Publications

BACKGROUND: Germ-free mice experiments indicate that human gut microbiota influence blood pressure (BP), but no studies have prospectively examined if infant gut microbiota affects their future childhood BP. We aim to investigate prospective associations of infant gut microbiota diversity and composition with childhood BP, examining effect measure modification by breastfeeding and mediation by a child's body mass index.

METHODS AND RESULTS: In the Copenhagen Prospective Studies on Asthma in Childhood 2010 cohort, we measured infant gut microbiota (16S rRNA V4) at 1 week, 1 month, and 1 year and child BP at 3 and 6 years. We assessed α diversity-BP, β diversity-BP, and microbe abundances-BP associations using linear regression, permutational multivariate analysis of variance, and beta-binomial count regression, respectively. Data from 526 children showed that α diversity and several Bifidobacterium spp. had protective associations with BP but only in children breastfed for ≥6 months. For instance, a 1-unit increment in 1 month Shannon index was associated with 1.86 mm Hg (95% CI, 0.66-3.05) lower 6-year systolic BP in children breastfed ≥6 months but a 0.73 (95% CI, -1.00 to 2.45) higher 6-year systolic BP in those breastfed <6 months (P-interaction=0.02). Greater abundance of 2 Bifidobacterium microbes at 1 week was negatively associated with 6-year systolic BP when breastfeeding ≥6 months (P-interaction<0.1). Further, abundance of 8 microbes at 1week or 1 month was linked to 3-year or 6-year BP (false discovery rate P<0.05), with 5 of them independent of a child's body mass index. Lastly, 1-week unweighted UniFrac distance and 1-year weighted UniFrac distance were associated with BP after adjustment (P<0.05).

CONCLUSIONS: Gut microbiota features at 1 week and 1 month of life were associated with BP at 6 years. Breastfeeding duration modified key associations including those for α diversity and Bifidobacteria.

IMPORTANCE: Black persons, including immigrants, in the US disparately experience poor cardiometabolic health (CMH). Limited research on the effect of lifestyle interventions that improve CMH among African immigrant populations is available.

OBJECTIVE: To test the effectiveness of a culturally adapted, virtual lifestyle intervention on control of blood pressure (BP) and hemoglobin A1c (HbA1c) levels among African immigrants with CMH risk factors.

DESIGN, SETTING, AND PARTICIPANTS: Afro-DPP (Diabetes Prevention Program), a pilot cluster-randomized clinical trial, evaluated the effectiveness of a multicomponent CMH intervention. The study took place in 2 churches with predominantly African immigrant congregations in the Baltimore-Washington, DC, metropolitan area from January 1, 2022, to July 31, 2023. Participants were adults aged 25 to 75 years with at least 2 CMH risk factors who self-identified as African immigrants and belonged to the participating churches. Analyses followed the intention-to-treat principle.

INTERVENTION: Participants received a 6-month culturally adapted lifestyle intervention based on the National DPP curriculum, delivered via virtual group sessions by a lifestyle coach of African origin. The delayed intervention began 6 months later with a follow-up time of 6 months. The intervention also included remote BP and weight monitoring.

MAIN OUTCOME AND MEASURES: Primary outcomes were changes in systolic and diastolic BP and HbA1c levels from baseline to 6 months. Secondary outcomes included reduced body weight and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared).

RESULTS: The analytic population included 60 participants (mean [SD] age, 50.6 [11.9] years; 40 [66.7%] women). In the first intervention group (n = 30), systolic BP decreased by 9.2 (95% CI, 2.5-15.9) mm Hg, diastolic BP by 6.1 (95% CI, 2.1-10.0) mm Hg, body weight by 4.9 (95% CI, 1.0-8.7) kg, and BMI by 1.1 (95% CI, 0.4-1.7) at 6 months. In the delayed intervention group (n = 30), systolic BP decreased by 11.4 (95% CI, 2.4-20.5) mm Hg, diastolic BP by 10.3 (95% CI, 5.4-15.2) mm Hg, and body weight by 3.3 (95% CI, 0.01-6.5) kg, while BMI increased by 0.3 (95% CI, -1.5 to 2.0).

CONCLUSIONS AND RELEVANCE: Trial findings indicate that interventions incorporating cultural adaptation and virtual components could help address CMH disparities in this population.

TRIAL REGISTRATION: ClincalTrials.gov Identifier NCT05144737.

IMPORTANCE: The patient portal has a growing role in health care. Many health systems have implemented shared access functionality in which patients may register a care partner with unique identity credentials to access their portal. Uptake of shared access has been limited.

OBJECTIVE: To examine the outcomes of a multisite demonstration involving organizational strategies associated with registration and use of patient portal shared access.

DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study was conducted in diverse sites within 3 health systems in the US: (1) geriatric oncology, (2) geriatric medicine, and (3) primary care. Patients aged 65 years or older with 1 or more visits during the 12-month demonstration period (July 1, 2022, through July 1, 2023, for sites 1 and 2; site 3 was delayed 3 months) and care partners who used the portal accounts of patients meeting these criteria were included. The 6-month postdemonstration period (August 1, 2023, through January 1, 2024) was compared with the 6-month predemonstration period (January 1 through June 1, 2022).

EXPOSURES: Organizational strategies (brochures, webpages, tip sheets, and implementation toolkits created using a human-centered design) to encourage shared access registration and use.

MAIN OUTCOMES AND MEASURES: Portal registration and use (logins, laboratory results viewed, clinical notes viewed, visits scheduled) by type of access (patient and care partner) from electronic health record data were examined. Patient- and care partner-reported awareness and use of shared access were measured using a postdemonstration survey.

RESULTS: A total of 16 005 patients from the 3 sites met the inclusion criteria (84.8% younger than 85 years and 61.5% women). Most patients had an activated portal account (91.0%) and logged in at least once (84.8%) during the 24 months spanning the demonstration and pre- and postdemonstration periods. New portal registrations were stable, but nonsignificant for shared access (110 of 14 758 [0.7%] vs 91 of 14 016 [0.6%]) and significantly decreased for patient access (677 of 3158 [21.5%] vs 225 of 1520 [13.2%]). Use of shared access before vs after the demonstration increased for number of logins (mean [SD], 5.9 [11.4] vs 6.8 [14.1]), laboratory results viewed (mean [SD], 0.7 [2.7] vs 1.1 [3.7]), clinical notes viewed (mean [SD], 0.2 [1.1] vs 0.6 [3.2]), and visits scheduled (mean [SD], 0.8 [10.8] vs 1.0 [5.4]). Of the 91 care partners reporting portal use in the postdemonstration survey, 48 (52.7%) indicated primarily using patient credentials and 31 (34.1%) indicated primarily using their own credentials. Less than one-half of patients (721 of 1664 [43.3%]) stated being aware of shared access.

CONCLUSIONS AND RELEVANCE: These findings show no association of the multisite demonstration with increased new registrations for shared access and only modest increases in portal use among care partners of older adults. As portal use expands to encompass legal documentation, medical decision-making, and patient education, policies to support proper use of identity credentials are needed.

BACKGROUND: Venous stasis, which can occur with prolonged sedentary behavior (SB), is associated with venous thromboembolism (VTE) risk, but VTE risk associated with accelerometer-measured SB has not been quantified.

OBJECTIVES: To evaluate accelerometer-based measures of SB in relation to incident VTE.

METHODS: We included 5,591 participants, aged 63-99 years, of the Women's Health Initiative Objective Physical Activity and Cardiovascular Health cohort study without prior VTE. Between May 2012-2014, participants wore the ActiGraph GT3X+ accelerometer at the hip for 7 days. Three SB measures were classified using the Convolutional Neural Network Hip Accelerometer Posture algorithm: total sitting time, mean sitting bout duration, and total time spent in prolonged (≥30 minute) sitting bouts. VTE events were centrally adjudicated. Multivariable-adjusted Cox models estimated hazard ratios (HRs) for each SB and VTE risk. Women were censored at first VTE, death, loss to follow-up, or February 2023. Mediation by body mass index (BMI) was evaluated.

RESULTS: Over a mean follow-up of 8.2 years, 229 women experienced a VTE. In adjusted models, longer mean sitting bout duration was associated with greater incident VTE risk (HR per 5-minute increase=1.15; 95% CI: 1.04, 1.28). BMI mediated approximately 30% of this association (p<0.01). We found no significant evidence that total sitting time or total time spent in prolonged sitting bouts were associated with VTE.

CONCLUSION: Longer mean sitting bout duration was associated with greater VTE risk, with substantial mediation by BMI. Behavioral efforts to reduce sedentary bout length in older women may reduce their VTE risk.

BACKGROUND: Cardiovascular disease (CVD) risk differs across Asian subgroups, possibly due to differences in hypertension burden. We characterized lifetime blood pressure (BP) trajectories for East and South Asian individuals and compared their associations with CVD risk.

METHODS: Among 148 872 UK Biobank participants with primary care utilization data, life course BP trajectories were fitted as a function of age by sex according to self-identified ethnicity. We determined associations of time-averaged young adulthood (18-39 years), middle age (40-64 years), and later life (≥65 years) systolic BP (SBP) and diastolic BP with incident atherosclerotic CVD risk.

RESULTS: The predicted SBP/diastolic BP (95% CI) at age 30 years was 108 (103-114)/68 (65-71) mm Hg for East Asian and 114 (110-118)/72 (71-73) mm Hg for South Asian individuals. By age 40, South Asian individuals were projected to reach an SBP of 130.0 mm Hg, whereas East Asian individuals reached the equivalent SBP by age 49 years. Among South Asian individuals, each SD increase in young adulthood SBP was associated with a higher atherosclerotic CVD risk with an odds ratio (95% CI) of 1.41 (1.12-1.75), but not among East Asians (Pinteraction=0.01). Midlife SBP was associated with peripheral artery disease among South Asian individuals (odds ratio, 2.08 [95% CI, 1.51-2.88]) and with ischemic stroke among East Asian individuals (odds ratio, 3.84 [95% CI, 1.08-5.07]). Later-life SBP was associated with myocardial infarction risk by 1.52 (1.15-1.92)-fold among South Asians and ischemic stroke by 2.50 (1.06-3.80)-fold among East Asian individuals.

CONCLUSIONS: East and South Asian individuals exhibit distinct BP trajectories that age-differentially associate with incident CVD. Disaggregating Asian subgroups may inform tailored hypertension screening and management.

[This corrects the article DOI: 10.1016/j.conctc.2022.101029.].

BACKGROUND: Orthostatic hypertension is an emerging risk factor for adverse events. Recent consensus statements combine an increase in blood pressure upon standing with standing hypertension, but whether these 2 components have similar risk associations with cardiovascular disease (CVD) is unknown.

METHODS: The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure during visit 1 (1987-1989). We defined systolic orthostatic increase (a rise in systolic blood pressure [SBP] ≥20 mm Hg, standing minus supine blood pressure) and elevated standing SBP (standing SBP ≥140 mm Hg) to examine the new consensus statement definition (rise in SBP ≥20 mm Hg and standing SBP ≥140 mm Hg). We used Cox regression to examine associations with incident coronary heart disease, heart failure, stroke, fatal coronary heart disease, and all-cause mortality.

RESULTS: Of 11 369 participants (56% female; 25% Black adults; mean age, 54 years) without CVD at baseline, 1.8% had systolic orthostatic increases, 20.1% had standing SBP ≥140 mm Hg, and 1.3% had systolic orthostatic increases with standing SBP ≥140 mm Hg. During up to 30 years of follow-up, orthostatic increases were not significantly associated with any of the adverse outcomes of interest, while standing SBP ≥140 mm Hg was significantly associated with all end points. In joint models comparing systolic orthostatic increases and standing SBP ≥140 mm Hg, standing SBP ≥140 mm Hg was significantly associated with a higher risk of CVD, and associations differed significantly from systolic orthostatic increases.

CONCLUSIONS: Unlike systolic orthostatic increases, standing SBP ≥140 mm Hg was strongly associated with CVD outcomes and death. These differences in CVD risk raise important concerns about combining systolic orthostatic increases and standing SBP ≥140 mm Hg in a consensus definition for orthostatic hypertension.

CONTEXT: The hospital discharge process is fraught for patients with serious illness and their caregivers.

OBJECTIVES: We sought to understand palliative care patient and caregiver concerns regarding the patient-centeredness of the hospital discharge process.

METHODS: We conducted semi-structured interviews with 11 patients receiving palliative care and 4 caregivers. Caregivers were interviewed with patient or alone, for a total of 13 interviews. Interviews were focused on the patient-centeredness of the discharge process, completeness of discharge education, and readmission. Transcripts were analyzed using an inductive approach with open coding.

RESULTS: We identified four themes: (i) symptoms, (ii) relationship to illness, (iii) variance in patient-provider alignment, and (iv) discharge readiness, including readmission. Physical and non-physical symptoms were common, though non-pain symptoms were more frequently concerns. Illness understanding and empowerment by the discharge process were low, with participants seeking more information. Alignment varied by provider with closer relationships with bedside nurses and outpatient providers, especially oncologists, than inpatient providers. Readmission was not perceived to be avoidable but was associated with symptom burden. Discharge readiness was mixed; common concerns included lack of clarity regarding next steps and post-discharge services. Up to 40% of participants reported incomplete education on given topics.

CONCLUSION: Our qualitative study of patients and caregivers receiving palliative care identified unmet needs in the discharge process: non-pain symptom burden, gaps in empowerment and illness understanding, and mixed discharge readiness. Relationship to care informs subsequent engagement with care and medical decision-making. Future interventions should focus on strengthening patient and caregiver empowerment and illness understanding.

OBJECTIVES: To summarize the delirium treatment trial literature, identify the unique challenges in delirium treatment trials, and formulate recommendations to address each in older adults.

DESIGN: A 39-member interprofessional and international expert working group of clinicians (physicians, nurses, and pharmacists) and nonclinicians (biostatisticians, epidemiologists, and trial methodologists) was convened. Four expert panels were assembled to explore key subtopics (pharmacological/nonpharmacologic treatment, methodological challenges, and novel research designs).

METHODS: To provide background and context, a review of delirium treatment randomized controlled trials (RCTs) published between 2003 and 2023 was conducted and evidence gaps were identified. The four panels addressed the identified subtopics. For each subtopic, research challenges were identified and recommendations to address each were proposed through virtual discussion before a live, full-day, and in-person conference. General agreement was reached for each proposed recommendation across the entire working group via moderated conference discussion. Recommendations were synthesized across panels and iteratively discussed through rounds of virtual meetings and draft reviews.

RESULTS: We identified key evidence gaps through a systematic literature review, yielding 43 RCTs of delirium treatments. From this review, eight unique challenges for delirium treatment trials were identified, and recommendations to address each were made based on panel input. The recommendations start with design of interventions that consider the multifactorial nature of delirium, include both pharmacological and nonpharmacologic approaches, and target pathophysiologic pathways where possible. Selecting appropriate at-risk patients with moderate vulnerability to delirium may maximize effectiveness. Targeting patients with at least moderate delirium severity and duration will include those most likely to experience adverse outcomes. Delirium severity should be the primary outcome of choice; measurement of short- and long-term clinical outcomes will maximize clinical relevance. Finally, plans for handling informative censoring and missing data are key.

CONCLUSIONS: By addressing key delirium treatment challenges and research gaps, our recommendations may serve as a roadmap for advancing delirium treatment research in older adults.