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Health and healthcare disparities are variances in the health of a population or the care rendered to a population. Disparities result in a disproportionately higher prevalence of disease or lower standard of care provided to the index group. Multiple theories exist regarding the genesis of this disturbing finding. The COVID-19 pandemic has had the unfortunate effect of amplifying health inequity in vulnerable populations. African Americans, who make up approximately 12% of the US population are reportedly being diagnosed with COVID-19 and dying at disproportionately higher rates. Viewed holistically, multiple factors are contributing to the perfect storm: 1) Limited availability of public testing, 2) A dramatic increase in low wage worker unemployment/health insurance loss especially in the service sector of the economy, 3) High rates of preexisting chronic disease states/reduced access to early healthcare and 4) Individual provider and structural healthcare system bias. Indeed, COVID-19 represents a pandemic superimposed on a historic epidemic of racial health inequity and healthcare disparities. Therapeutic solutions are not expected in the near term. Thus, identifying the genesis and magnitude of COVID-19's impact on African American communities is the requisite first step toward crafting an immediate well designed response. The mid and long term approach should incorporate population health based tactics and strategies.

The aim of this study was to provide a contemporary analysis of longitudinal kidney transplant outcomes and to evaluate potential causes of ethnic disparities among African American (AA) and Caucasian American (CA) patients undergoing kidney transplantation at our institution.

Due to the increasing diversity within the United States population, there is an ever-increasing need for increased education on cultural literacy and tolerance in medical schools and residency programs. The purpose of this article was to review how a person’s culture can play a substantive role in effecting and influencing (1) medical diagnosis, (2) patient and health provider medical decision-making, (3) the patient’s perception of disease, and (4) the doctor-patient relationships. Many of the decisions we make as orthopedic surgeons must account for the patient’s cultural needs, as much of our work impacts patients’ daily activities and function. When considering the patient’s perception of disease, validated tools have been developed, such as the Patient-Specific Index, which can be used to assess the feelings, goals, and expectations of patients. Cultural competency should be a part of curricula at every level of medical education.

Health literacy remains a key factor in the continuance of health disparities in our society as health related quality of life can be negatively affected by limited health literacy. This study explores how limited health literacy among minority men, attending a community health fair, correlates with their health related quality of life. Findings reflect that minority men who possess lower levels of health literacy experience lower self-reported quality of life. Directions for healthcare providers, community health educators and future research approaches are provided.

Purpose: This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men.Design: Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months.Setting: Academic health center.Participants: Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19).Intervention: Self-management training, delivered in 1 individual and 4 group sessions (over 3 months).Measures: Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants.Analysis: Ttests for paired differences and nonparametric tests. Thematic content qualitative analysis.Results: Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1cand high-density lipoprotein cholesterol (P= .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

African Americans comprise 11 % of living organ donors, yet constitute 34 % of the kidney transplant waiting list. There are many barriers to organ donation among minorities that include decreased awareness of transplantation, cultural mistrust of the medical community, financial concerns, and fear of the transplant operation. This study investigates the societal misconceptions and demographic health factors that correlate with minority participation in organ and tissue donation. A 57 question Health and Wellness survey was designed to assess participants’ demographic information, medical history, professional background, and opinions regarding organ transplantation. Participants were also asked to complete Quality Metric’s Short Form-8 (SF-8) survey to assess physical health, mental health, and quality-of-life. Three hundred twenty-six surveys were administered to minority men. The majority of men were identified as African American, and 55 % were below the age of 40. Though 44 % of participants were willing to donate, only 27 % were registered as organ and tissue donors. Minorities who held misconceptions about organ donation—including the belief that they were too old or unhealthy to donate, for example—had lower general, physical, and mental health scores than those who did not (p= <0.0001). Minorities aware of the shortage for organs or who know a registered donor, an organ recipient, a dialysis patient, or someone on the waiting list were more willing to donate organs. Improving the general, physical, and mental health of minorities, coupled with an active educational outreach program, could result in a greater percentage of minorities registering and willing to be organ and tissue donors.

In the United States, disparities in health care delivery and access are apparent between different racial and ethnic groups. Minorities, including African Americans, often suffer disproportionately from disease compared to Caucasians. In the urologic arena, this is apparent in urologic cancer screening, treatment choices, and survival, as well as in the arena of chronic kidney disease, transplant allocation, and transplant outcomes. Latino men also seem to be affected more often by erectile dysfunction than Caucasian counterparts. Disparities such as these have been identified as a problem in the delivery of health care in the United States, and resources have been allocated to help allay the disparity. Through organizations such as the Cleveland Clinic Minority Men’s Health Center, policy initiatives, and increased cultural awareness by physicians, steps can be made to reduce and eliminate health care disparities.

Wound healing problems and lymphoceles have been reported with greater frequency in kidney recipients given de novo sirolimus. This problem has led to increased patient morbidity and cost; and has been an impediment to the completion of randomized controlled trials in which wound problems have necessitated premature discontinuation of mammalian target of rapamycin inhibitors.

We report the 5-year outcomes from a randomized prospective trial in primary adult renal allograft recipients, designed to evaluate calcineurin inhibitor (CNI)-free immunosuppression on kidney transplant function.

Ischemia/reperfusion injury is an inherent consequence of solid organ transplantation that increases tissue inflammation and negatively impacts organ transplant function and survival. This study investigated the expression levels of chemokine and chemokine receptor genes in living versus cadaver donor renal allografts before and after reperfusion.

The aim of this study was to evaluate the incidence and risk factors for posttransplant diabetes mellitus (PTDM; defined as new insulin use and/or new hyperglycemia) in 528 kidney recipients using different immunosuppressive agents.

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

We compared gene expression profiles from six donor kidneys prior to surgical manipulation to six kidneys removed after laparoscopic donor nephrectomy (LDN) and several hours of CO2pneumoperitoneum. Biopsies were obtained from renal cortex and hybridized to Affymetrix HG-U133A GeneChips. For control kidneys, we identified 1380 genes present on all six samples that had a signal intensity >1,000. Functional classification of these revealed genes for cellular signaling (201; 15%), regulation of transcription (156; 11%), cellular transport (144; 10%) and cellular metabolism (111; 8%). A class comparison between the controls and LDN kidneys yielded 865 differentially expressed genes. Functional classification of the 502 genes differentially upregulated in LDN kidneys identified associations with apoptosis, cell adhesion, cell signaling, regulation of cell growth/proliferation, immune/inflammation, ischemia/stress response and proteolysis/peptidolysis. These data demonstrate an altered renal transcriptome induced by several hours of CO2pneumoperitoneum and laparoscopic surgery characterized by upregulation of ischemia and injury associated genes.

We performed a sequential study to determine the efficacy and side effects of low-dose (1 g) mycophenolate mofetil (MMF) in a CNI drug avoidance regimen including sirolimus/steroids.

Kidney transplant surgery can be complicated by short, attenuated, or injured renal vessels which are now more frequently encountered with laparoscopic right donor nephrectomy. We describe a technique to overcome this problem in seven recipients (2 cadaveric and 5 living donors) by constructing third-party “vascular extenders” using cadaveric iliac vessels retrieved previously and preserved at 4°C in University of Wisconsin solution. Mean vessel cold storage time was 25.7 days (range, 2–56 days). Immunosuppression consisted of sirolimus, mycophenolate mofetil, and steroids. Prompt reperfusion of all allografts was observed, and there were no surgical complications. Integrity of the extenders was confirmed using serial MAG3 renal scans and magnetic resonance angiography. Mean serum creatinine was 1.44 mg/dl at 19.2 months (range, 0.7–2 mg/dl at 3–31 months). Each recipient had a negative posttransplant kidney donor specific flow cytometry crossmatch. Two recipients developed HLA antibodies, one to DR7 and another DR13 (mismatched to the vessel donor) at 4 and 11 months posttransplant, respectively.

Delayed graft function after live donor transplantation affects 5% to 10% of recipients regardless of procurement technique. This delay in function is associated with an increased risk of rejection and decreased graft survival. In the present study we critically assess allograft recovery to identify the risk factors related to delayed graft function.

The aim of this study was to determine whether there has been an increase in the incidence or severity of wound-healing complications that can be attributed to the introduction of newer immunosuppressive drugs.

Progressive nephrotoxicity caused by calcineurin inhibitor drugs contributes to the long-term decline in renal function in kidney transplant patients.

We attempted to minimize the undesired side effects and maximize the benefit of OKT3 induction therapy in renal transplantation.

To maximize the renal donor pool, cadaveric pediatric en bloc kidneys have been transplanted as a dual unit by some transplant centers. We compared the short- and long-term outcomes of adult recipients of cadaveric pediatric en bloc renal transplants versus those of matched recipients of cadaveric adult kidneys.

Posttransplantation cytomegalovirus (CMV) infection remains a significant cause of morbidity in kidney transplant recipients. We performed a randomized prospective controlled trial of oral acyclovir versus oral ganciclovir for CMV prophylaxis in a group of renal allograft recipients considered at high risk for CMV disease due to the use of OKT3 induction therapy.

Acute rejection (AR) of the transplanted kidney has been identified as the major risk factor for the development of chronic rejection and immunological graft loss. However, the clinical presentation and response to AR therapy can vary considerably between recipients.

PurposeThe disparity between the number of patients awaiting organ transplantation and the number of available donor organs continues to increase. We report the outcomes of transplantation using kidneys from living donors who had unilateral renovascular disease.Materials and MethodsWe identified 5 living donors who had unilateral renovascular disease, including saccular renal artery aneurysms, an arteriovenous malformation, localized atherosclerosis and fibromuscular renal artery stenosis. Each donor was normotensive and asymptomatic, and had otherwise normal renal function.ResultsIn each case the abnormal kidney was removed, the lesion was repaired ex vivo and the kidney was successfully transplanted without complication in the donor or recipient. Each recipient had a serum creatinine of less than 2 mg./dl. and each donor remained normotensive with stable renal function at up to 3 years of followup.ConclusionsKidneys from living donors with renovascular disease can be transplanted safely provided that careful selection, informed consent and a normal remaining kidney are ensured.

The superantigen vSAG-7 (or MIs 1a) is a membrane glycoprotein encoded by the endogenous retrovirus mouse mammary tumor virus 7 (MMTV-7) and is highly stimulatory for Vβ6/CD4+T cells. Priming of adult MMTV-7-negative mice with vSAG-7-expressing cells initially results in the activation of the peripheral Vβ6/CD4+T cell compartment and is followed by T cell tolerance to the superantigen. During the course of tolerance induction the number of recipient B lymphocytes increases in the lymph nodes, but not the spleen, of vSAG-7-primed recipients. These B cells also express increased levels of class II MHC and present passively acquired superantigen. In this study we asked if these effects on the host B cell compartment are followed by the production of immunoglobulin. Priming of MMTV-7-negative BALB/c or CB.17 mice with vSAG-7-expressing cells from DBA/2 mice induced increases of both IgM and IgG2ain the serum. Use of Igh congenic CB.17 (IgMb) mice as recipients of the vSAG-7-presenting cells from DBA/2 (IgMa) donors indicated that the IgM and IgG produced were entirely of host origin. Priming with vSAG-7 also amplified (four- to fivefold) the antibody-producing cell response induced to a suboptimal dose of sheep RBC. Priming with purified B cells from vSAG-7 donors resulted in recipient Vβ6/CD4+T cell activation and increased numbers of recipient B cell in the lymph nodes, but did not induce immunoglobulin production. In contrast, priming with purified CD8+T cells resulted in increased quantities of serum IgM but not vSAG-7-reactive T cell activation or increased numbers of recipient B cells in the lymph nodes. These results indicate that the T cell activation and increased B cell number with upregulated class II MHC expression initially observed following vSAG-7 priming of adult MMTV-7-negative recipients are not linked to the induction of the recipient-derived immunoglobulin production.

We analyzed the development of chronic rejection in 511 kidney-only renal transplants in 507 patients between July 1987 and November 1994. A database was established for recipients ≥18 years old who received cyclosporine-based immunosuppression and demonstrated graft survival for a minimum of 12 months. The 347 recipients of cadaver transplants (67.9%) and 164 recipients of live donor transplants (32.1%) were followed for 12 to 102 months (mean 51 months). Chronic rejection was diagnosed in 124 transplants(24%), with a mean time to diagnosis of 23±18 months (range 3-92). Risk factors were identified in a multivariate analysis using the Cox model. The impact of the timing and severity of rejection episodes was analyzed in a univariate model.

The results of renal transplantation in obese recipients have been controversial, with some reports finding increased morbidity prohibitive and others finding increased morbidity acceptable. We attempted to determine whether obese patients in extreme excess of their ideal body weight should undergo transplantation.

Endogenous retroviral superantigens such as vSAG-7 are highly stimulatory for T cells through interaction with the T cell receptor on the basis of Vβ usage. Priming of adult MMTV 7-negative mice with vSAG-7-expressing cells has been shown to result in peripheral Vβ6/CD4⁺ T cell activation followed by tolerance to further interaction with the superantigen. The goal of the current study was to examine the cells presenting vSAG-7 during this initial burst of in vivo T cell activation. Priming of MMTV 7-negative BALB/c (H-2^d) mice with DBA/2 (H-2^d, MMTV 7⁺) spleen cells resulted in a 5- to 12-fold increase in the number of B cells in the lymph nodes. These B cells expressed increased levels of I-A and I-E class II MHC determinants. Use of MMTV 7-negative CB.17 (H-2^d, Igh^b) mice as recipients of DBA/2 (Igh^a) cells indicated that the increased number of B cells was of host, rather than donor, origin. The number of donor-derived (IgM/B220⁺) B cells observed during the course of vSAG-7-reactive Vβ6/CD4⁺ T cell activation was very low. Proliferation of unprimed T cells from MMTV 7-negative mice was induced during coculture with B cells from the lymph nodes of vSAG-7-primed recipients and was blocked by anti-class II MHC antibodies, as well as by an anti-vSAG-7 antibody. Highly purified host B cells from vSAG-7-primed recipients specifically stimulated the blastogenesis of Vβ6/CD4⁺ T cells in vitro. Collectively, the results indicate that following priming to induce peripheral tolerance, vSAG-7 is transferred from donor cells to class II MHC determinants on recipient B cells and is presented to the T cell repertoire by the autologous B cells. Copyright 1995, 1999 Academic Press