Faculty Bibliography

ABSTRACT/UNASSIGNED:Chronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the last two decades. Differences in prevalence of non-medical cannabis use and cannabis use disorder (CUD) were examined across two groups: veterans/non-veterans and those reporting/not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n=36,309) were analyzed using logistic regression. Prevalence Differences (PD) for three cannabis outcomes: (1) past-year non-medical cannabis use, (2) frequent (≥3 times a week) non-medical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate-severe pain (veterans/non-veterans), and veterans reporting/not reporting recent pain. Difference in differences were calculated to investigate prevalence differences on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. Results indicated that the prevalence of recent pain was greater among veterans (PD=7.25%, 95% CI [4.90, 9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD=1.92%, 98% CI [0.21, 3.63]), and, among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD=3.88%, 98% CI [0.36, 7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD.

Importance/UNASSIGNED:There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19. Objective/UNASSIGNED:To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen. Design, Setting, and Participants/UNASSIGNED:CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation. Interventions/UNASSIGNED:A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline). Main Outcomes and Measures/UNASSIGNED:The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8. Results/UNASSIGNED:Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06). Conclusions and Relevance/UNASSIGNED:In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use. Trial Registration/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04364737.

BACKGROUND:Pregnant adolescent girls and young women (AGYW, aged 12-24 years) are at high risk for mental health problems, particularly in the Sub-Saharan African (SSA) region. METHODS:We performed a systematic review of mental health studies among pregnant AGYW in SSA published between January 1, 2007 and December 31, 2020 in PubMed, Embase, CINAHL, PsycInfo, and Global Index Medicus following PRISMA guidelines (PROSPERO: CRD42021230980). We used Bronfenbrenner's bioecological model to frame and synthesize results from included studies. FINDINGS/RESULTS: = 3). Studies reported life course factors, individual, microsystem, exosystem, macrosystem, and chronosystem-level factors associated with mental health problems. Gaps in mental health service delivery for pregnant AGYW included lack of confidentiality, judgmental healthcare worker attitudes, and lack of services tailored to their unique needs. INTERPRETATION/CONCLUSIONS:Gaps remain in research and services for mental health among pregnant AGYW in SSA. Integration of mental health services within school, community, and healthcare settings that are tailored to pregnant AGYW could strengthen health systems within SSA. FUNDING/BACKGROUND:Author contributions were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (F31HD101149 to AL) and the Fogarty International Center (K43TW010716 to MK). The funding agencies had no role in the writing of the manuscript or the decision to submit it for publication. The project itself was not funded.

BACKGROUND:A contextual understanding of hypertension control can inform population health management strategies to mitigate cardiovascular disease events. This retrospective cohort study links neighborhood-level data with patients' health records to describe racial/ethnic differences in uncontrolled hypertension and determine if and to what extent these differences are mediated by neighborhood socioeconomic status (nSES). METHODS:We conducted a mediation analysis using a sample of patients with hypertension from 2 health care delivery systems in San Francisco over 2 years (n=47 031). We used generalized structural equation modeling, adjusted for age, sex, and health care system, to estimate the contribution of nSES to disparities in uncontrolled hypertension between White patients and Black, Hispanic/Latino, and Asian patients, respectively. Sensitivity analysis removed adjustment for health care system. RESULTS:Over half the cohort (62%) experienced uncontrolled hypertension during the study period. Racial/ethnic groups showed substantial differences in prevalence of uncontrolled hypertension and distribution of nSES quintiles. Compared with White patients, Black, and Hispanic/Latino patients had higher adjusted odds of uncontrolled hypertension: odds ratio, 1.79 [95% CI, 1.67-1.91] and odds ratio, 1.38 [95% CI, 1.29-1.47], respectively and nSES accounted for 7% of the disparity in both comparisons. Asian patients had slightly lower adjusted odds of uncontrolled hypertension when compared with White patients: odds ratio, 0.95 [95% CI, 0.89-0.99] and the mediating effect of nSES did not change the direction of the relationship. Sensitivity analysis increased the proportion mediated by nSES to 11% between Black and White patients and 13% between Hispanic/Latino and White patients, but did not influence differences between Asian and White patients. CONCLUSIONS:Among patients with hypertension in this study, nSES mediated a small proportion of racial/ethnic disparities in uncontrolled hypertension. Population health management strategies may be most effective by focusing on additional structural and interpersonal pathways such as racism and discrimination in health care settings.

OBJECTIVES/OBJECTIVE:In this study, we examined (1) whether a reading aloud intervention, Universidade do Bebê (UBB), had impacts on self-regulation; (2) whether effects on child outcomes were mediated by self-regulation; and (3) whether effects of UBB were explained through a sequential pathway of impact, including cognitive stimulation in the home, parent-child interactive reading, and self-regulation. METHODS:We performed a cluster randomized controlled trial of UBB in child care centers serving low-income children (mean age 37.4 months; SD = 6.5) in Northern Brazil. The child care centers were randomized to receive UBB or standard care (control). Families in UBB could borrow children's books weekly and participate in monthly workshops focused on reading aloud. Parent-child dyads (n = 484, intervention = 232, control = 252) were evaluated at baseline and 9 months later on: child self-regulation, vocabulary, intelligence quotient (IQ), working memory, and phonological memory and measures of cognitive stimulation in the home and parent-child interactive reading. Multilevel analyses accounted for baseline performance, sociodemographics, and clustering within centers and sites. RESULTS:The UBB group showed significantly higher self-regulation (Cohen's d = 0.25), compared with the control group, particularly in the subdomains of Attention (d = 0.24) and Impulse Control (d = 0.21). Previously shown impacts of UBB on receptive vocabulary, IQ, and working memory were mediated by self-regulation. Effects of UBB on self-regulation and child outcomes were partially explained through cognitive stimulation in the home and parent-child interactive reading. CONCLUSION/CONCLUSIONS:Self-regulation represents an important mechanism by which reading aloud interventions affect language and cognitive outcomes. Investigators should consider the role of self-regulation when refining interventions, seeking to prevent poverty-related disparities.

This is the first real-world study to examine the association between a voluntary 16-ounce (oz) portion-size cap on sugar-sweetened beverages (SSB) at a sporting arena on volume of SSBs and food calories purchased and consumed during basketball games. Cross-sectional survey data from adults exiting a Brooklyn, NY, USA arena (Barclays, n = 464) with a 16-oz portion-size restriction and a Manhattan, NY, USA arena with no portion-size restriction (Madison Square Garden, control, n = 295) after the portion cap policy was put in place from March through June 2014 were analyzed. Linear regression models adjusting for sex, age, BMI, ethnicity, race, marital status, education, and income were used to compare the two arenas during the post-implementation period. The survey response rate was 45.9% and equivalent between venues. Among all arena goers, participants at Barclays purchased significantly fewer SSB oz (-2.24 oz, 95% CI [-3.95, -0.53], p = .010) and consumed significantly fewer SSB oz (-2.34 oz, 95% CI[-4.01, -0.68], p = .006) compared with MSG after adjusting for covariates. Among those buying at least one SSB, Barclays' participants purchased on average 11.03 fewer SSB oz. (95% CI = [4.86, 17.21], p < .001) and consumed 12.10 fewer SSB oz (95% CI = [5.78, 18.42], p < .001). There were no statistically significant differences between arenas in food calories and event satisfaction. In addition, no one reported not ordering a drink due to small size. An SSB portion-size cap was associated with purchasing and consuming fewer SSB oz. without evidence of decreasing satisfaction with the event experience.

Uremic symptoms are common in patients with advanced chronic kidney disease, but the toxins that cause these symptoms are unknown. To evaluate this, we performed a cross-sectional study of the 12 month post-randomization follow-up visit of Modification of Diet in Renal Disease (MDRD) participants reporting uremic symptoms who also had available stored serum. We quantified 1,163 metabolites by liquid chromatography-tandem mass spectrometry. For each uremic symptom, we calculated a score as the severity multiplied by the number of days the symptom was experienced. We analyzed the associations of the individual symptom scores with metabolites using linear models with empirical Bayesian inference, adjusted for multiple comparisons. Among 695 participants, the mean measured glomerular filtration rate (mGFR) was 28 mL/min/1.73 m². Uremic symptoms were more common in the subgroup of 214 patients with an mGFR under 20 mL/min/1.73 m² (mGFR under 20 subgroup) than in the full group. For all metabolites with significant associations, the direction of the association was concordant in the full group and the subgroup. For gastrointestinal symptoms (bad taste, loss of appetite, nausea, and vomiting), eleven metabolites were associated with symptoms. For neurologic symptoms (decreased alertness, falling asleep during the day, forgetfulness, lack of pep and energy, and tiring easily/weakness), seven metabolites were associated with symptoms. Associations were consistent across sensitivity analyses. Thus, our proof-of-principle study demonstrates the potential for metabolomics to understand metabolic pathways associated with uremic symptoms. Larger, prospective studies with external validation are needed.

BACKGROUND:Public health measures to control the COVID-19 pandemic have led to feelings of loneliness among older adults, which, prior to COVID, has been associated with subsequent morbidity and mortality. We sought to identify differences in feelings of loneliness, sadness, and social disconnection early in the pandemic across racial groups, and possible mitigating factors. METHODS:We performed a cross-sectional analysis using the weighted nationally-representative Medicare Current Beneficiaries Survey COVID-19 supplement, collected summer 2020. We included all Medicare beneficiaries aged 65 years and older who did not respond by proxy. We examined changes in loneliness, sadness, or feelings of social disconnection. Multivariable logistic regression models accounted for sociodemographic variables, access to primary care and the internet, and history of depression or dementia. RESULTS:Among 8125 beneficiaries, representative of 43.7 million Medicare beneficiaries, 22.6% reported loneliness or sadness, and 37.1% feeling socially disconnected. In fully-adjusted models, Hispanic/Latinx beneficiaries were most likely to report loneliness or sadness (OR = 1.3, CI: 1.02-1.65; p = 0.02) and Black beneficiaries were least likely to report feeling socially disconnected (OR = 0.55; CI: 0.42-0.73; p < 0.001). Internet access was associated with increased odds of both (OR = 1.29, 95 CI: 1.07-1.56; p = 0.009; and OR = 1.42, 95 CI: 1.24-1.63; p < 0.001, respectively). Access to primary care was associated with lower odds of both (OR = 0.77, 95 CI: 0.61-0.96; p = 0.02; and OR = 0.72, 95 CI: 0.61-0.87; p < 0.001). CONCLUSIONS:Loneliness, sadness, and feelings of social disconnection were common among older Medicare beneficiaries early in the COVID-19 pandemic. Differences by race/ethnicity may be driven by different living structures and social networks, and warrant further study. Policy makers and clinicians should consider facilitating connection by phone or in person, as internet access did not diminish feelings of loneliness, particularly for those living alone. Access to primary care, and tools for clinicians to address loneliness should be prioritized.

BACKGROUND:Despite significant increase in COVID-19 publications, characterization of COVID-19 infection in patients with gynecologic cancer remains limited. Here we present an update of COVID-19 outcomes among people with gynecologic cancer in New York City (NYC) during the initial surge of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]). METHODS:Data were abstracted from gynecologic oncology patients with COVID-19 infection among 8 NYC area hospital systems between March and June 2020. Multivariable logistic regression was utilized to estimate associations between factors and COVID-19 related hospitalization and mortality. RESULTS:Of 193 patients with gynecologic cancer and COVID-19, the median age at diagnosis was 65.0 years (interquartile range (IQR), 53.0-73.0 years). One hundred six of the 193 patients (54.9%) required hospitalization; among the hospitalized patients, 13 (12.3%) required invasive mechanical ventilation, 39 (36.8%) required ICU admission. Half of the cohort (49.2%) had not received anti-cancer treatment prior to COVID-19 diagnosis. No patients requiring mechanical ventilation survived. Thirty-four of 193 (17.6%) patients died of COVID-19 complications. In multivariable analysis, hospitalization was associated with an age ≥ 65 years (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.11, 4.07), Black race (OR 2.53, CI 1.24, 5.32), performance status ≥2 (OR 3.67, CI 1.25, 13.55) and ≥ 3 comorbidities (OR 2.00, CI 1.05, 3.84). Only former or current history of smoking (OR 2.75, CI 1.21, 6.22) was associated with death due to COVID-19 in multivariable analysis. Administration of cytotoxic chemotherapy within 90 days of COVID-19 diagnosis was not predictive of COVID-19 hospitalization (OR 0.83, CI 0.41, 1.68) or mortality (OR 1.56, CI 0.67, 3.53). CONCLUSIONS:The case fatality rate among patients with gynecologic malignancy with COVID-19 infection was 17.6%. Cancer-directed therapy was not associated with an increased risk of mortality related to COVID-19 infection.