Pre-treatment bone mineral density (BMD) and the benefit of pharmacologic treatment on fracture risk and BMD change: analysis from the FNIH-ASBMR SABRE project

Some osteoporosis drug trials have suggested that treatment is more effective in those with low bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA). This study used data from a large set of randomised controlled trials (RCTs) to determine whether the anti-fracture efficacy of treatments differs according to baseline BMD. We used individual patient data from 25 RCTs (103 086 subjects) of osteoporosis medications collected as part of the FNIH-ASBMR SABRE project. Participants were stratified into femoral neck (FN) BMD T-score subgroups (≤ -2.5, > -2.5). We used Cox proportional hazard regression to estimate treatment effect for clinical fracture outcomes and logistic regression for the radiographic vertebral fracture outcome. We also performed analyses based on BMD quintiles. Overall, 42% had a FN BMD T-score ≤ -2.5. Treatment with anti-osteoporosis drugs led to significant reductions in fractures in both T-score ≤ -2.5 and > -2.5 subgroups. Compared to those with FN BMD T-score > -2.5, the risk reduction for each fracture outcome was greater in those with T-score ≤ -2.5, but only the all fracture outcome reached statistical significance (interaction p = 0.001). Results were similar when limited to bisphosphonate trials. In the quintile analysis, there was significant anti-fracture efficacy across all quintiles for vertebral fractures and with greater effects on fracture risk reduction for non-vertebral, all and all clinical fractures in the lower BMD quintiles (all interaction p ≤ 0.03). In summary, anti-osteoporotic medications reduced the risk of fractures regardless of baseline BMD. Significant fracture risk reduction with treatment for 4 of the 5 fracture endpoints was seen in participants with T-scores above -2.5, though effects tended to be larger and more significant in those with baseline T-scores <-2.5.

Comparison of a Person-Centered Pregnancy Prevention Question and One Key Question® to Assess Postpartum Contraceptive Needs

INTRODUCTION

Pregnancy intention is widely used to screen for contraceptive needs, yet its relevance to postpartum individuals has not been demonstrated.

METHODS

We surveyed 234 postpartum individuals to assess the alignment between pregnancy intentions in the next year and current desire to prevent pregnancy.

RESULTS

Most individuals (87%) desired pregnancy prevention now, including 73% of individuals who desired or were ambivalent about pregnancy in the next year.

CONCLUSION

A majority of individuals considering pregnancy in the next year desired pregnancy prevention now. Directly assessing current desire to prevent pregnancy may be more specific for contraceptive needs in postpartum individuals.

Brief Report: The Role of Substance Use in Structural Heart Disease Among Women Living With HIV

BACKGROUND

People living with HIV have increased risk of cardiovascular disease, but few studies focus on women with HIV (WWH) and few account for the use of multiple substances.

SETTING

We recruited WWH from San Francisco shelters, free meal programs, street encampments, and a safety net HIV clinic.

METHODS

Between 2016 and 2019, participants completed 6 monthly interviews, specimen collection, and a transthoracic echocardiogram. We assessed associations between 3 echocardiographic indices of cardiac hypertrophy (concentric hypertrophy, concentric remodeling, and eccentric hypertrophy) and study factors, including cardiovascular risk factors, substance use, and HIV-specific factors (CD4 + count, viral load, HIV medication).

RESULTS

Among 62 participants, the average age was 53 years and 70% were ethnic minority women. Just over 70% had elevated blood pressure. Toxicology-confirmed substance use included tobacco (63%), cannabis (52%), cocaine (51%), methamphetamine (29%), and alcohol (26%). Concentric hypertrophy was detected in 26% of participants. It was positively associated with cocaine use [adjusted relative risk (aRR) = 32.5, P < 0.01] and negatively associated with cannabis use (aRR = 0.07, P < 0.01). Concentric remodeling was detected in 40% of participants. It was positively associated with cocaine use (aRR = 11.2, P < 0.01) and negatively associated with cannabis use (aRR = 0.17, P = 0.02). Eccentric hypertrophy was not significantly associated with factors studied here.

CONCLUSIONS

Routine evaluation of stimulant use as a contributing factor to cardiovascular risk may improve risk assessment in WWH. Whether cannabis use mitigates the impact of cocaine use on structural heart disease among WWH merits further investigation.

Cannabis use and incident atrial fibrillation in a longitudinal cohort

BACKGROUND

Cannabis use is increasing worldwide. While prior studies have reported an association between cannabis use and a higher risk of atrial fibrillation (AF), most were cross-sectional and generally relied on diagnostic coding to identify cannabis users, which may not be representative of the typical recreational cannabis user.

OBJECTIVE

The purpose of this study was to examine the association between recreational cannabis use and lifetime AF risk.

METHODS

We evaluated the AF risk of participants of the UK Biobank cohort who completed the cannabis use lifestyle questionnaire. Cannabis exposure was categorized as "Occasional Use" for less than 100 times used, "Frequent Use" for more than 100 times used, and "Never" users. AF events were identified using International Classification of Diseases codes. Cox models were used to estimate the hazard ratios (HRs) between cannabis use and incident AF and were subsequently adjusted for age, sex, race, alcohol, coffee, smoking, education, and baseline cardiovascular comorbidities.

RESULTS

A total of 150,554 participants (mean age 63.4 ± 7.7 years; 86,487 (57.4%) female; and 33,442 (22.2%) using cannabis at least once) were followed for a mean period of 6.1 ± 0.6 years. After multivariable adjustment, there were no statistically significant differences in incident AF among occasional users (HR 0.98; 95% confidence interval 0.89-1.08) nor frequent users (HR 1.03; 95% confidence interval 0.81-1.32) as compared with never users.

CONCLUSION

In a large prospective cohort study, there was no evidence that cannabis use was associated with a higher risk of incident AF. An evaluation of cannabis ingestion methods and quantification was not possible using the current data set.

Anti-fracture treatment efficacy by age

There is a common belief that antiosteoporosis medications are less effective in older adults. This study used data from randomized controlled trials (RCTs) to determine whether the anti-fracture efficacy of treatments and their effects on bone mineral density (BMD) differ in people ≥70 compared to those <70 years. We used individual patient data from 23 RCTs of osteoporosis medications collected as part of the FNIH-ASBMR SABRE project. We assessed the following fractures: radiographic vertebral, non-vertebral, hip, all clinical and all fractures. We used Cox proportional hazard regression to estimate treatment effect for clinical fracture outcomes, logistic regression for the radiographic vertebral fracture outcome and linear regression to estimate treatment effect on 24-month change in hip and spine BMD in each age subgroup. The analysis included 123,164 (99% female) participants; 43% being ≥ 70 years. Treatment with anti-osteoporosis drugs significantly and similarly reduced fractures in both subgroups [e.g. OR = 0.47 and 0.51 for vertebral fractures in those below and above 70 years, interaction p = 0.19; HR for all fractures: 0.72 vs 0.70, interaction p = 0.20)]. Results were similar when limited to bisphosphonate trials with the exception of hip fracture risk reduction which was somewhat greater in those <70 (HR = 0.44) vs ≥70 (HR = 0.79) years (interaction p = 0.02). Allocation to anti-osteoporotic drugs resulted in significantly greater increases in hip and spine BMD at 24 months in those >70 compared to those <70 years. In summary, anti-osteoporotic medications similarly reduced the risk of fractures regardless of age and the few small differences in fracture risk reduction by age were of uncertain clinical significance.

Association of urine biomarkers of kidney health with subclinical cardiovascular disease among men with and without HIV

OBJECTIVE

The aim of this study was to determine whether urine biomarkers of kidney health are associated with subclinical cardiovascular disease among men with and without HIV.

DESIGN

A cross-sectional study within the Multicenter AIDS Cohort Study (MACS) among 504 men with and without HIV infection who underwent cardiac computed tomography scans and had urine biomarkers measured within the preceding 2 years.

METHODS

Our primary predictors were four urine biomarkers of endothelial (albuminuria), proximal tubule dysfunction (alpha-1-microglobulin [A1 M] and injury (kidney injury molecule-1 [KIM-1]) and tubulointerstitial fibrosis (pro-collagen-III N-terminal peptide [PIIINP]). These were evaluated for association with coronary artery calcium (CAC) prevalence, CAC extent, total plaque score, and total segment stenosis using multivariable regression.

RESULTS

Of the 504 participants, 384 were men with HIV (MWH) and 120 were men without HIV. In models adjusted for sociodemographic factors, cardiovascular disease risk factors, eGFR, and HIV-related factors, each two-fold higher concentration of albuminuria was associated with a greater extent of CAC (1.35-fold higher, 95% confidence interval 1.11-1.65), and segment stenosis (1.08-fold greater, 95% confidence interval 1.01-1.16). Associations were similar between MWH and men without HIV in stratified analyses. The third quartile of A1 M showed an association with greater CAC extent, total plaque score, and total segment stenosis, compared with the lowest quartile.

CONCLUSION

Worse endothelial and proximal tubule dysfunction, as reflected by higher urine albumin and A1 M, were associated with greater CAC extent and coronary artery stenosis.

Acute alcohol exposure and electrocardiographic changes: Finding from the HOLIDAY trial

BACKGROUND

Alcohol consumption is associated with a higher increased risk of atrial fibrillation (AF), but the acute effects on cardiac electrophysiology in humans remain poorly understood. The HOw ALcohol InDuces Atrial TachYarrhythmias (HOLIDAY) Trial revealed that alcohol shortened pulmonary vein atrial effective refractory periods, but more global electrophysiologic changes gleaned from the surface ECG have not yet been reported.

METHODS

This was a secondary analysis of the HOLIDAY Trial. During AF ablation procedures, 100 adults were randomized to intravenous alcohol titrated to 0.08% blood alcohol concentration versus a volume and osmolarity-matched, masked, placebo. Intervals measured from 12‑lead ECGs were compared between pre infusion and at infusion steady state (20 min).

RESULTS

The average age was 60 years and 11% were female. No significant differences in the P-wave duration, PR, QRS or QT intervals, were present between alcohol and placebo arms. However, infusion of alcohol was associated with a statistically significant relative shortening of the JT interval (r: -14.73, p = 0.048) after multivariable adjustment.

CONCLUSION

Acute exposure to alcohol was associated with a relative reduction in the JT interval, reflecting shortening of ventricular repolarization. These acute changes may reflect a more global shortening of refractoriness, suggesting immediate proarrhythmic effects pertinent to the atria and ventricles.

TV Viewing From Young Adulthood to Middle Age and Cardiovascular Disease Risk

INTRODUCTION

Few studies have longitudinally examined TV viewing trajectories and cardiovascular disease risk factors. The objective of this study was to determine the association between level and annualized changes in young adult TV viewing and the incidence of cardiovascular disease risk factors from young adulthood to middle age.

METHODS

In 2023, prospective community-based cohort data of 4,318 Coronary Artery Risk Development in Young Adults study participants (1990-1991 to 2015-2016) were analyzed. Individualized daily TV viewing trajectories for each participant were developed using linear mixed models.

RESULTS

Every additional hour of TV viewing at age 23 years was associated with higher odds of incident hypertension (AOR=1.16; 95% CI=1.11, 1.22), diabetes (AOR=1.19; 95% CI=1.11, 1.28), high triglycerides (AOR=1.17; 95% CI=1.08, 1.26), dyslipidemia (AOR=1.10; 95% CI=1.03, 1.16), and obesity (AOR=1.12; 95% CI=1.06, 1.17). In addition, each hourly increase in daily TV viewing was associated with higher annual odds of incident hypertension (AOR=1.26; 95% CI=1.16, 1.37), low high-density lipoprotein cholesterol (AOR=1.15; 95% CI=1.03, 1.30), high triglycerides (AOR=1.32; 95% CI=1.15, 1.51), dyslipidemia (AOR=1.22; 95% CI=1.11, 1.34), and obesity (AOR=1.17; 95% CI=1.07, 1.27) over the follow-up period.

CONCLUSIONS

In this prospective cohort study, higher TV viewing in young adulthood and annual increases in TV viewing were associated with incident hypertension, high triglycerides, and obesity. Young adulthood as well as behaviors across midlife may be important time periods to promote healthful TV viewing behavior patterns.

Changes in alcohol consumption during the COVID-19 pandemic: a longitudinal cohort study using smart-breathalyzer data

Previous studies relying on alcohol sales, alcohol-related injuries, and surveys have suggested that alcohol consumption increased during the COVID-19 pandemic. We sought to leverage over 1 million Breath Alcohol Concentration (BrAC) measurements from Bluetooth-enabled breathalyzers to conduct an objective and longitudinal assessment of alcohol use during the pandemic. Serial BrAC measurements revealed a decrease in drinking between January 1, 2020 and March 30, 2020, an increase between March 30, 2020 and May 25, 2020, a statistically insignificant decrease between May 25, 2020 and January 1, 2021, and an increase again between January 1, 2021 and June 4, 2021. No statistically significant relationships between shelter-in-place orders and alcohol consumption were detected. These findings demonstrate the complex relationship between the pandemic and alcohol consumption patterns, providing insights that may be relevant to the use of this commonly consumed substance with implications relevant to long-term effects from the patterns observed.

Bisphosphonate Use and Risk of Atypical Femoral Fractures: A Danish Case Cohort Study with Blinded Radiographic Review

CONTEXT

Prolonged bisphosphonate (BP) treatment for osteoporosis prevents hip and other fractures but causes atypical femoral fractures (AFF).

OBJECTIVE

To establish the relationship between patterns of BP use and the risk of AFF and hip fractures. Other potential risk factors for AFF were also examined.

DESIGN

Population-based case-cohort study.

SETTING

The Danish National Healthcare system maintains longitudinal records of medication use, healthcare utilization, and x-ray images.

PARTICIPANTS

Among all 1.9 million Danish adults ≥50, those with subtrochanteric or femoral shaft fractures between 2010-2015 (n = 4,973) were identified and compared to a random sample (n = 37,021).

PREDICTORS

Bisphosphonate use was collected from 1995-2015.

MAIN OUTCOME MEASURES

Fracture radiographs (n = 4,769) were reviewed by blinded study radiologists to identify AFFs (n = 181) using established criteria. Traditional hip fractures in the random sample (n = 691) were identified by ICD-10.

RESULTS

Compared to <1 year of BP use, 5-7 years of use was associated with a 7-fold increase in AFF [adjusted HR = 7.29 (CI: 3.07,17.30)]; the risk of AFF fell quickly after discontinuation. The 5-year number-needed-to-harm for one AFF was 1,424, while the 5-year number-needed-to-treat to prevent one hip fracture was 56. Glucocorticoid and proton pump inhibitor use were independently associated with increased AFF risk. Thirty-one percent of those with AFF had no BP exposure.

CONCLUSIONS

The risk of AFF increases with duration of BP use but the beneficial effects of BP therapy in adults ≥50 dramatically exceed this increased risk. Nearly one-third of those with AFF have no BP exposure.

Preceding Night Sleep Quality and Atrial Fibrillation Episodes in the I-STOP-AFIB Randomized Trial

BACKGROUND

Chronic sleep disruption is associated with incident atrial fibrillation (AF), but it is unclear whether poor sleep quality acutely triggers AF.

OBJECTIVES

The aim of this study was to characterize the relationship between a given night's sleep quality and the risk of a discrete AF episode.

METHODS

Patients with symptomatic paroxysmal AF in the I-STOP-AFIB (Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation) trial reported sleep quality on a daily basis. Participants were also queried daily regarding AF episodes and were provided smartphone-based mobile electrocardiograms (ECGs) (KardiaMobile, AliveCor).

RESULTS

Using 15,755 days of data from 419 patients, worse sleep quality on any given night was associated with a 15% greater odds of a self-reported AF episode the next day (OR: 1.15; 95% CI: 1.10-1.20; P < 0.0001) after adjustment for the day of the week. No statistically significant associations between worsening sleep quality and mobile ECG-confirmed AF events were observed (OR: 1.04; 95% CI: 0.95-1.13; P = 0.43), although substantially fewer of these mobile ECG-confirmed events may have limited statistical power. Poor sleep was also associated with longer self-reported AF episodes, with each progressive category of worsening sleep associated with 16 (95% CI: 12-21; P < 0.001) more minutes of AF the next day.

CONCLUSIONS

Poor sleep was associated with an immediately heightened risk for self-reported AF episodes, and a dose-response relationship existed such that progressively worse sleep was associated with longer episodes of AF the next day. These data suggest that sleep quality may be a potentially modifiable trigger relevant to the near-term risk of a discrete AF episode.

Effect of Personalized Risk-Reduction Strategies on Cognition and Dementia Risk Profile Among Older Adults: The SMARRT Randomized Clinical Trial

Importance

Modifiable risk factors are hypothesized to account for 30% to 40% of dementia; yet, few trials have demonstrated that risk-reduction interventions, especially multidomain, are efficacious.

Objective

To determine if a personalized, multidomain risk reduction intervention improves cognition and dementia risk profile among older adults.

Design, Setting, and Participants

The Systematic Multi-Domain Alzheimer Risk Reduction Trial was a randomized clinical trial with a 2-year personalized, risk-reduction intervention. A total of 172 adults at elevated risk for dementia (age 70-89 years and with ≥2 of 8 targeted risk factors) were recruited from primary care clinics associated with Kaiser Permanente Washington. Data were collected from August 2018 to August 2022 and analyzed from October 2022 to September 2023.

Intervention

Participants were randomly assigned to the intervention (personalized risk-reduction goals with health coaching and nurse visits) or to a health education control.

Main Outcomes and Measures

The primary outcome was change in a composite modified Neuropsychological Test Battery; preplanned secondary outcomes were change in risk factors and quality of life (QOL). Outcomes were assessed at baseline and 6, 12, 18, and 24 months. Linear mixed models were used to compare, by intention to treat, average treatment effects (ATEs) from baseline over follow-up. The intervention and outcomes were initially in person but then, due to onset of the COVID-19 pandemic, were remote.

Results

The 172 total participants had a mean (SD) age of 75.7 (4.8) years, and 108 (62.8%) were women. After 2 years, compared with the 90 participants in the control group, the 82 participants assigned to intervention demonstrated larger improvements in the composite cognitive score (ATE of SD, 0.14; 95% CI, 0.03-0.25; P = .02; a 74% improvement compared with the change in the control group), better composite risk factor score (ATE of SD, 0.11; 95% CI, 0.01-0.20; P = .03), and improved QOL (ATE, 0.81 points; 95% CI, -0.21 to 1.84; P = .12). There were no between-group differences in serious adverse events (24 in the intervention group and 23 in the control group; P = .59), but the intervention group had greater treatment-related adverse events such as musculoskeletal pain (14 in the intervention group vs 0 in the control group; P < .001).

Conclusions and Relevance

In this randomized clinical trial, a 2-year, personalized, multidomain intervention led to modest improvements in cognition, dementia risk factors, and QOL. Modifiable risk-reduction strategies should be considered for older adults at risk for dementia.

Trial Registration

ClinicalTrials.gov Identifier: NCT03683394.

HIV Viral Suppression Among Psychiatric Inpatients with Schizophrenia in San Francisco: A Retrospective Cohort Study

People with schizophrenia are at increased risk for contracting HIV and face higher mortality rates compared with the general population. Viral suppression is key to HIV care, yet little is known about this metric among people with HIV and schizophrenia. A chart review was conducted among people with HIV/AIDS and schizophrenia living in San Francisco who had received inpatient mental health services between 2010 and 2016. Demographic, laboratory, medication, encounter, and discharge data were collected, and were compared with all people living with HIV in San Francisco (PLWH-SF). Among 153 people living with HIV and comorbid schizophrenia, 77% were virally suppressed, compared to 67% for all PLWH-SF. Viral suppression for people with comorbid HIV and schizophrenia living in San Francisco appears higher than PLWH-SF. Further research is needed to confirm the association and mechanisms behind better treatment outcomes for people living with HIV and comorbid schizophrenia.

Ambulatory urine biomarkers associations with acute kidney injury and hospitalization in people with HIV

BACKGROUND

People with HIV (PWH) generally have worse ambulatory levels of kidney injury biomarkers and excess risk of acute kidney injury (AKI) compared to persons without HIV. We evaluated whether ambulatory measures of subclinical kidney injury among PWH are associated with subsequent AKI.

METHODS

In the Predictors of Acute Renal Injury Study (PARIS), which enrolled 468 PWH from April 2016 to August 2019, we measured 10 urine biomarkers of kidney health (albumin, a1m, b2M, NGAL, IL18, KIM-1, EGF, UMOD, MCP-1, YKL40) at baseline and annually during follow-up. Using multivariable Cox regression models, we evaluated baseline and time-updated biomarker associations with the primary outcome of AKI (≥0.3 mg/dl or ≥1.5-times increase in serum creatinine from baseline) and secondary outcome of all-cause hospitalization.

RESULTS

At baseline, the mean age was 53 years old, and 45% self-identified as female. In time-updated models adjusting for sociodemographic factors, comorbidities, albuminuria, estimated glomerular filtration rate, and HIV-associated factors, higher KIM-1 [hazard ratio (HR) = 1.30 per twofold higher; 95% confidence interval (CI) 1.03-1.63] and NGAL concentrations (HR = 1.24, 95% CI 1.06-1.44) were associated with higher risk of hospitalized AKI. Additionally, in multivariable, time-updated models, higher levels of KIM-1 (HR = 1.19, 95% CI 1.00, 1.41), NGAL (HR = 1.13, 95% CI 1.01-1.26), and MCP-1 (HR = 1.20, 95% CI 1.00, 1.45) were associated with higher risk of hospitalization.

CONCLUSIONS

Urine biomarkers of kidney tubular injury, such as KIM-1 and NGAL, are strongly associated with AKI among PWH, and may hold potential for risk stratification of future AKI.

Cocaine Use is Associated With Increased LVMI in Unstably Housed Women With Polysubstance Use

BACKGROUND

While substance use is known to influence cardiovascular health, most prior studies only consider one substance at a time. We examined associations between the concurrent use of multiple substances and left ventricular mass index (LVMI) in unhoused and unstably housed women.

METHODS

Between 2016 and 2019, we conducted a cohort study of unstably housed women in which measurements included an interview, serum/urine collection, vital sign assessment, and a single transthoracic echocardiogram at baseline. We evaluated independent associations between 39 separate substances confirmed through toxicology and echocardiography-confirmed LVMI.

RESULTS

The study included 194 participants with a median age of 53.5 years and a high proportion of women of color (72.6%). Toxicology-confirmed substance use included: 69.1% nicotine, 56.2% cocaine, 28.9% methamphetamines, 28.9% alcohol, 23.2% opioid analgesics, and 9.8% opioids with catecholaminergic effects. In adjusted analysis, cocaine was independently associated with higher LVMI (Adjusted linear effect: 18%; 95% CI 9.9, 26.6). Associations with other substances did not reach levels of significance and did not significantly interact with cocaine.

CONCLUSION

In a population of vulnerable women where the use of multiple substances is common, cocaine stands out as having particularly detrimental influences on cardiac structure. Blood pressure did not attenuate the association appreciably, suggesting direct effects of cocaine on LVMI. Routinely evaluating stimulant use as a chronic risk factor during risk assessment and preventive clinical care planning may reduce end organ damage, particularly in highly vulnerable women.

Housing Instability Associated with Return to Stimulant Use among Previously Abstaining Women

Stimulant use among unstably housed individuals is associated with increased risks of psychiatric co-morbidity, violence, HIV transmission, and overdose. Due to a lack of highly effective treatments, evidence-based policies targeting the prevention of stimulant use disorder are of critical importance. However, little empirical evidence exists on risks associated with initiating or returning to stimulant use among at-risk populations. In a longitudinal cohort of unstably housed women in San Francisco (2016-2019), self-reported data on stimulant use, housing status, and mental health were collected monthly for up to 6 months, and factors associated with initiating stimulants after a period of non-use were identified through logistic regression. Among 245 participants, 42 (17.1%) started using cocaine and 46 (18.8%) started using methamphetamine. In analyses adjusting for demographics and socio-structural exposures over the preceding month, experiencing street homelessness was associated with initiating cocaine use (AOR: 2.10; 95% CI: 1.04, 4.25) and sheltered homelessness with initiating methamphetamine use (AOR: 2.57; 95% CI: 1.37, 4.79). Other factors-including race, income, unmet subsistence needs, mental health, and treatment adherence-did not reach levels of significance, suggesting the paramount importance of policies directed toward improving access to permanent supportive housing to prevent stimulant use among unstably housed women.

Examining the Impact of State-Level Factors on HIV Testing for Medicaid Enrollees With Schizophrenia

BACKGROUND

People with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia.

SETTING

Nationally representative sample of Medicaid enrollees with and without schizophrenia.

METHODS

Using retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts.

RESULTS

Higher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia.

CONCLUSION

Overall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.

Efficacy of Continuous Transdermal Nitroglycerin for Treating Hot Flashes by Inducing Nitrate Cross-tolerance in Perimenopausal and Postmenopausal Women: A Randomized Clinical Trial

Importance

Due to the potential risks of long-term systemic estrogen therapy, many menopausal women are interested in nonhormonal treatments for vasomotor symptoms. Physiologic studies indicate that nitric oxide plays a key role in mediating hot flash-related vasodilation, suggesting that nonhormonal medications that induce nitrate tolerance in the vasculature may offer therapeutic benefit for vasomotor symptoms.

Objective

To determine whether uninterrupted administration of transdermal nitroglycerin (NTG) to induce nitrate cross-tolerance decreased the frequency or severity of menopause-related hot flashes.

Design, Setting, and Participants

This randomized, double-blinded, placebo-controlled clinical trial included perimenopausal or postmenopausal women reporting 7 or more hot flashes per day who were recruited from northern California by study personnel at a single academic center. Patients were randomized between July 2017 and December 2021, and the trial ended in April 2022 when the last randomized participant completed follow-up.

Interventions

Uninterrupted daily use of transdermal NTG (participant-directed dose titration from 0.2-0.6 mg/h) or identical placebo patches.

Main Outcome Measures

Validated symptom diaries assessing changes in any hot flash frequency (primary outcome) and moderate-to-severe hot flash frequency over 5 and 12 weeks.

Results

Among the 141 randomized participants (70 NTG [49.6%], 71 placebo [50.4%]; 12 [85.8%] Asian, 16 [11.3%] Black or African American, 15 [10.6%] Hispanic or Latina, 3 [2.1%] multiracial, 1 [0.7%] Native Hawaiian or Pacific Islander, and 100 [70.9%] White or Caucasian individuals), a mean (SD) of 10.8 (3.5) hot flashes and 8.4 (3.6) moderate-to-severe hot flashes daily was reported at baseline. Sixty-five participants assigned to NTG (92.9%) and 69 assigned to placebo (97.2%) completed 12-week follow-up (P = .27). Over 5 weeks, the estimated change in any hot flash frequency associated with NTG vs placebo was -0.9 (95% CI, -2.1 to 0.3) episodes per day (P = .10), and change in moderate-to-severe hot flash frequency with NTG vs placebo was -1.1 (95% CI, -2.2 to 0) episodes per day (P = .05). At 12 weeks, treatment with NTG did not significantly decrease the frequency of any hot flashes (-0.1 episodes per day; 95% CI, -1.2 to 0.4) or moderate-to-severe hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.7) relative to placebo. In analyses combining 5-week and 12-week data, no significant differences in change in the frequency of any hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.6; P = .25) or moderate-to-severe hot flashes (-0.8 episodes per day; 95% CI, -1.9 to 0.2; P = .12) were detected with NTG vs placebo. At 1 week, 47 NTG (67.1%) and 4 placebo participants (5.6%) reported headache (P < .001), but only 1 participant in each group reported headache at 12 weeks.

Conclusions and Relevance

This randomized clinical trial found that continuous use of NTG did not result in sustained improvements in hot flash frequency or severity relative to placebo and was associated with more early but not persistent headache.

Trial Registration

Clinicaltrials.gov Identifier: NCT02714205.

Characteristics and Trends in HIV Testing Among Medicaid Enrollees Diagnosed as Having Schizophrenia

OBJECTIVE

People with schizophrenia have more HIV risk factors and higher rates of HIV infection than the general U.S. population. The authors aimed to examine HIV testing patterns in this population nationally and by demographic characteristics and presence of high-risk comorbid conditions.

METHODS

This retrospective longitudinal study compared HIV testing between Medicaid-only enrollees with schizophrenia and without schizophrenia during 2002-2012 (N=6,849,351). Interrupted time series were used to analyze the impacts of the 2006 federal policy change recommending expanded HIV testing. Among enrollees with schizophrenia, multivariable logistic regression was used to estimate associations between testing and both demographic characteristics and comorbid conditions. Sensitivity analyses were also conducted.

RESULTS

Enrollees diagnosed as having schizophrenia had consistently higher HIV testing rates than those without schizophrenia. When those with comorbid substance use disorders or sexually transmitted infections were excluded, testing was higher for individuals without schizophrenia (p<0.001). The federal policy change likely increased testing for both groups (p<0.001), but the net change was greater for those without schizophrenia (3.1 vs. 2.2 percentage points). Among enrollees with schizophrenia, testing rates doubled during 2002-2012 (3.9% to 7.2%), varied across states (range 17 percentage points), and tripled for those with at least one annual nonpsychiatric medical visit (vs. no visit; adjusted OR=3.10, 95% CI=2.99-3.22).

CONCLUSIONS

Nationally, <10% of enrollees with schizophrenia had annual HIV testing. Increases appear to be driven by high-risk comorbid conditions and nonpsychiatric encounters, rather than by efforts to target people with schizophrenia. Psychiatric guidelines for schizophrenia care should consider HIV testing alongside annual metabolic screening.

Association Between Intensive vs Standard Blood Pressure Control and Incident Left Ventricular Conduction Disease: A Post Hoc Analysis of the SPRINT Randomized Clinical Trial

Importance

Left ventricular conduction disease predicts heart failure and death, and the only strategies to mitigate its effects involve implantation of a permanent pacemaker. There are currently no proven preventive strategies for this common condition.

Objective

To determine the association between targeting intensive blood pressure (BP) control and the risk of developing left ventricular conduction disease.

Design, Setting, and Participants

This was a post hoc analysis of the 2-arm multicenter Systolic Blood Pressure Intervention Trial (SPRINT), which recruited participants from 102 sites in the US and Puerto Rico and was conducted from November 2010 until August 2015. Adults 50 years and older with hypertension and at least 1 other cardiovascular risk factor were included. Participants with baseline left ventricular conduction disease, ventricular pacing, or ventricular pre-excitation were excluded for the current analysis. Data were analyzed from November 2021 to November 2022.

Intervention

Participants were randomly assigned to a systolic BP target of less than 140 mm Hg (standard treatment group) or less than 120 mm Hg (intensive treatment group).

Main Outcome

The primary outcome was incident left ventricular conduction disease, including any fascicular or left bundle-branch block, assessed by serial electrocardiography. Incident right bundle-branch block was examined as a negative control.

Results

Among 3918 participants randomized to standard treatment and 3956 to intensive treatment (mean [SD] age, 67.6 [9.2] years; 2815 [36%] female) monitored for a median [IQR] 3.5 (0.02-5.2) years, 203 developed left ventricular conduction disease. Older age (hazard ratio per 10-year increase [HR], 1.42; 95% CI, 1.21-1.67; P < .001), male sex (HR, 2.31; 95% CI, 1.63-3.32; P < .001), and cardiovascular disease (HR, 1.46; 95% CI, 1.06-2.00; P = .02) were associated with a higher risk of left ventricular conduction disease. Assignment to intensive treatment was associated with a 26% lower risk of left ventricular conduction disease (HR, 0.74; 95% CI, 0.56-0.98; P = .04). These results persisted when incident ventricular pacing was included in the outcome and when considering all-cause death as a competing risk. In contrast, no association between randomization assignment and right bundle-branch block was observed (HR, 0.95; 95% CI, 0.71-1.27; P = .75).

Conclusions and Relevance

In this study, targeting intensive BP control was associated with lower risk of left ventricular conduction disease in a randomized clinical trial, suggesting that clinically relevant conduction disease may be preventable.

Trial Registration

ClinicalTrials.gov Identifier: NCT01206062.

Multiple substance use and blood pressure in women experiencing homelessness

Background

Substance use increases risk of cardiovascular events, particularly among women with additional risk factors like housing instability. While multiple substance use is common among unstably housed individuals, relationships between multiple substance use and cardiovascular risk factors like blood pressure are not well characterized.

Methods

We conducted a cohort study between 2016 and 2019 to examine associations between multiple substance use and blood pressure in women experiencing homelessness and unstable housing. Participants completed six monthly visits including vital sign assessment, interview, and blood draw to assess toxicology-confirmed substance use (e.g., cocaine, alcohol, opioids) and cardiovascular health. We used linear mixed models to evaluate the outcomes of systolic and diastolic blood pressure (SBP; DBP).

Results

Mean age was 51.6 years; 74 % were women of color. Prevalence of any substance use was 85 %; 63 % of participants used at least two substances at baseline. Adjusting for race, body mass index and cholesterol, cocaine was the only substance significantly associated with SBP (4.71 mmHg higher; 95 % CI 1.68, 7.74) and DBP (2.83 mmHg higher; 95 % CI 0.72, 4.94). Further analysis found no differences in SBP or DBP between those with concurrent use of other stimulants, depressants, or both with cocaine, compared to those who used cocaine only.

Conclusions

Cocaine was the only substance associated with higher SBP and DBP, even after accounting for simultaneous use of other substances. Along with interventions to address cocaine use, stimulant use screening during cardiovascular risk assessment and intensive blood pressure management may improve cardiovascular outcomes among women experiencing housing instability.

Screen Time from Adolescence to Adulthood and Cardiometabolic Disease: a Prospective Cohort Study

BACKGROUND

Previous studies have analyzed the relationship between screen time and cardiometabolic disease risk factors among adolescents, but few have examined the longitudinal effects of screen time on cardiometabolic health into adulthood using nationally representative data.

OBJECTIVE

To determine prospective associations between screen time and later cardiometabolic disease over a 24-year period using a nationally representative adolescent cohort.

DESIGN

Longitudinal prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) collected from 1994 to 2018.

PARTICIPANTS

Adolescents aged 11-18 years old at baseline (1994-1995) followed for 24 years.

MAIN MEASURES

Predictors: screen time (five repeated measures of self-reported television and video watching from adolescence to adulthood).

OUTCOMES

Five repeated measures of body mass index (BMI); two repeated measures of waist circumference, hypertension, hyperlipidemia, and diabetes collected at 15- and 24-year follow-up exams.

KEY RESULTS

For the 7105 adolescents in the sample (49.7% female, 35.0% non-white), the baseline adolescent average screen time per day was 2.86 ± 0.08 hours per day, which generally declined through 24-year follow-up. Average BMI at baseline was 22.57 ± 0.13 kg/m2, which increased to 30.27 ± 0.18 kg/m2 through follow-up. By 24-year follow-up, 43.4% of participants had obesity, 8.4% had diabetes, 31.8% had hypertension, and 14.9% had hyperlipidemia. In mixed-effects generalized linear models, each additional hour of screen time per day was associated with 0.06 (95% CI 0.04-0.09) within-person increase in BMI. Each additional hour of screen time per day was associated with higher within-person odds of high waist circumference (AOR 1.17, 95% CI 1.09-1.26), obesity (AOR 1.09, 95% CI 1.03-1.15), and diabetes (AOR 1.17, 95% CI 1.07-1.28). Screen time was not significantly associated with hypertension or hyperlipidemia.

CONCLUSIONS

In this prospective cohort study, higher screen time in adolescence was associated with higher odds of select indicators of cardiometabolic disease in adulthood.

Disruption in Blood Pressure Control With the COVID-19 Pandemic: The PCORnet Blood Pressure Control Laboratory

OBJECTIVE

To explore trends in blood pressure (BP) control before and during the COVID-19 pandemic.

PATIENTS AND METHODS

Health systems participating in the National Patient-Centered Clinical Research Network (PCORnet) Blood Pressure Control Laboratory Surveillance System responded to data queries, producing 9 BP control metrics. Averages of the BP control metrics (weighted by numbers of observations in each health system) were calculated and compared between two 1-year measurement periods (January 1, 2019, through December 31, 2019, and January 1, 2020, through December 31, 2020).

RESULTS

Among 1,770,547 hypertensive persons in 2019, BP control to <140/<90 mm Hg varied across 24 health systems (range, 46%-74%). Reduced BP control occurred in most health systems with onset of the COVID-19 pandemic; the weighted average BP control was 60.5% in 2019 and 53.3% in 2020. Reductions were also evident for BP control to <130/<80 mm Hg (29.9% in 2019 and 25.4% in 2020) and improvement in BP (reduction of 10 mm Hg in systolic BP or achievement of systolic BP <140 mm Hg; 29.7% in 2019 and 23.8% in 2020). Two BP control process metrics exhibited pandemic-associated disruption: repeat visit in 4 weeks after a visit with uncontrolled hypertension (36.7% in 2019 and 31.7% in 2020) and prescription of fixed-dose combination medications among those with 2 or more drug classes (24.6% in 2019 and 21.5% in 2020).

CONCLUSION

BP control decreased substantially during the COVID-19 pandemic, with a corresponding reduction in follow-up health care visits among persons with uncontrolled hypertension. It is unclear whether the observed decline in BP control during the pandemic will contribute to future cardiovascular events.

Breast Cancer Screening Rates Among Medicaid Beneficiaries With Schizophrenia

OBJECTIVE

Women with serious mental illness are more likely to be diagnosed as having late-stage breast cancer than women without serious mental illness, suggesting a disparity in screening mammography. This study aimed to compare screening mammography rates in a nationally representative sample of Medicaid beneficiaries with and without schizophrenia.

METHODS

Medicaid Analytic eXtract files, 2007-2012, were used to identify a cohort of women ages 40-64 with schizophrenia who were eligible for Medicaid but not Medicare (N=87,572 in 2007 and N=114,341 in 2012) and a cohort without schizophrenia, frequency-matched by age, race-ethnicity, and state (N=97,003 in 2007 and N=126,461 in 2012). Annual screening mammography rates were calculated and adjusted for demographic characteristics and comorbid conditions. Multivariable logistic regression was used to estimate the association between beneficiary characteristics and screening mammography rates.

RESULTS

In 2012, 27.2% of women with schizophrenia completed screening mammography, compared with 26.8% of the control cohort. In the schizophrenia cohort, American Indian/Alaskan Native women had significantly lower odds of receiving mammography (OR=0.82, p=0.02) than White women, whereas Hispanic/Latina women had higher odds (OR=1.16, p<0.001). Women with schizophrenia and a nonalcohol-related substance use disorder had lower odds of receiving mammography (OR=0.74, p<0.001) than women without a substance use disorder. Having at least one medical visit in the past year (vs. no visits) increased the odds of receiving screening mammography (OR=5.08, p<0.001).

CONCLUSIONS

Screening mammography rates were similar between Medicaid-insured women with and those without schizophrenia. Interventions to increase uptake may need to focus on improving socioeconomic conditions and primary care engagement for vulnerable populations, regardless of psychiatric condition.

TReating Incontinence for Underlying Mental and Physical Health (TRIUMPH): a study protocol for a multicenter, double-blinded, randomized, 3-arm trial to evaluate the multisystem effects of pharmacologic treatment strategies for urgency-predominant urinary incontinence in ambulatory older women

BACKGROUND

Urgency-type urinary incontinence affects one in four older community-dwelling women and overlaps with other common aging-associated health syndromes such as cognitive impairment, physical mobility impairment, and depression. Observational studies have raised concern about potentially higher rates of delirium and dementia in older adults taking anticholinergic bladder medications, but few prospective data are available to evaluate the effects of these and other pharmacologic treatments for urgency incontinence on cognition and other multisystem functional domains important to older women.

METHODS

The TRIUMPH study is a randomized, double-blinded, 3-arm, parallel-group trial comparing the multisystem effects of anticholinergic versus beta-3-adrenergic agonist bladder therapy and versus no active bladder anti-spasmodic pharmacotherapy in older women with urgency incontinence. Women aged 60 years and older (target N = 270) who have chronic urgency-predominant urinary incontinence and either normal or mildly impaired cognition at baseline are recruited from the community by investigators based in northern California, USA. Participants are randomized in equal ratios to take identically encapsulated oral anticholinergic bladder therapy (in the form of tolterodine 2 mg extended release [ER]), oral beta-3 adrenergic agonist bladder therapy (mirabegron 25 mg ER), or placebo daily for 24 weeks, with the option of participant-directed dose titration (to tolterodine 4 mg ER, mirabegron 50 mg ER, or matching placebo daily). Participants also receive patient-oriented information and instructions about practicing first-line behavioral management strategies for incontinence. The primary outcome is change in composite cognitive function over 24 weeks assessed by a comprehensive battery of cognitive tests, with a secondary exploration of the persistence of change at 36 weeks. Secondary outcomes include changes over 24 and 36 weeks in domain-specific cognitive function; frequency, severity, and impact of urgency-associated urinary symptoms; physical function and balance; sleep quality and daytime sleepiness; psychological function; and bowel function.

DISCUSSION

The TRIUMPH trial addresses the need for rigorous evidence to guide counseling and decision-making for older women who are weighing the potential multisystem benefits and risks of pharmacologic treatments for urgency incontinence in order to preserve their day-to-day functioning, quality of life, and independence in older age.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05362292. Registered on May 5, 2022.

Postexposure Doxycycline to Prevent Bacterial Sexually Transmitted Infections

BACKGROUND

Interventions to reduce sexually transmitted infections (STIs) among men who have sex with men (MSM) are needed.

METHODS

We conducted an open-label, randomized study involving MSM and transgender women who were taking preexposure prophylaxis (PrEP) against human immunodeficiency virus (HIV) infection (PrEP cohort) or living with HIV infection (persons living with HIV infection [PLWH] cohort) and who had had Neisseria gonorrhoeae (gonorrhea), Chlamydia trachomatis (chlamydia), or syphilis in the past year. Participants were randomly assigned in a 2:1 ratio to take 200 mg of doxycycline within 72 hours after condomless sex (doxycycline postexposure prophylaxis) or receive standard care without doxycycline. STI testing was performed quarterly. The primary end point was the incidence of at least one STI per follow-up quarter.

RESULTS

Of 501 participants (327 in the PrEP cohort and 174 in the PLWH cohort), 67% were White, 7% Black, 11% Asian or Pacific Islander, and 30% Hispanic or Latino. In the PrEP cohort, an STI was diagnosed in 61 of 570 quarterly visits (10.7%) in the doxycycline group and 82 of 257 quarterly visits (31.9%) in the standard-care group, for an absolute difference of -21.2 percentage points and a relative risk of 0.34 (95% confidence interval [CI], 0.24 to 0.46; P<0.001). In the PLWH cohort, an STI was diagnosed in 36 of 305 quarterly visits (11.8%) in the doxycycline group and 39 of 128 quarterly visits (30.5%) in the standard-care group, for an absolute difference of -18.7 percentage points and a relative risk of 0.38 (95% CI, 0.24 to 0.60; P<0.001). The incidences of the three evaluated STIs were lower with doxycycline than with standard care; in the PrEP cohort, the relative risks were 0.45 (95% CI, 0.32 to 0.65) for gonorrhea, 0.12 (95% CI, 0.05 to 0.25) for chlamydia, and 0.13 (95% CI, 0.03 to 0.59) for syphilis, and in the PLWH cohort, the relative risks were 0.43 (95% CI, 0.26 to 0.71), 0.26 (95% CI, 0.12 to 0.57), and 0.23 (95% CI, 0.04 to 1.29), respectively. Five grade 3 adverse events and no serious adverse events were attributed to doxycycline. Of the participants with gonorrhea culture available, tetracycline-resistant gonorrhea occurred in 5 of 13 in the doxycycline groups and 2 of 16 in the standard-care groups.

CONCLUSIONS

The combined incidence of gonorrhea, chlamydia, and syphilis was lower by two thirds with doxycycline postexposure prophylaxis than with standard care, a finding that supports its use among MSM with recent bacterial STIs. (Funded by the National Institutes of Health; DoxyPEP ClinicalTrials.gov number, NCT03980223.).

Adverse childhood experiences and sipping alcohol in U.S. Children: Findings from the Adolescent Brain Cognitive Development study

The objective of this study was to explore the relationship between accumulating adverse childhood experiences (ACEs) and sipping alcohol in a large, nationwide sample of 9-to-10-year-old U.S. children. We analyzed data from the Adolescent Brain Cognitive Development (ABCD) Study (2016-2018). Of 10,853 children (49.1 % female), 23.4 % reported ever sipping alcohol. A greater ACE score was associated with a higher risk of sipping alcohol. Having 4 or more ACEs placed children at 1.27 times the risk (95 % CI 1.11-1.45) of sipping alcohol compared to children with no ACEs. Among the nine distinct ACEs examined, household violence (Risk Ratio [RR] = 1.13, 95 % CI 1.04-1.22) and household alcohol abuse (RR = 1.14, 95 % CI 1.05-1.22) were associated with sipping alcohol during childhood. Our findings indicate a need for increased clinical attention to alcohol sipping among ACE-exposed children.

Acute Effects of Coffee Consumption on Health among Ambulatory Adults

BACKGROUND

Coffee is one of the most commonly consumed beverages in the world, but the acute health effects of coffee consumption remain uncertain.

METHODS

We conducted a prospective, randomized, case-crossover trial to examine the effects of caffeinated coffee on cardiac ectopy and arrhythmias, daily step counts, sleep minutes, and serum glucose levels. A total of 100 adults were fitted with a continuously recording electrocardiogram device, a wrist-worn accelerometer, and a continuous glucose monitor. Participants downloaded a smartphone application to collect geolocation data. We used daily text messages, sent over a period of 14 days, to randomly instruct participants to consume caffeinated coffee or avoid caffeine. The primary outcome was the mean number of daily premature atrial contractions. Adherence to the randomization assignment was assessed with the use of real-time indicators recorded by the participants, daily surveys, reimbursements for date-stamped receipts for coffee purchases, and virtual monitoring (geofencing) of coffee-shop visits.

RESULTS

The mean (±SD) age of the participants was 39±13 years; 51% were women, and 51% were non-Hispanic White. Adherence to the random assignments was assessed to be high. The consumption of caffeinated coffee was associated with 58 daily premature atrial contractions as compared with 53 daily events on days when caffeine was avoided (rate ratio, 1.09; 95% confidence interval [CI], 0.98 to 1.20; P = 0.10). The consumption of caffeinated coffee as compared with no caffeine consumption was associated with 154 and 102 daily premature ventricular contractions, respectively (rate ratio, 1.51; 95% CI, 1.18 to 1.94); 10,646 and 9665 daily steps (mean difference, 1058; 95% CI, 441 to 1675); 397 and 432 minutes of nightly sleep (mean difference, 36; 95% CI, 25 to 47); and serum glucose levels of 95 mg per deciliter and 96 mg per deciliter (mean difference, -0.41; 95% CI, -5.42 to 4.60).

CONCLUSIONS

In this randomized trial, the consumption of caffeinated coffee did not result in significantly more daily premature atrial contractions than the avoidance of caffeine. (Funded by the University of California, San Francisco, and the National Institutes of Health; CRAVE ClinicalTrials.gov number, NCT03671759.).

Lifestyle habits associated with cardiac conduction disease

AIMS

Cardiac conduction disease can lead to syncope, heart failure, and death. The only available therapy is pacemaker implantation, with no established prevention strategies. Research to identify modifiable risk factors has been scant.

METHODS AND RESULTS

Data from the Cardiovascular Health Study, a population-based cohort study of adults ≥ 65 years with annual 12-lead electrocardiograms obtained over 10 years, were utilized to examine relationships between baseline characteristics, including lifestyle habits, and conduction disease. Of 5050 participants (mean age 73 ± 6 years; 52% women), prevalent conduction disease included 257 with first-degree atrioventricular block, 99 with left anterior fascicular block, 9 with left posterior fascicular block, 193 with right bundle branch block (BBB), 76 with left BBB, and 102 with intraventricular block at baseline. After multivariable adjustment, older age, male sex, a larger body mass index, hypertension, and coronary heart disease were associated with a higher prevalence of conduction disease, whereas White race and more physical activity were associated with a lower prevalence. Over a median follow-up on 7 (interquartile range 1-9) years, 1036 developed incident conduction disease. Older age, male sex, a larger BMI, and diabetes were each associated with incident conduction disease. Of lifestyle habits, more physical activity (hazard ratio 0.91, 95% confidence interval 0.84-0.98, P = 0.017) was associated with a reduced risk, while smoking and alcohol did not exhibit a significant association.

CONCLUSION

While some difficult to control comorbidities were associated with conduction disease as expected, a readily modifiable lifestyle factor, physical activity, was associated with a lower risk.

Prioritizing Patient Experience: Validation of the Person-Centered Contraceptive Counseling Measure as a Performance Measure

OBJECTIVE

A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum.

STUDY DESIGN

We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of a the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction.

RESULTS

We included 22 facilities and 34 providers in analyses. The average PCCC top-box score by provider and facility was 81% and 79% respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs. English) in PCCC scores.

DISCUSSION

The PCCC is a valid and reliable performance measure for use at the provider and facility level. Use of this measure can facilitate the identification of gaps in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care.

A Randomized Trial of High vs Standard Power Radiofrequency Ablation for Pulmonary Vein Isolation

BACKGROUND

High-power, short duration (HPSD) radiofrequency ablation (RFA) is a commonly used strategy for pulmonary vein isolation (PVI).

OBJECTIVES

This study sought to compare HPSD with standard power, standard duration (SPSD) RFA in patients undergoing PVI.

METHODS

Patients with paroxysmal or persistent (<1 year) atrial fibrillation (AF) were randomized to HPSD (50 W) or SPSD (25-30 W) RFA to achieve PVI. Outcomes assessed included time to achieve PVI (primary), left atrial dwell time, total procedure time, first-pass isolation, PV reconnection with adenosine, procedure complications including asymptomatic cerebral emboli (ACE), and freedom from atrial arrhythmias.

RESULTS

Sixty patients (median age 66 years; 75% male) with paroxysmal (57%) or persistent (43%) AF were randomized to HPSD (n = 29) or SPSD (n = 31). Median time to achieve PVI was shorter with HPSD vs SPSD (87 minutes vs 126 minutes; P = 0.003), as was left atrial dwell time (157 minutes vs 180 minutes; P = 0.04). There were no differences in first-pass isolation (79% vs 76%; P = 0.65) or PV reconnection with adenosine (12% vs 20%; P = 0.26) between groups. At 12 months, recurrent atrial arrhythmias occurred less in the HPSD group compared with the SPSD group (n = 3 of 29 [10%] vs n = 11 of 31 [35%]; HR: 0.26; P = 0.027). There was a trend toward more ACE with HPSD RFA (40% HPSD vs 17% SPSD; P = 0.053).

CONCLUSIONS

In patients undergoing AF ablation, HPSD compared with SPSD RFA results in shorter time to achieve PVI, greater freedom from AF at 12 months, and a trend toward increased ACE.

Risk Factors for Arrhythmic Death, Overall Mortality, and Ventricular Tachyarrhythmias Requiring Shock After Myocardial Infarction

The VEST (Vest Prevention of Early Sudden Death Trial) showed a trend toward decreased sudden death and lower overall mortality with a wearable cardioverter-defibrillator (WCD) in the postmyocardial infarction (post-MI) period. However, it is unclear which patients should receive WCD therapy. We aimed to identify the risk factors for arrhythmic death, all-cause mortality, and ventricular tachyarrhythmias requiring appropriate shock to identify patients most likely to benefit from a WCD. The VEST trial included patients with acute MI with ejection fraction ≤35%. Using logistic regression, 7 risk factors were evaluated for association with arrhythmic death, all-cause mortality, and appropriate shock. Among 2,302 participants, 44 had arrhythmic death (1.9%) and 86 died of any cause (3.7%). Among 1,524 participants randomized to WCD, 20 experienced appropriate shock (1.3%) over 90 days. In the multivariable analyses, lower systolic blood pressure (SBP; odds ratio [OR] 1.64 per 10 mm Hg) and higher heart rate at discharge (OR 1.19 per 10 beats/min) were associated with arrhythmic death. Lower SBP (OR 1.37) and higher heart rate (OR 1.10) were associated with all-cause mortality. Higher heart rate (OR 1.20) was associated with appropriate shock. Patients with both SBP ≤100 and heart rate ≥100 were at increased odds of arrhythmic death (OR 4.82), all-cause mortality (OR 3.10), and appropriate shock (OR 6.13). In patients with acute MI and reduced ejection fraction, lower SBP and higher heart rate at discharge were strongly associated with arrhythmic death and all-cause mortality. In conclusion, these risk factors identify a select group at high risk of adverse events in a setting where WCD therapy is reasonable.

Randomized Controlled Trial of Automated Directly Observed Therapy for Measurement and Support of PrEP Adherence Among Young Men Who have Sex with Men

Measurement of adherence to oral pre-exposure prophylaxis (PrEP) in real-time has been challenging. We developed DOT Diary, a smartphone application that combines automated directly observed therapy with a PrEP adherence visualization toolkit, and tested its ability to measure PrEP adherence and to increase adherence among a diverse cohort of young men who have sex with men (MSM). We enrolled 100 MSM in San Francisco and Atlanta and randomly assigned them 2:1 to DOT Diary versus standard of care. Concordance between DOT Diary measurement and drug levels in dried blood spots was substantial, with 91.0% and 85.3% concordance between DOT Diary and emtricitabine-triphosphate and tenofovir-diphosphate, respectively. There was no significant difference in the proportion of participants with detectable PrEP drug levels at 24 weeks between study arms. These results suggest DOT Diary is substantially better than self-reported measures of adherence, but additional interventions are needed to improve PrEP adherence over time.

Cognitive and Functional Trajectories in Older Adults With Prediagnostic Parkinson Disease

BACKGROUND AND OBJECTIVES

There is increasing interest in characterizing the earliest phases of Parkinson's Disease (PD). However, few studies have investigated prediagnostic trajectories of cognition and function. Our objective was to describe prediagnostic cognitive and functional trajectories in PD in older women and men.

METHODS

We studied 9,595 women and 5,795 men from two prospective cohort studies of community-dwelling elders followed up to 20 years. In individuals without prevalent PD, we estimated the associations of incident PD diagnosis with rates of change in cognition and function before and after diagnosis compared to healthy older adults using multivariate mixed-effects models.

RESULTS

Over follow-up, 297 individuals developed incident PD. Interactions between the terms in our model and sex were statistically significant for the three outcomes (p<0.001 for all), so we stratified results by sex. Compared to older men without PD, men who developed PD exhibited faster decline in global cognition (0.04 SD more annual change, p<0.001), executive function (0.05 SD more annual change, p<0.001), and functional status (0.06 SD more annual change, p<0.001) in the prediagnostic period. Women who developed PD compared to women without PD displayed faster decline in executive function (0.02 SD more annual change, p=0.006) and functional status in the prediagnostic period (0.07 SD more annual change, p<0.001).

DISCUSSION

Individuals with incident PD exhibit cognitive and functional decline during the prediagnostic phase that exceeds rates associated with normal aging. Better understanding heterogeneity in prodromal PD is essential to enable earlier diagnosis and identify impactful nonmotor symptoms in all subgroups.

Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation

AIMS

Atrial fibrillation (AF) is now regarded as a preventable disease, requiring a search for modifiable risk factors. With legalization of cannabis and more lenient laws regarding the use of other illicit substances, investigation into the potential effects of methamphetamine, cocaine, opiate, and cannabis exposure on incident AF is needed.

METHODS AND RESULTS

Using Office of Statewide Health Planning and Development databases, a longitudinal analysis was performed of adult Californians ≥18 years of age who received care in an emergency department, outpatient surgery facility, or hospital from 1 January 2005 to 31 December 2015. Associations between healthcare coding for the use of each substance and a new AF diagnosis were assessed. Among 23,561,884 patients, 98 271 used methamphetamine, 48 701 used cocaine, 10 032 used opiates, and 132 834 used cannabis. Of the total population, 998 747 patients (4.2%) developed incident AF during the study period. After adjusting for potential confounders and mediators, use of methamphetamines, cocaine, opiates, and cannabis was each associated with increased incidence of AF: hazard ratios 1.86 [95% confidence interval (CI) 1.81-1.92], 1.61 (95% CI 1.55-1.68), 1.74 (95% CI 1.62-1.87), and 1.35 (95% CI 1.30-1.40), respectively. Negative control analyses in the same cohort failed to reveal similarly consistent positive relationships.

CONCLUSION

Methamphetamine, cocaine, opiate, and cannabis uses were each associated with increased risk of developing incident AF. Efforts to mitigate the use of these substances may represent a novel approach to AF prevention.

Impact of multiple substance use on circulating ST2, a biomarker of adverse cardiac remodelling, in women

CONTEXT

Cardiovascular disease (CVD) and heart failure (HF) are major causes of mortality in low-income populations and differ by sex. Risk assessment that incorporates cardiac biomarkers is common. However, research evaluating the utility of biomarkers rarely includes controlled substances, which may influence biomarker levels and thus influence CVD risk assessment.

MATERIALS AND METHODS

We identified the effects of multiple substances on soluble "suppression of tumorigenicity 2" (sST2), a biomarker of adverse cardiac remodelling, in 245 low-income women. Adjusting for CVD risk factors, we examined associations between substance use and sST2 over six monthly visits.

RESULTS

Median age was 53 years and 74% of participants were ethnic minority women. An sST2 level > 35 ng/mL (suggesting cardiac remodelling) during ≥1 study visit was observed in 44% of participants. In adjusted analysis, higher sST2 levels were significantly and positively associated with the presence of cocaine (Adjusted Linear Effect [ALE]:1.10; 95% CI:1.03-1.19), alcohol (ALE:1.10; 95% CI:1.04-1.17), heroin (ALE:1.25; 95% CI:1.10-1.43), and the interaction between heroin and fentanyl use.

CONCLUSION

Results suggest that the use of multiple substances influences the level of sST2, a biomarker often used to evaluate cardiovascular risk. Incorporating substance use alongside cardiac biomarkers may improve CVD risk assessment in vulnerable women.

Targeted Oral Naltrexone for Mild to Moderate Alcohol Use Disorder Among Sexual and Gender Minority Men: A Randomized Trial

OBJECTIVE

The authors sought to determine the efficacy of targeted naltrexone in sexual and gender minority men (SGM) who binge drink and have mild to moderate alcohol use disorder.

METHODS

In a double-blind placebo-controlled trial, a total of 120 SGM who binge drink and have mild to moderate alcohol use disorder were randomized in a 1:1 ratio to receive targeted oral naltrexone (50 mg) or placebo with weekly counseling for 12 weeks. The study's primary endpoints were binge-drinking intensity, defined as 1) number of drinks in the past 30 days; 2) any binge drinking in the past week; 3) number of binge-drinking days in the past week; and 4) number of drinking days in the past week. The study also measured changes in alcohol use with two alcohol biomarker measures: ethyl glucuronide in urine samples and phosphatidylethanol (PEth) in dried blood spot samples.

RESULTS

Ninety-three percent completed the trial, with 85% of weekly follow-up visits completed. In intention-to-treat analyses, naltrexone was associated with a significantly reduced reported number of binge-drinking days (incidence rate ratio [IRR]=0.74, 95% CI=0.56, 0.98; number needed to treat [NNT]=2), weeks with any binge drinking (IRR=0.83, 95% CI=0.72, 0.96; NNT=7.4), number of drinks per month (IRR=0.69, 95% CI=0.52, 0.91; NNT=5.7 for 10 drinks), and alcohol craving scores (coefficient=-9.25, 95% CI=-17.20, -1.31). In as-treated analyses among those who took their medication on average at least 2.5 days per week (the median frequency in the study), naltrexone reduced any binge drinking (IRR=0.84, 95% CI=0.71, 0.99), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.96), and PEth concentrations (coefficient=-55.47, 95% CI=-110.75, -0.20). At 6 months posttreatment, naltrexone had sustained effects in number of drinks per month (IRR=0.69, 95% CI=0.50, 0.97), number of binge-drinking days (IRR=0.67, 95% CI=0.47, 0.95), and any binge drinking in the past week (IRR=0.79, 95% CI=0.63, 0.99).

CONCLUSIONS

Targeted naltrexone significantly reduced drinking outcomes among SGM with mild to moderate alcohol use disorder during treatment, with sustained effects at 6 months posttreatment. Naltrexone may be an important pharmacotherapy to address binge drinking in populations with mild to moderate alcohol use disorder.

CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care

BACKGROUND

Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care.

METHODS

The study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites.

RESULTS

Rates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P &lt; .001]. While we observed a significant increase in A1c screening rates at the intervention site, this increase did not persist after multivariable adjustment (aOR 1.37, 95% CI .95-1.99, P = .09).

CONCLUSIONS

This low-cost, reverse integrated care model targeting community psychiatrist practices had modest effects on increasing preventive care screenings, with the biggest effect seen for HIV testing rates. Additional incentives and structural supports may be needed to further promote screening practices for individuals with serious mental illness.

Diabetes Mellitus and the Benefit of Antiresorptive Therapy on Fracture Risk

Type 2 diabetes (T2D) is associated with increased risk of fractures. However, it is unclear whether current osteoporosis treatments reduce fractures in individuals with diabetes. The aim of the study was to determine whether presence of T2D influences the efficacy of antiresorptive treatment for osteoporosis using the Foundation for the National Institutes of Health (FNIH)-American Society for Bone and Mineral Research (ASBMR)-Study to Advance Bone Mineral Density (BMD) as a Regulatory Endpoint (SABRE) cohort, which includes individual patient data from randomized trials of osteoporosis therapies. In this study we included 96,385 subjects, 6.8% of whom had T2D, from nine bisphosphonate trials, two selective estrogen receptor modulator (SERM) trials, two trials of menopausal hormone therapy, one denosumab trial, and one odanacatib trial. We used Cox regression to obtain the treatment hazard ratio (HR) for incident nonvertebral, hip, and all fractures and logistic regression to obtain the treatment odds ratio (OR) for incident morphometric vertebral fractures, separately for T2D and non-DM. We used linear regression to estimate the effect of treatment on 2-year change in BMD (n = 49,099) and 3-month to 12-month change in bone turnover markers (n = 12,701) by diabetes status. In all analyses, we assessed the interaction between treatment and diabetes status. In pooled analyses of all 15 trials, we found that diabetes did not impact treatment efficacy, with similar reductions in vertebral, nonvertebral, all, and hip fractures, increases in total hip and femoral neck BMD, and reductions in serum C-terminal cross-linking telopeptide (CTX), urinary N-telopeptide of type I collagen/creatinine (NTX/Cr) and procollagen type 1 N propeptide (P1NP) (all interactions p > 0.05). We found similar results for the pooled analysis of bisphosphonate trials. However, when we considered trials individually, we found a few interactions within individual studies between diabetes status and the effects of denosumab and odanacatib on fracture risk, change in BMD or bone turnover markers (BTMs). In sum, these results provide strong evidence that bisphosphonates and most licensed antiresorptive drugs are effective at reducing fracture risk and increasing BMD irrespective of diabetes status. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Hospitalized Patients With COVID-19 Have Higher Plasma Aldosterone-Renin Ratio and Lower ACE Activity Than Controls

Context

SARS-CoV-2 infects cells via the angiotensin converting enzyme 2 (ACE2) receptor, whose downstream effects "counterbalance" the classical renin angiotensin aldosterone system (RAAS).

Objective

We aimed to determine to what extent circulating RAAS biomarker levels differ in persons with and without COVID-19 throughout the disease course.

Methods

We measured classical (renin, aldosterone, aldosterone/renin ratio [ARR], Ang2, ACE activity) and nonclassical (ACE2, Ang1,7) RAAS biomarkers in hospitalized COVID-19 patients vs SARS-CoV-2 negative controls. We compared biomarker levels in cases with contemporaneous samples from control patients with upper respiratory symptoms and a negative SARS-CoV-2 PCR test. To assess RAAS biomarker changes during the course of COVID-19 hospitalization, we studied cases at 2 different times points ∼ 12 days apart. We employed age- and sex-adjusted generalized linear models and paired/unpaired t tests.

Results

Mean age was 51 years for both cases (31% women) and controls (50% women). ARR was higher in the first sample among hospitalized COVID-19 patients vs controls (P = 0.02). ACE activity was lower among cases at their first sample vs controls (P = <0.001). ACE2 activity, Ang 1,7, and Ang2 did not differ at the 2 COVID-19 case time points and they did not differ in COVID-19 cases vs controls. Additional adjustment for body mass index (BMI) did not change our findings.

Conclusions

High ARR, independent of BMI, may be a risk marker for COVID-19 hospitalization. Serum ACE activity was lower in patients with COVID-19 vs controls at the beginning of their hospitalization and then increased to similar levels as controls, possibly due to lung injury, which improved with inpatient disease management.

Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain

Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.

Effectiveness of Standard vs Enhanced Self-measurement of Blood Pressure Paired With a Connected Smartphone Application: A Randomized Clinical Trial

Importance

Self-measured blood pressure (SMBP) with commercially available connected smartphone applications may help patients effectively use SMBP measurements.

Objective

To determine if enhanced SMBP paired with a connected smartphone application was superior to standard SMBP for blood pressure (BP) reduction or patient satisfaction.

Design, Setting, and Participants

This randomized clinical trial was conducted among 23 health systems participating in PCORnet, the National Patient-Centered Clinical Research Network, and included patients who reported having uncontrolled BP at their last clinic visit, a desire to lower their BP, and a smartphone. Enrollment and randomization occurred from August 3, 2019, to December 31, 2020, which was followed by 6 months of follow-up for each patient. Analysis commenced shortly thereafter.

Interventions

Eligible participants were randomly assigned to enhanced SMBP using a device that paired with a connected smartphone application (enhanced) or a standard device (standard). Participants received their device in the mail, along with web-based educational materials and phone-based support as needed. No clinician engagement was undertaken, and the study provided no special mechanisms for delivering measurements to clinicians for use in BP management.

Main Outcomes and Measures

Reduction in systolic BP, defined as the difference between clinic BP at baseline and the most recent clinic BP extracted from electronic health records at 6 months.

Results

Enrolled participants (1051 enhanced [50.0%] vs 1050 standard [50.0%]; 1191 women [56.7%]) were mostly middle-aged or older (mean [SD] age, 58 [13] years), nearly a third were Black or Hispanic (645 [31%]), and most were relatively comfortable using technology (mean [SD], 4.1 [1.1] of 5). The mean (SD) change in systolic BP from baseline to 6 months was -10.8 (18) mm Hg vs -10.6 (18) mm Hg (enhanced vs standard: adjusted difference, -0.19 mm Hg; 95% CI, -1.83 to 1.44; P = .81). Secondary outcomes were mostly null, except for documented attainment of BP control to lower than 140/<90 mm Hg, which occurred in 32% enhanced vs 29% standard groups (odds ratio, 1.15; 95% CI, 1.01-1.34). Most participants were very likely to recommend their SMBP device to a friend (70% vs 69%).

Conclusions and Relevance

This randomized clinical trial found that enhanced SMBP paired with a smartphone application is not superior to standard SMBP for BP reduction or patient satisfaction.

Trial Registration

ClinicalTrials.gov Identifier: NCT03796689.

Physical activity from young adulthood to middle age and premature cardiovascular disease events: a 30-year population-based cohort study

Background

Although physical activity is generally protective of cardiovascular disease (CVD), less is known about how young adult physical activity relates to premature CVD events. The objective of this study was to determine the association between level and change in physical activity from young adulthood to middle age and incidence of premature CVD events before age 60.

Methods

We analyzed data collected across four urban sites from nine visits over 30 years of follow-up (1985–2016) from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective community-based cohort study of 5115 Black and White women and men aged 18–30 years at baseline (1985–1986). Linear mixed models were used to develop individualized moderate-to-vigorous intensity self-reported physical activity trajectories per participant. Fatal and nonfatal coronary heart disease (CHD), heart failure, and stroke outcomes were analyzed separately and as a combined CVD event outcome.

Results

Overall, physical activity declined in young adults as they progressed through middle age. Lower physical activity scores (per 100 exercise units) in 18 year-olds were associated with higher odds of premature CHD (AOR 1.14, 95% CI 1.02–1.28), heart failure (AOR 1.21, 95% CI 1.05–1.38), stroke (AOR 1.20, 95% CI 1.04–1.39), and any CVD (AOR 1.15, 95% CI 1.06–1.24) events. Each additional annual 1-unit reduction in the physical activity score was associated with a higher annual odds of incident heart failure (1.07, 95% CI 1.02–1.13), stroke (1.06, 95% CI 1.00–1.13), and CVD (1.04, 95% CI 1.01–1.07) events. Meeting the minimum (AOR 0.74, 95% CI 0.0.57–0.96) and twice the minimum (AOR 0.55, 95% CI 0.34–0.91) Department of Health and Human Services physical activity guidelines through follow up was protective of premature CVD events.

Conclusions

Given recent trends in declining physical activity with age and associated premature CVD events, the transition from young adult to midlife is an important time period to promote physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01357-2.

Racial/ethnic differences in fibrosis prevalence and progression in biopsy-proven steatosis: A focus on the Asian American population

Fatty liver disease (FLD) is a leading cause of chronic liver disease (CLD) globally, and vulnerable populations are disproportionately affected. Prior studies have suggested racial/ethnic differences in FLD prevalence and severity; however, these studies often excluded Asian Americans. This study aims to evaluate racial/ethnic differences in the prevalence of, and predictors associated with steatohepatitis, advanced fibrosis, and fibrosis progression over time within a diverse population. Using descriptive analyses and multivariable modeling, we performed a longitudinal evaluation of 648 patients with histologic evidence of FLD (steatosis or steatohepatitis) from August 2009 to February 2020 within San Francisco's safety-net health care system. Overall demographics were median age of 53 years, 54% male, and 38% Asian (40% Hispanic, 14% White). On histology, 61% had steatohepatitis and 30% had advanced fibrosis (≥F3). The comparison between steatosis and steatohepatitis groups showed differences in sex, race/ethnicity, metabolic risk factors, and co-existing CLD (predominantly viral hepatitis); patients with steatosis were more likely to be Asian (50%), and those with steatohepatitis were more likely to be Hispanic (51%). On multivariable modeling, while Asian race (vs. non-Asian) was not associated with steatohepatitis or advanced fibrosis when models included all relevant clinical predictors, Asian race was associated with higher relative risk of fibrosis progression as defined by change in Fibrosis-4 category over time (relative risk ratio = 1.9; p = 0.047). Conclusion: In this vulnerable population with a large proportion of Asian Americans, Asian race was associated with progression of fibrosis. Given the relative paucity of data in this high-risk group, future studies should confirm these findings.

Multiple substance use, inflammation and cardiac stretch in women living with HIV

BACKGROUND

Cardiovascular disease (CVD) and heart failure (HF) are disproportionately high in people living with HIV and differ by sex. Few CVD-related studies focus on drug use, yet it is common in low-income women living with HIV (WLWH) and increases cardiac dysfunction.

SETTING

We recruited unsheltered and unstably housed WLWH from San Francisco community venues to participate in a six-month cohort study investigating linkages between drug use, inflammation, and cardiac dysfunction.

METHODS

Adjusting for CVD risk factors, co-infections, medications, and menopause, we examined the effects of toxicology-confirmed drug use and inflammation (C-reactive protein, sCD14, sCD163 and sTNFR2) on levels of NT-proBNP, a biomarker of cardiac stretch and HF.

RESULTS

Among 74 WLWH, the median age was 53 years and 45 % were Black. At baseline, 72 % of participants had hypertension. Substances used included tobacco (65 %), cannabis (53 %), cocaine (49 %), methamphetamine (31 %), alcohol (28 %), and opioids (20 %). Factors significantly associated with NT-proBNP included cannabis use (Adjusted Relative Effect [ARE]: -39.6 %) and sTNFR2 (ARE: 65.5 %). Adjusting for heart failure and restricting analyses to virally suppressed persons did not diminish effects appreciably. Cannabis use was not significantly associated with sTNFR2 and did not change the association between sTNFR2 and NT-proBNP.

CONCLUSIONS

Among polysubstance-using WLWH, NT-proBNP levels signaling cardiac stretch were positively associated with sTNFR2, but 40 % lower in people who used cannabis. Whether results suggest that cardiovascular pathways associated with cannabis use mitigate cardiac stress and dysfunction independent of inflammation in WLWH who use multiple substances merits further investigation.

Moderate-to-vigorous intensity physical activity from young adulthood to middle age and metabolic disease: a 30-year population-based cohort study

OBJECTIVES

To determine the association between moderate-to-vigorous intensity physical activity (MVPA) trajectories (course over age and time) through the adult life course and onset of metabolic disease (diabetes and dyslipidaemia).

METHODS

We analysed prospective community-based cohort data of 5115 participants in the Coronary Artery Risk Development in Young Adults study, who were black and white men and women aged 18-30 years at baseline (1985-1986) at four urban sites, collected through 30 years of follow-up. Individualised MVPA trajectories were developed for each participant using linear mixed models.

RESULTS

Lower estimated MVPA score at age 18 was associated with a 12% (95% CI 6% to 18%) higher odds of incident diabetes, a 4% (95% CI 1% to 7%) higher odds of incident low high-density lipoprotein (HDL) and a 6% (95% CI 2% to 11%) higher odds of incident high triglycerides. Each additional annual 1-unit reduction in the MVPA score was associated with a 6% (95% CI 4% to 9%) higher annual odds of diabetes incidence and a 4% (95% CI 2% to 6%) higher annual odds of high triglyceride incidence. Analysing various MVPA trajectory groups, participants who were in the most active group at age 18 (over 300 min/week), but with sharp declines in midlife, had higher odds of high low-density lipoprotein and low HDL incidence, compared with those in the most active group at age 18 with subsequent gains.

CONCLUSION

Given recent trends in declining MVPA across the life course and associated metabolic disease risk, young adulthood is an important time period for interventions to increase and begin the maintenance of MVPA.