Faculty Bibliography

BACKGROUND:In individuals with chronic kidney disease (CKD), healthy dietary patterns are inversely associated with CKD progression. Metabolomics, an approach that measures many small molecules in biofluids, can identify biomarkers of healthy dietary patterns. OBJECTIVES/OBJECTIVE:We aimed to identify known metabolites associated with greater adherence to 4 healthy dietary patterns in CKD patients. METHODS:We examined associations between 486 known plasma metabolites and Healthy Eating Index (HEI)-2015, Alternative Healthy Eating Index (AHEI)-2010, the Dietary Approaches to Stop Hypertension (DASH) diet, and alternate Mediterranean diet (aMED) in 1056 participants (aged 21-74 y at baseline) in the Chronic Renal Insufficiency Cohort (CRIC) Study. Usual dietary intake was assessed using a semiquantitative FFQ. We conducted multivariable linear regression models to study associations between healthy dietary patterns and individual plasma metabolites, adjusting for sociodemographic characteristics, health behaviors, and clinical factors. We used principal component analysis to identify groups of metabolites associated with individual food components within healthy dietary patterns. RESULTS:After Bonferroni correction, we identified 266 statistically significant diet-metabolite associations (HEI: n = 60; AHEI: n = 78; DASH: n = 77; aMED: n = 51); 78 metabolites were associated with >1 dietary pattern. Lipids with a longer acyl chain length and double bonds (unsaturated) were positively associated with all 4 dietary patterns. A metabolite pattern low in saturated diacylglycerols and triacylglycerols, and a pattern high in unsaturated triacylglycerols was positively associated with intake of healthy food components. Plasmalogens were negatively associated with the consumption of nuts and legumes and healthy fat, and positively associated with the intake of red and processed meat. CONCLUSIONS:We identified many metabolites associated with healthy dietary patterns, indicative of food consumption. If replicated, these metabolites may be considered biomarkers of healthy dietary patterns in patients with CKD.

Importance:Black and Latinx communities have faced disproportionate harm from the COVID-19 pandemic. Increasing COVID-19 vaccine acceptance and access has the potential to mitigate mortality and morbidity from COVID-19 for all communities, including those most impacted by the pandemic. Objective:To investigate and understand factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities. Design, Setting, and Participants:This community-partnered qualitative study conducted semistructured, in-depth focus groups with Black and Latinx participants from March 17 to March 29, 2021, using a secure video conferencing platform. Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven, Connecticut, Health Department, and in-person distribution of study information from community health workers. A total of 8 focus groups were conducted, including 4 in Spanish and 4 in English, with 72 participants from a diverse range of community roles, including teachers, custodial service workers, and health care employees, in New Haven, Connecticut. Data were analyzed from March 17 to July 30, 2021. Main Outcomes and Measures:Interviews were audio-recorded, transcribed, translated, and analyzed using an inductive content analysis approach. Themes and subthemes were identified on the acceptability and accessibility of the COVID-19 vaccine among participants who identified as Black and/or Latinx. Results:Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx and 56 (78%) identified as women and 16 (22%) identified as men. Participants described 3 major themes that may represent facilitators and barriers to COVID-19 vaccinations: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Conclusions and Relevance:The findings of this qualitative study may impact what health care systems, public health officials, policy makers, health care practitioners, and community leaders can do to facilitate equitable uptake of the COVID-19 vaccine. Community-informed insights are imperative to facilitating COVID-19 vaccine access and acceptance among communities hardest hit by the pandemic. Preventing the further widening of inequities and addressing structural barriers to vaccination access are vital to protecting all communities, especially Black and Latinx individuals who have experienced disproportionate death and loss from COVID-19.

BACKGROUND:Individuals that have both diabetes and substance use disorder (SUD) are more likely to have adverse health outcomes and are less likely to receive high quality diabetes care, compared with patients without coexisting SUD. Care management programs for patients with chronic diseases, such as diabetes and SUD, have been associated with improvements in the process and outcomes of care. OBJECTIVE:The aim was to assess the impact of having coexisting SUD on diabetes process of care metrics. RESEARCH DESIGN/METHODS:Preintervention/postintervention triple difference analysis. SUBJECTS/METHODS:Participants in the New York State Medicaid Health Home (NYS-HH) care management program who have diabetes and a propensity-matched comparison group of nonparticipants (N=37,260). MEASURES/METHODS:Process of care metrics for patients with diabetes: an eye (retinal) exam, HbA1c test, medical attention (screening laboratory measurements) for nephropathy, and receiving all 3 in the past year. RESULTS:Before enrollment in NYS-HH, individuals with comorbid SUD had fewer claims for eye exams and HbA1c tests compared with those without comorbid SUD. Diabetes process of care improvements associated with NYS-HH enrollment were larger among those with comorbid SUD [eye exam: adjusted odds ratio (AOR)=1.08; 95% confidence interval (CI): 1.01-1.15]; HbA1c test: AOR=1.20 (95% CI: 1.11-1.29); medical attention for nephropathy: AOR=1.21 (95% CI: 1.12-1.31); all 3: AOR=1.09 (95% CI: 1.02-1.16). CONCLUSIONS:Individuals with both diabetes and SUD may benefit moderately more from care management than those without comorbid SUD. Individuals with both SUD and diabetes who are not enrolled in care management may be missing out on crucial diabetes care.

Importance/UNASSIGNED:Prescription opioids are involved in more than half of opioid overdoses among younger persons. Understanding opioid prescribing practices is essential for developing appropriate interventions for this population. Objective/UNASSIGNED:To examine temporal trends in opioid prescribing practices in children, adolescents, and younger adults in the US from 2006 to 2018. Design, Setting, and Participants/UNASSIGNED:A population-based, cross-sectional analysis of opioid prescription data was conducted from January 1, 2006, to December 31, 2018. Longitudinal data on retail pharmacy-dispensed opioids for patients younger than 25 years were used in the analysis. Data analysis was performed from December 26, 2019, to July 8, 2020. Main Outcomes and Measures/UNASSIGNED:Opioid dispensing rate, mean amount of opioid dispensed in morphine milligram equivalents (MME) per day (individuals aged 15-24 years) or MME per kilogram per day (age <15 years), duration of prescription (mean, short [≤3 days], and long [≥30 days] duration), high-dosage prescriptions, and extended-release or long-acting (ER/LA) formulation prescriptions. Outcomes were calculated for age groups: 0 to 5, 6 to 9, 10 to 14, 15 to 19, and 20 to 24 years. Joinpoint regression was used to examine opioid prescribing trends. Results/UNASSIGNED:From 2006 to 2018, the opioid dispensing rate for patients younger than 25 years decreased from 14.28 to 6.45, with an annual decrease of 15.15% (95% CI, -17.26% to -12.99%) from 2013 to 2018. The mean amount of opioids dispensed and rates of short-duration and high-dosage prescriptions decreased for all age groups older than 5 years, with the largest decreases in individuals aged 15 to 24 years. Mean duration per prescription increased initially for all ages, but then decreased for individuals aged 10 years or older. The duration remained longer than 5 days across all ages. The rate of long-duration prescriptions increased for all age groups younger than 15 years and initially increased, but then decreased after 2014 for individuals aged 15 to 24 years. For children aged 0 to 5 years dispensed an opioid, annual increases from 2011 to 2014 were noted for the mean amount of opioids dispensed (annual percent change [APC], 10.58%; 95% CI, 1.77% to 20.16%) and rates of long-duration (APC, 30.42%; 95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI, 16.81% to 47.53%), and ER/LA formulation (APC, 27.86%; 95% CI, 12.04% to 45.91%) prescriptions, although the mean amount dispensed and rate of high-dosage prescriptions decreased from 2014 to 2018. Conclusions and Relevance/UNASSIGNED:These findings suggest that opioid dispensing rates decreased for patients younger than 25 years, with decreasing rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, opioids remain readily dispensed, and possible high-risk prescribing practices appear to be common, especially in younger children.

California's Mental Health Services Act (MHSA) substantially expanded funding of county mental health services through a state tax, and led to broad prevention efforts and intensive services for individuals experiencing serious mental disorders. We estimated the associations between MHSA and mortality due to suicide, homicide, and acute effects of alcohol. Using annual cause-specific mortality data for each US state and the District of Columbia from 1976-2015, we used a generalization of the quasi-experimental synthetic control method to predict California's mortality rate for each outcome in the absence of MHSA using a weighted combination of comparison states. We calculated the association between MHSA and each outcome as the absolute difference and percentage difference between California's observed and predicted average annual rates over the postintervention years (2007-2015). MHSA was associated with modest decreases in average annual rates of homicide (-0.81/100,000 persons, corresponding to a 13% reduction) and mortality from acute alcohol effects (-0.35/100,000 persons, corresponding to a 12% reduction). Placebo test inference suggested that the associations were unlikely to be due to chance. MHSA was not associated with suicide. Protective associations with mortality due to homicide and acute alcohol effects provide evidence for modest health benefits of MHSA at the population level.

Importance/UNASSIGNED:Diabetes causes substantial morbidity and mortality among adults in the US, yet its incidence varies across the country, suggesting that neighborhood factors are associated with geographical disparities in diabetes. Objective/UNASSIGNED:To examine the association between neighborhood food environment and risk of incident type 2 diabetes across different community types (high-density urban, low-density urban, suburban, and rural). Design, Setting, and Participants/UNASSIGNED:This is a national cohort study of 4 100 650 US veterans without type 2 diabetes. Participants entered the cohort between 2008 and 2016 and were followed up through 2018. The median (IQR) duration of follow-up was 5.5 (2.6-9.8) person-years. Data were obtained from Veterans Affairs electronic health records. Incident type 2 diabetes was defined as 2 encounters with type 2 diabetes International Classification of Diseases, Ninth Revision or Tenth Revision codes, a prescription for diabetes medication other than metformin or acarbose alone, or 1 encounter with type 2 diabetes International Classification of Diseases Ninth Revision or Tenth Revision codes and 2 instances of elevated hemoglobin A1c (≥6.5%). Data analysis was performed from October 2020 to March 2021. Exposures/UNASSIGNED:Five-year mean counts of fast-food restaurants and supermarkets relative to other food outlets at baseline were used to generate neighborhood food environment measures. The association between food environment and time to incident diabetes was examined using piecewise exponential models with 2-year interval of person-time and county-level random effects stratifying by community types. Results/UNASSIGNED:The mean (SD) age of cohort participants was 59.4 (17.2) years. Most of the participants were non-Hispanic White (2 783 756 participants [76.3%]) and male (3 779 555 participants [92.2%]). The relative density of fast-food restaurants was positively associated with a modestly increased risk of type 2 diabetes in all community types. The adjusted hazard ratio (aHR) was 1.01 (95% CI, 1.00-1.02) in high-density urban communities, 1.01 (95% CI, 1.01-1.01) in low-density urban communities, 1.02 (95% CI, 1.01-1.03) in suburban communities, and 1.01 (95% CI, 1.01-1.02) in rural communities. The relative density of supermarkets was associated with lower type 2 diabetes risk only in suburban (aHR, 0.97; 95% CI, 0.96-0.99) and rural (aHR, 0.99; 95% CI, 0.98-0.99) communities. Conclusions and Relevance/UNASSIGNED:These findings suggest that neighborhood food environment measures are associated with type 2 diabetes among US veterans in multiple community types and that food environments are potential avenues for action to address the burden of diabetes. Tailored interventions targeting the availability of supermarkets may be associated with reduced diabetes risk, particularly in suburban and rural communities, whereas restrictions on fast-food restaurants may help in all community types.

OBJECTIVE:To characterize the general health status of infertile men in the United States using a nationally representative sample of men. METHODS:Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men. RESULTS:Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis. CONCLUSIONS:In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

OBJECTIVE:To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation. METHODS:Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload. RESULTS:QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives. CONCLUSION/CONCLUSIONS:QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

Chronic kidney disease (CKD) affects 15-20% of adults globally and causes various complications, one of the most important being cardiovascular disease (CVD). CKD has been associated with many CVD subtypes, especially severe ones like heart failure, independent of potential confounders such as diabetes and hypertension. There is no consensus in major clinical guidelines as to how to incorporate the two key measures of CKD (glomerular filtration rate and albuminuria) for CVD risk prediction. This is a critical missed opportunity to appropriately refine predicted risk and personalize prevention therapies according to CKD status, particularly since these measures are often already evaluated in clinical care. In this review, we provide an overview of CKD definition and staging, the subtypes of CVD most associated with CKD, major pathophysiological mechanisms, and the current state of CKD as a predictor of CVD in major clinical guidelines. We will introduce the novel concept of a "CKD Add-on", which allows the incorporation of CKD measures in existing risk prediction models, and the implications of taking into account CKD in the management of CVD risk.