. Latency periods from initial steroid administration to delivery were defined in grouped intervals until ≥72 hours. The primary outcome was neonatal hypoglycemia, defined as a neonatal glucose level of <40 mg/dL within 24 hours of life. Poisson regression was used to generate an adjusted relative risk of hypoglycemia for each latency period adjusting for confounders. RESULTS: A total of 812 women were included in the analysis (406 exposed and 406 unexposed). Women who received antenatal corticosteroids were more likely to be nulliparous (P=.009); moreover, the women were well matched on pregnancy complications and baseline demographics. Neonatal hypoglycemia was more frequently identified in women receiving antenatal corticosteroids than in women not receiving antenatal corticosteroids (42% vs 26%; P<.001). Severe hypoglycemia, defined as a glucose level of <20 mg/dL, was significantly more common in patients receiving antenatal corticosteroids than in patients not receiving antenatal corticosteroids (8.4% vs 2.7%; P<.001). Latency time intervals of 12 to 71 hours from antenatal corticosteroid administration were significantly associated with neonatal hypoglycemia in exposed women compared with unexposed women after adjustment; within this time frame, the highest risk was 24 to 47 hours after antenatal corticosteroid administration (adjusted relative risk, 2.09; 95% confidence interval, 1.29-3.38). CONCLUSION: In the late preterm period, the risk of neonatal hypoglycemia is the greatest in the latency period of 12 to 71 hours between steroid administration and delivery. Neonates exposed to antenatal corticosteroids were more likely to experience severe hypoglycemia within 24 hours of life than unexposed neonates.

Indication Creep of Antenatal Late Preterm Steroids.

OBJECTIVE: While antenatal corticosteroids (ACS) administered in the late preterm period have been shown to reduce respiratory morbidity, this finding was demonstrated in a well-designed randomized controlled trial (the Antenatal Betamethasone for Women at Risk for Late Preterm Delivery [ALPS]) with strict inclusion/exclusion criteria that may differ from clinical practice. The aim of this study was to investigate whether there has been indication creep since use of late preterm ACS became standard of care. STUDY DESIGN: Retrospective cohort study of pregnant women who received late preterm ACS between 2016 and 2019 were identified and separated into epochs of 2016 to 2017 and 2018 to 2019 based on year of exposure. The primary outcome was rate of inappropriate ACS exposure, defined as nonadherence to the inclusion/exclusion criteria of the ALPS trial. Secondary outcomes were rates of nonoptimal ACS exposure (delivery >7 days from ACS or term delivery). Logistic regression was used to generate adjusted odds ratios (aORs) between epochs for the primary outcome adjusting for confounders. RESULTS: There were 660 women who received late preterm ACS during the study period with 229 (34.6 %) deemed inappropriate exposures. The most common reason for inappropriate treatment was preterm premature rupture of membrane (PPROM; 29.0%) with exclusionary cervical examination or contraction frequency. No difference was observed in inappropriate ACS exposure between epochs (aOR = 0.83, 95% confidence interval [CI]: 0.59-1.2). However, there was a reduction in nonoptimal exposure over time (aOR = 0.67, 95% CI: 0.47-0.97) . Women receiving inappropriate ACS were more likely to deliver at term if indicated for maternal/fetal status (50.0 vs. 19.5%, p < 0.001) and preterm labor (66.0 vs. 41.9%; p = 0.015). Further, inappropriate exposure in preterm labor had higher rates of exposure latency >7 days (62.3 vs. 39.1%, p = 0.006) with a longer latency to delivery (3 vs. 16 days; p < 0.001). CONCLUSION: Over one-third of women received late preterm ACS for an indication that could be classified as indication creep. Depending on indication, inappropriate administration is associated with higher rates of nonoptimal exposure. KEY POINTS: · There is potential for indication creep of ACS administration.. · One third of late preterm ACS exposures in our study were inappropriate.. · Utilizing clinical criteria can aid in identifying patients who best benefit from late preterm ACS..

Impact of Fatty Acid Supplementation on Cognitive Performance among United States (US) Military Officers: The Ranger Resilience and Improved Performance on Phospholipid-Bound Omega-3's (RRIPP-3) Study.

Studies have assessed omega-3 fatty acids and cognitive decline among older adults and cognitive development among children, although less is known about cognitive or neurological effects among young adults. We examined whether omega-3 supplementation from krill oil could improve cognition and resilience among young military officers compared to a control. This double-blind, placebo-controlled trial enrolled 555 officers (mean age 23.4 ± 2.8, 98.6% male) entering the United States (US) Army Infantry Basic Officer Leaders Course (IBOLC) with the intention to complete the US Ranger Course. Volunteer participants consumed eight dietary supplements daily of krill oil containing 2.3 g omega-3 or control (macadamia nut oil) over an approximate 20-week period. Cognitive functioning, resilience, and mood were assessed during a well-rested period at approximately 14 weeks and after a battlefield simulation at 16 weeks. Blood spot samples were collected to monitor compliance and dietary intake was assessed. All hypotheses were tested using both 'Intention to Treat' (ITT) and 'As Per Protocol' (APP) approaches. Of the 555 randomized individuals, 245 (44.1%) completed the study. No statistically significant group-by-time interactions indicating treatment effect were found on any outcomes. Poor compliance was indicated by lower than expected omega-3 elevations in the treatment group, and may have contributed to a failure to detect a response.

Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk factor: Protocol of a RCT.

BACKGROUND: Geographical and racial disparities in stroke outcomes are especially prominent in the Southeastern United States, which represents a region more heavily burdened with stroke compared to the rest of the country. While stroke is eminently preventable, particularly via blood pressure control, fewer than one third of patients with a stroke have their blood pressure controlled ≥ 75% of the time, and low consistency of blood pressure control is linked to higher stroke risk. OBJECTIVE: To demonstrate that a mHealth technology-centered, integrated approach can effectively improve sustained blood pressure control among stroke patients (half of whom will be Black). DESIGN: The Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk-factor is a prospective randomized controlled trial, which will include a cohort of 200 patients with a stroke, encountered at two major safety net health care systems in South Carolina. The intervention comprises utilization of a Vaica electronic pill tray & blue-toothed UA-767Plus BT blood pressure device and a dedicated app installed on patients' smart phones for automatic relay of data to a central server. Providers will follow care protocols based on expert consensus practice guidelines to address optimal blood pressure management. STUDY OUTCOMES: Primary outcome is systolic blood pressure at 12-months, which is the major modifiable step to stroke event rate reduction. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. DISCUSSION: We anticipate that a successful intervention will serve as a scalable model of effective chronic blood pressure management after stroke, to bridge racial and geographic disparities in stroke outcomes in the United States. TRIAL REGISTRATION: ClinicalTrials.gov - NCT03401489.

Very low birth weight infants receive full enteral nutrition within 2 postnatal weeks.

OBJECTIVE: Identify whether an enteral nutrition goal of reaching full feeds by 7 postnatal days for infants 1-1.5 kg and by 14 postnatal days for infants <1 kg was feasible and its associated outcomes. STUDY DESIGN: Very low birth weight infant cohort admitted in the first postnatal day and categorized as either Epoch 1 or Epoch 2, 12 months before and after implementation of a revised feeding protocol were compared. RESULT: In Epoch 2, 83% infants born 1-1.5 kg and 77% infants born <1 kg reached full feeds by 7 and 14 days compared to 26% and 25%, respectively in Epoch 1 (p < 0.0001). Central line and parental nutrition days were significantly lower in Epoch 2 compared to Epoch 1 with sustained and potentially improved infant growth. CONCLUSION: An evidence-based advancement feeding protocol was associated with achieving full feeds within the first 2 postnatal weeks for very low birth weight infants.

Modeling Possible Outcomes of Updated Daily Values on Nutrient Intakes of the United States Adult Population.

The United States (US) Food and Drug Administration has updated the Daily Values (DVs) for the Nutrition Facts Label on packaged foods. We used the National Health and Nutrition Examination Survey 2009-2012 data with the International Life Sciences Institute, North America Fortification Database, which identifies intrinsic, mandatory enriched, and fortified sources of nutrients in foods and beverages, to model the new DVs' potential impact on adult (≥19 years of age) intake. We assumed that manufacturers will adjust voluntary fortification to maintain percent DV claims. We assessed the percent of the US population whose usual intake (UI) was < the Estimated Average Requirement (EAR), and ≥ the Upper Limit (UL) based on the current DVs, and modeled estimated UI and %

Effect of Intensive vs Standard Blood Pressure Treatment Upon Erectile Function in Hypertensive Men: Findings From the Systolic Blood Pressure Intervention Trial.

INTRODUCTION: The effect of intensive blood pressure control upon erectile function in men with hypertension, but without diabetes, is largely unknown. AIM: To examine the effects of intensive systolic blood pressure (SBP) lowering on erectile function in a multiethnic clinical trial of men with hypertension. METHODS: We performed subgroup analyses from the Systolic Blood Pressure Intervention Trial ([SPRINT]; ClinicalTrials.gov: NCT120602, in a sample of 1255 men aged 50 years or older with hypertension and increased cardiovascular disease risk. Participants were randomly assigned to an intensive treatment group (SBP goal of <120 mmHg) or a standard treatment group (SBP goal of <140 mmHg). MAIN OUTCOME MEASURE: The main outcome measure was change in erectile function from baseline, using the 5-item International Index of Erectile Function (IIEF-5) total score, and erectile dysfunction ([ED]; defined as IIEF-5 score ≤21) after a median follow-up of 3 years. RESULTS: At baseline, roughly two-thirds (66.1%) of the sample had self-reported ED. At 48 months after randomization, we determined that the effects of more intensive blood pressure lowering were significantly moderated by race-ethnicity (p for interaction = 0.0016), prompting separate analyses stratified by race-ethnicity. In non-Hispanic whites, participants in the intensive treatment group reported slightly, but significantly better change in the IIEF-5 score than those in the standard treatment group (mean difference = 0.67; 95% CI = 0.03, 1.32; P = 0.041). In non-Hispanic blacks, participants in the intensive group reported slightly worse change in the IIEF-5 score than those in the standard group (mean difference = -1.17; 95% CI = -1.92, -0.41; P = 0.0025). However, in non-Hispanic whites and non-Hispanic blacks, further adjustment for the baseline IIEF-5 score resulted in nonsignificant differences (P > 0.05) according to the treatment group. In Hispanic/other participants, there were no significant differences in change in the IIEF-5 score between the two treatment groups (P = 0.40). In a subgroup of 280 participants who did not report ED at baseline, the incidence of ED did not differ in the two treatment groups (P = 0.53) and was without interaction by race-ethnicity. CLINICAL IMPLICATIONS: The effect of intensive treatment of blood pressure on erectile function was very small overall and likely not of great clinical magnitude. STRENGTH & LIMITATIONS: Although this study included a validated measure of erectile function, testosterone, other androgen, and estrogen levels were not assessed. CONCLUSION: In a sample of male patients at high risk for cardiovascular events but without diabetes, targeting a SBP of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in statistically significant effects on erectile function that differed in accordance with race-ethnicity, although the clinical importance of the differences may be of small magnitude. Foy CG, Newman JC, Russell GB, et al. Effect of Intensive vs Standard Blood Pressure Treatment Upon Erectile Function in Hypertensive Men: Findings From the Systolic Blood Pressure Intervention Trial. J Sex Med 2020;17:238-248.

Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): A Randomized Clinical Trial.

OBJECTIVE: The authors sought to determine whether targeted treatment of insomnia with controlled-release zolpidem (zolpidem-CR) in suicidal adults with insomnia would provide a reduction in suicidal ideation superior to placebo. METHODS: Reducing Suicidal Ideation Through Insomnia Treatment was an 8-week three-site double-blind placebo-controlled parallel-group randomized controlled trial of zolpidem-CR hypnotic therapy compared with placebo, in conjunction with an open-label selective serotonin reuptake inhibitor. Participants were medication-free 18- to 65-year-olds with major depressive disorder, insomnia, and suicidal ideation. Suicidal ideation was the main outcome, measured first by the Scale for Suicide Ideation and second by the Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS: A total of 103 participants were randomly assigned to receive zolpidem-CR (N=51) or placebo (N=52) (64 women and 39 men; mean age=40.5 years). Zolpidem-CR had a robust anti-insomnia effect, especially in patients with the most severe insomnia symptoms. No significant treatment effect was observed on the Scale for Suicide Ideation (least squares mean estimate=-0.56, SE=0.83, 95% CI=-2.19, 1.08), but the reduction in scores was significantly positively related to improvement in insomnia after accounting for the effect of other depression symptoms. The C-SSRS indicated that zolpidem-CR had a significant treatment effect (least squares mean estimate=-0.26, SE=0.12, 95% CI=-0.50, -0.02). The advantage for zolpidem-CR in reducing suicidal ideation on the C-SSRS was greater in patients with more severe insomnia. No deaths or suicide attempts occurred. CONCLUSIONS: Although the results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that coprescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia.

Trends in Intake of Energy and Total Sugar from Sugar-Sweetened Beverages in the United States among Children and Adults, NHANES 2003-2016.

Consumption of sugar-sweetened beverages (SSBs) increases total caloric intake, is linked to cardiometabolic outcomes as well as dental caries, and sugar in SSBs is associated with mortality and frailty among adults. We describe energy and total sugar intake trends among the United States (US) population from SSBs, soft drinks, other beverage groups, and the total diet based on the first 24-h recall data from the National Health and Nutrition Examination Survey (NHANES) cycles (2003-2004 through 2015-2016). SSBs included soft drinks, sports drinks, energy drinks, and fruit drinks, but excluded sports beverages with protein and sweetened teas/coffees. Among the total population (age ≥2 years: 57,026), energy intake from SSBs declined significantly from 183.9 ± 6.9 mean kcal/d (±SE) in 2003-2004 to 95.0 ± 3.5 in 2015-2016, while total sugar intake declined from 43.6 ± 1.7 mean g/d to 22.3 ± 0.8 (p-trend < 0.0001). Decreases were found for energy and total sugar intake, as well as percentage of energy and total sugar intake from SSBs, soft drinks, and all beverages for all age groups examined (≥2, 2-19, ≥20 years) (p-trend < 0.0001). From 2003 to 2016, energy and sugar intake from all beverages, SSBs, soft drinks, and the total diet decreased among the total population, children, and adults.

Race/Ethnicity, Enrichment/Fortification, and Dietary Supplementation in the U.S. Population, NHANES 2009⁻2012.

In the United States (U.S.), food fortification and/or enrichment and dietary supplement (DS) use impacts nutrient intakes. Our aim was to examine race/ethnicity and income (Poverty Income Ratio, PIR) differences in meeting the Dietary Reference Intakes based on estimated dietary intakes among the U.S. population age ≥2 years (n = 16,975). Two 24-hour recalls from the National Health and Nutrition Examination Survey (NHANES) cycles 2009-2012 were used to estimate the intake of 15 nutrients as naturally occurring, enriched/fortified, and plus DSs. Across racial/ethnic groups and within PIR categories, significant differences were observed in the %< Estimated Average Requirement (EAR) for vitamin A following enrichment/fortification (E/F) and for vitamin B12 and riboflavin following both E/F and DS use when comparing non-Hispanic blacks, Hispanics, and the other race/ethnicity group to non-Hispanic whites. The %

Nutrients in the US Diet: Naturally Occurring or Enriched/Fortified Food and Beverage Sources, Plus Dietary Supplements: NHANES 2009-2012.

BACKGROUND: Nutrients are added to the diet through fortification/enrichment and dietary supplements (DSs). Meeting the US Dietary Reference Intakes (DRIs) varies by nutrient and population subsegments. OBJECTIVE: The aim of this study was to assess the relative role of naturally occurring, enriched/fortified, and DS sources of 15 micronutrients with reference to the DRIs. METHODS: We used the NHANES 2009-2012 (≥2 y old, n = 16,975) data, the ILSI North America Fortification database, and the National Cancer Institute usual intake method. RESULTS: Prevalence of nutrient intake from naturally occurring sources below the Estimated Average Requirement (EAR) varied from 5% for vitamin B-12 to 100% for vitamin D, with ≥40% of the population below the EAR for 8 of the 14 nutrients (ages ≥2 y). With enrichment/fortification, the percentage below the EAR decreased to the following for vitamins A (35%), C (34%), and B-6 (7%), folate (8%), thiamin (5%), riboflavin (3%), niacin (1%), and iron (2%). Nutrients from DSs further improved intakes related to the EAR for 12 nutrients (ages ≥2 y). For 9-18-y-olds, the percentages of nutrient intakes below the EAR were 14-50% higher than for 2-8-y-olds. The Tolerable Upper Intake Level (UL) was exceeded among children aged 2-8 y for folate (41.7%), niacin (10.1%), and zinc (39.9%), whereas among ages ≥2 y and 9-18 y no prevalence of intakes over the UL exceeded 10%. CONCLUSIONS: Fortification/enrichment constitutes a meaningful contribution to reducing the percentage of individuals with less than the EAR for their demographic. These data underscore the need to encourage better dietary patterns to improve the intake of nutrients at risk of low intake.

Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT).

INTRODUCTION: Erectile function, an important aspect of quality of life, is gaining increased research and clinical attention in older men with hypertension. AIM: To assess the cross-sectional association between blood pressure measures (systolic blood pressure [SBP]; diastolic blood pressure [DBP]; and pulse pressure [PP]) and (i) sexual activity and (ii) erectile function in hypertensive men. METHODS: We performed analyses of 1,255 male participants in a larger randomized clinical trial of 9,361 men and women with hypertension aged ≥50 years. MAIN OUTCOME MEASURES: The main outcome measures were self-reported sexual activity (yes/no) and erectile function using the 5-item International Index of Erectile Function (IIEF-5). RESULTS: 857 participants (68.3%) reported being sexually active during the previous 4 weeks. The mean (SD) IIEF-5 score for sexually active participants was 18.0 (5.8), and 59.9% of the sample reported an IIEF-5 score <21, suggesting erectile dysfunction (ED). In adjusted logistic regression models, neither SBP (adjusted odds ratio = 0.998; P = .707) nor DBP (adjusted odds ratio = 1.001; P = .929) was significantly associated with sexual activity. In multivariable linear regression analyses in sexually active participants, lower SBP (ß = -0.04; P = .025) and higher DBP (ß = 0.05; P = .029) were associated with better erectile function. In additional multivariable analyses, lower PP pressure was associated with better erectile function (ß = -0.04; P = .02). CLINICAL IMPLICATIONS: Blood pressure is an important consideration in the assessment of erectile function in men with hypertension. STRENGTHS & LIMITATIONS: Assessments of blood pressure and clinical and psychosocial variables were performed using rigorous methods in this multi-ethnic and geographically diverse sample. However, these cross-sectional analyses did not include assessment of androgen or testosterone levels. CONCLUSIONS: Erectile dysfunction was highly prevalent in this sample of men with hypertension, and SBP, DBP, and PP were associated with erectile function in this sample. Foy CG, Newman JC, Berlowitz DR, et al. Blood Pressure, Sexual Activity, and Erectile Function in Hypertensive Men: Baseline Findings from the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med 2019;16:235-247.

Severity of Gastrointestinal Bleeding in Patients Treated with Direct-Acting Oral Anticoagulants.

BACKGROUND: Direct-acting oral anticoagulants (DOACs), which have gained approval for stroke prevention in nonvalvular atrial fibrillation and treatment of venous thromboembolism, have become increasingly preferred over warfarin given their predictable pharmacodynamics, lack of required monitoring, and superior outcomes. Direct-acting oral anticoagulants have been shown to be associated with an increased frequency of gastrointestinal bleeding compared with warfarin, but the severity and characteristics of gastrointestinal bleeding in these patients is poorly understood. METHODS: We retrospectively evaluated electronic medical records of patients with gastrointestinal bleeding (n = 8496) from 2010-2016. We identified 61 patients with gastrointestinal bleeding episodes while treated with DOACs (rivaroxaban, dabigatran, or apixaban) and 123 patients with gastrointestinal bleeding while taking warfarin. We randomly selected a control group of 296 patients with gastrointestinal bleeding who were not receiving anticoagulation treatment from the same sample. Outcomes included the need for hospitalization, blood transfusion, endoscopic or surgical intervention, and 30-day mortality. RESULTS: The DOAC and warfarin groups were similar in terms of age and underlying comorbidity (assessed using the Charlson Comorbidity Index), but the DOAC group had greater concomitant aspirin use. Gastrointestinal bleeding was classified as upper (n = 186), lower (n = 88), anorectal (n = 183), small bowel (n = 9), and indeterminate (n = 14). After adjusting for differences in baseline variables, the DOAC group had fewer hospitalizations and required fewer transfusions than the warfarin group. The DOAC and control groups were not statistically different for all outcomes. There were no significant mortality differences among groups. CONCLUSION: Although prior studies have shown a higher frequency of gastrointestinal bleeding in patients treated with DOACs compared with warfarin, our data suggest that gastrointestinal bleeding in patients taking DOACs may be less severe. These differences occurred despite significantly greater concomitant aspirin use in the DOAC group compared with warfarin users.

Higher number of live births is associated with left ventricular diastolic dysfunction and adverse cardiac remodelling among US Hispanic/Latina women: results from the Echocardiographic Study of Latinos.

INTRODUCTION: Female sex is a risk factor for heart failure with preserved ejection fraction (HFpEF). Previous literature suggests that some diastolic dysfunction (DD) develops during pregnancy and may persist postdelivery. Our objective was to examine the relationship between parity and cardiac structure and function in a population-based cohort. METHODS: Participants included 1172 Hispanic/Latina women, aged ≥45 years, enrolled in the Echocardiographic Study of Latinos from four US communities (Bronx, Miami, San Diego and Chicago). Standard echocardiographic techniques were used to measure cardiac volumes, left ventricular mass, systolic and diastolic function. Using sampling weights and survey statistics, multivariable linear and logistic regression models were constructed adjusting for age, body mass index, diabetes or prediabetes, systolic blood pressure, use of antihypertensive medications, smoking, total cholesterol and high-density lipoprotein cholesterol. RESULTS: In the target population, 5.0% were nulliparous (no live births) and 10.5% were grand multiparous (≥5 live births). Among the nulliparous women, 46% had DD as compared with 51%-58% of women with 1-4 live births and 81% of women with ≥5 live births (p<0.01). In full multivariate models, higher parity was significantly associated with greater left ventricular end-systolic volumes, end-diastolic volumes, left atrial volume indices and presence of DD (all p<0.01) but was not associated with ejection fraction. The log odds for having any grade of DD in grand-multiparous women was over three times that seen in nulliparous women (OR=3.4, 95% CI 1.5 to 7.9, p<0.01) in models further adjusted for income and education. CONCLUSIONS: Higher parity is associated with increased cardiac mass, volumes and the presence of DD. Further studies are needed to elucidate this apparent deleterious relation and whether parity can help explain the increased risk of HFpEF in women.