Publications by authors named "Eric Vittinghoff"

592 Publications

Increased Colorectal Cancer Screening Sustained with Mailed Fecal Immunochemical Test Outreach.

Clin Gastroenterol Hepatol 2021 Jul 16. Epub 2021 Jul 16.

Division of Gastroenterology, University of California San Francisco, San Francisco, CA, United States. Electronic address:

Background & Aims: Reports of mailed fecal immunochemical test (FIT) outreach effectiveness over time are minimal. We aimed to better evaluate a mailed FIT program with longitudinal metrics.

Methods: A total of 10,771 patients aged 50-75 years not up-to-date (UTD) with colorectal cancer (CRC) screening were randomized to intervention or usual care. The intervention arm received an advanced notification call and informational postcard prior to a mailed FIT. Usual care was at the discretion of the primary care provider. Patients were followed for up to 2.5 years. The primary outcome was the difference in cumulative proportion of completed FIT screening between arms. Screening was further examined with the proportion of time UTD, consistency of adherence, and frequency of abnormal FIT.

Results: The cumulative proportion of FIT completion was higher in the outreach intervention (73.2% vs. 55.1%, p<0.001). The proportion of time covered by screening was higher in the intervention group (46.8% vs. 27.3%, Δ19.6%, 95% CI 18.2%-20.9%). Patients assigned to FIT outreach were more likely to consistently complete FITs (2 completed of 2 offered) (50.1% vs. 21.8%, p<0.001). However, for patients who did not complete the FIT during the first cycle, only 17.1% completed a FIT during the second outreach cycle. The number and overall proportion of abnormal FIT was significantly higher in the outreach intervention (6.9% Outreach vs. 4.1% Usual Care, p<0.01).

Conclusions: Organized mailed FIT outreach significantly increased CRC screening over multiple years in this safety-net health system. While mailing was overall effective, the effect was modest in patients who did not complete FIT in first cycle of intervention. (ClincialTrials.gov, NCT02613260).
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http://dx.doi.org/10.1016/j.cgh.2021.07.022DOI Listing
July 2021

Coffee Consumption and Incident Tachyarrhythmias: Reported Behavior, Mendelian Randomization, and Their Interactions.

JAMA Intern Med 2021 Jul 19. Epub 2021 Jul 19.

Division of Cardiology, University of California, San Francisco, San Francisco.

Importance: The notion that caffeine increases the risk of cardiac arrhythmias is common. However, evidence that the consumption of caffeinated products increases the risk of arrhythmias remains poorly substantiated.

Objective: To assess the association between consumption of common caffeinated products and the risk of arrhythmias.

Design, Setting, And Participants: This prospective cohort study analyzed longitudinal data from the UK Biobank between January 1, 2006, and December 31, 2018. After exclusion criteria were applied, 386 258 individuals were available for analyses.

Exposures: Daily coffee intake and genetic polymorphisms that affect caffeine metabolism.

Main Outcomes And Measures: Any cardiac arrhythmia, including atrial fibrillation or flutter, supraventricular tachycardia, ventricular tachycardia, premature atrial complexes, and premature ventricular complexes.

Results: A total of 386 258 individuals (mean [SD] age, 56 [8] years; 52.3% female) were assessed. During a mean (SD) follow-up of 4.5 (3.1) years, 16 979 participants developed an incident arrhythmia. After adjustment for demographic characteristics, comorbid conditions, and lifestyle habits, each additional cup of habitual coffee consumed was associated with a 3% lower risk of incident arrhythmia (hazard ratio [HR], 0.97; 95% CI, 0.96-0.98; P < .001). In analyses of each arrhythmia alone, statistically significant associations exhibiting a similar magnitude were observed for atrial fibrillation and/or flutter (HR, 0.97; 95% CI, 0.96-0.98; P < .001) and supraventricular tachycardia (HR, 0.96; 95% CI, 0.94-0.99; P = .002). Two distinct interaction analyses, one using a caffeine metabolism-related polygenic score of 7 genetic polymorphisms and another restricted to CYP1A2 rs762551 alone, did not reveal any evidence of effect modification. A mendelian randomization study that used these same genetic variants revealed no significant association between underlying propensities to differing caffeine metabolism and the risk of incident arrhythmia.

Conclusions And Relevance: In this prospective cohort study, greater amounts of habitual coffee consumption were inversely associated with a lower risk of arrhythmia, with no evidence that genetically mediated caffeine metabolism affected that association. Mendelian randomization failed to provide evidence that caffeine consumption was associated with arrhythmias.
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http://dx.doi.org/10.1001/jamainternmed.2021.3616DOI Listing
July 2021

Cycling for Health.

JAMA Intern Med 2021 Jul 19. Epub 2021 Jul 19.

NYC Health + Hospitals, New York, New York.

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http://dx.doi.org/10.1001/jamainternmed.2021.3830DOI Listing
July 2021

Pilot study of extended-release lorcaserin for cocaine use disorder among men who have sex with men: A double-blind, placebo-controlled randomized trial.

PLoS One 2021 15;16(7):e0254724. Epub 2021 Jul 15.

Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, United States of America.

Objective: To determine if men who have sex with men (MSM) with cocaine use disorder (CUD) and actively-using cocaine could be enrolled and retained in a pharmacologic intervention trial of lorcaserin-a novel 5-HT2cR agonist-and determine the degree to which participants would adhere to study procedures.

Methods: This was a phase II randomized, double-blind, placebo-controlled pilot study with 2:1 random parallel group assignment to daily extended-release oral lorcaserin 20 mg versus placebo (clinicaltrials.gov identifier-NCT03192995). Twenty-two of a planned 45 cisgender MSM with CUD were enrolled and had weekly follow-up visits during a 12-week treatment period, with substance use counseling, urine specimen collection, and completion of audio-computer assisted self-interview (ACASI) behavioral risk assessments. Adherence was measured by medication event monitoring systems (MEMS) caps and self-report. This study was terminated early because of an FDA safety alert for lorcaserin's long-term use.

Results: Eighty-six percent completed the trial, with 82% of weekly study follow-up visits completed. Adherence was 55.3% (lorcaserin 51.6% vs. placebo 66.2%) by MEMS cap and 56.9% (56.5% vs. placebo 57.9%) by self-report and did not differ significantly by treatment assignment. Intention-to-treat analyses (ITT) did not show differences in cocaine positivity by urine screen between the lorcaserin and placebo groups by 12 week follow-up (incidence risk ratio [IRR]: 0.96; 95%CI = 0.24-3.82, P = 0.95). However, self-reported cocaine use in timeline follow-back declined more significantly in the lorcaserin group compared to placebo (IRR: 0.66; 95%CI = 0.49-0.88; P = 0.004).

Conclusion: We found that it is feasible, acceptable, and tolerable to conduct a placebo-controlled pharmacologic trial for MSM with CUD who are actively using cocaine. Lorcaserin was not associated with significant reductions in cocaine use by urine testing, but was associated with significant reductions in self-reported cocaine use. Future research may be needed to continue to explore the potential utility of 5-HT2cR agonists.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254724PLOS
July 2021

Follicle-stimulating hormone level and changes in bone mass and body composition in older women and men.

J Clin Endocrinol Metab 2021 Jul 2. Epub 2021 Jul 2.

Department of Medicine, University of California San Francisco, San Francisco, CA, USA.

Context: Follicle-stimulating hormone (FSH) may have independent actions on bone remodeling and body fat regulation. Cross-sectionally, we have shown that serum FSH is associated with bone mineral density (BMD) and body fat in older postmenopausal women, but it remains unknown whether FSH predicts bone and fat changes.

Objective: We examined whether baseline FSH level is associated with subsequent bone loss or body composition changes in older adults.

Setting, Design, Participants: We studied 162 women and 158 men (mean age 82 ±4 years) from the AGES-BMA cohort, a substudy of the AGES-Reykjavik Study of community-dwelling older adults. Skeletal health and body composition were characterized at baseline and 3 years later.

Main Outcomes: Annualized change in BMD and body composition by dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). Models were adjusted for serum estradiol and testosterone levels.

Results: There was no evidence for an association between baseline FSH level and change in BMD or body composition by DXA or QCT. For femoral neck areal BMD, adjusted mean difference (95% CI) per SD increase in FSH was 1.3 (-0.7, 3.3) mg/cm 2/year in women, and -0.2 (-2.6, 2.2) mg/cm 2/year in men. For visceral fat, adjusted mean difference (95% CI) per SD increase in FSH was 1.80 (-0.03, 3.62) cm 2/year in women, and -0.33 (-3.73, 3.06) cm 2/year in men.

Conclusions: Although cross-sectional studies and studies in perimenopausal women have demonstrated associations between FSH and BMD and body composition, in older adults, FSH level is not associated with bone mass or body composition changes.
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http://dx.doi.org/10.1210/clinem/dgab481DOI Listing
July 2021

Prevalence and Sociodemographic Correlates of Unmet Need for Mental Health Counseling Among Adults During the COVID-19 Pandemic.

Psychiatr Serv 2021 Jun 30:appips202100111. Epub 2021 Jun 30.

Department of Pediatrics (Nagata), Department of Medicine (Garcia, Weiser), and Department of Epidemiology and Biostatistics (Vittinghoff), University of California, San Francisco; Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto (Ganson); Public Health Sciences Program, Santa Clara University, Santa Clara, California (Bonin, Twadell, Langrock, Magid); Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston (Tsai); Harvard Medical School, Boston (Tsai); Department of Epidemiology and Population Health, Stanford University, Stanford, California (Magid).

Objective: This study aimed to determine the prevalence and correlates of unmet need for mental health counseling among U.S. adults during the COVID-19 pandemic.

Methods: Data from the December 9-21, 2020, cross-sectional Household Pulse Survey (N=69,944) were analyzed.

Results: Overall, 12.8% of adults reported an unmet need for mental health counseling in the past month, including 25.2% of adults with a positive screen for depression or anxiety. Among adults with a positive screen, risk factors associated with an unmet need for mental health counseling included female sex, younger age, income below the federal poverty line, higher education, and household job loss during the pandemic, while protective factors included Asian and Black race.

Conclusions: Over one-quarter of U.S. adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling during the pandemic. Policy makers should consider increasing funding for mental health services as part of pandemic relief legislation.
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http://dx.doi.org/10.1176/appi.ps.202100111DOI Listing
June 2021

Predictors of incident viral symptoms ascertained in the era of COVID-19.

PLoS One 2021 17;16(6):e0253120. Epub 2021 Jun 17.

Division of Cardiology, Department of Medicine, University of California, San Francisco, California, United States of America.

Background: In the absence of universal testing, effective therapies, or vaccines, identifying risk factors for viral infection, particularly readily modifiable exposures and behaviors, is required to identify effective strategies against viral infection and transmission.

Methods: We conducted a world-wide mobile application-based prospective cohort study available to English speaking adults with a smartphone. We collected self-reported characteristics, exposures, and behaviors, as well as smartphone-based geolocation data. Our main outcome was incident symptoms of viral infection, defined as fevers and chills plus one other symptom previously shown to occur with SARS-CoV-2 infection, determined by daily surveys.

Findings: Among 14, 335 participants residing in all 50 US states and 93 different countries followed for a median 21 days (IQR 10-26 days), 424 (3%) developed incident viral symptoms. In pooled multivariable logistic regression models, female biological sex (odds ratio [OR] 1.75, 95% CI 1.39-2.20, p<0.001), anemia (OR 1.45, 95% CI 1.16-1.81, p = 0.001), hypertension (OR 1.35, 95% CI 1.08-1.68, p = 0.007), cigarette smoking in the last 30 days (OR 1.86, 95% CI 1.35-2.55, p<0.001), any viral symptoms among household members 6-12 days prior (OR 2.06, 95% CI 1.67-2.55, p<0.001), and the maximum number of individuals the participant interacted with within 6 feet in the past 6-12 days (OR 1.15, 95% CI 1.06-1.25, p<0.001) were each associated with a higher risk of developing viral symptoms. Conversely, a higher subjective social status (OR 0.87, 95% CI 0.83-0.93, p<0.001), at least weekly exercise (OR 0.57, 95% CI 0.47-0.70, p<0.001), and sanitizing one's phone (OR 0.79, 95% CI 0.63-0.99, p = 0.037) were each associated with a lower risk of developing viral symptoms.

Interpretation: While several immutable characteristics were associated with the risk of developing viral symptoms, multiple immediately modifiable exposures and habits that influence risk were also observed, potentially identifying readily accessible strategies to mitigate risk in the COVID-19 era.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253120PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211176PMC
July 2021

Sudden Cardiac Death and Myocardial Fibrosis, Determined by Autopsy, in Persons with HIV.

N Engl J Med 2021 06;384(24):2306-2316

From the Section of Cardiac Electrophysiology, Cardiology Division, Department of Medicine (Z.H.T., J.E.O.), the Departments of Neurology (A.K.), Epidemiology and Biostatistics (E.V.), and Pathology (P.U., A.C.), the Division of Infectious Disease, Veterans Affairs Medical Center (J.K.W.), and the Division of Cardiology, Zuckerberg San Francisco General Hospital (P.Y.H.), University of California, San Francisco, and the Office of the Chief Medical Examiner, City and County of San Francisco (E.M.) - all in San Francisco.

Background: The incidence of sudden cardiac death and sudden death caused by arrhythmia, as determined by autopsy, in persons with human immunodeficiency virus (HIV) infection has not been clearly established.

Methods: Between February 1, 2011, and September 16, 2016, we prospectively identified all new deaths due to out-of-hospital cardiac arrest among persons 18 to 90 years of age, with or without known HIV infection, for comprehensive autopsy and toxicologic and histologic testing. We compared the rates of sudden cardiac death and sudden death caused by arrhythmia between groups.

Results: Of 109 deaths from out-of-hospital cardiac arrest among 610 unexpected deaths in HIV-positive persons, 48 met World Health Organization criteria for presumed sudden cardiac death; of those, fewer than half (22) had an arrhythmic cause. A total of 505 presumed sudden cardiac deaths occurred between February 1, 2011, and March 1, 2014, in persons without known HIV infection. Observed incidence rates of presumed sudden cardiac death were 53.3 deaths per 100,000 person-years among persons with known HIV infection and 23.7 deaths per 100,000 person-years among persons without known HIV infection (incidence rate ratio, 2.25; 95% confidence interval [CI], 1.37 to 3.70). Observed incidence rates of sudden death caused by arrhythmia were 25.0 and 13.3 deaths per 100,000 person-years, respectively (incidence rate ratio, 1.87; 95% CI, 0.93 to 3.78). Among all presumed sudden cardiac deaths, death due to occult drug overdose was more common in persons with known HIV infection than in persons without known HIV infection (34% vs. 13%). Persons who were HIV-positive had higher histologic levels of interstitial myocardial fibrosis than persons without known HIV infection.

Conclusions: In this postmortem study, the rates of presumed sudden cardiac death and myocardial fibrosis were higher among HIV-positive persons than among those without known HIV infection. One third of apparent sudden cardiac deaths in HIV-positive persons were due to occult drug overdose. (Supported by the National Heart, Lung, and Blood Institute.).
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http://dx.doi.org/10.1056/NEJMoa1914279DOI Listing
June 2021

HIV Testing and Counseling at U.S. Substance Use Treatment Facilities: A Missed Opportunity for Early Identification.

Psychiatr Serv 2021 Jun 15:appips202000524. Epub 2021 Jun 15.

Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences (Riano, Bazazi, Mangurian), School of Medicine (Borowsky, Arnold), Center for AIDS Prevention Studies (Arnold), and Department of Epidemiology and Biostatistics (Vittinghoff, Mangurian), University of California, San Francisco, San Francisco; New York State Psychiatric Institute, New York City (Olfson, Cournos); Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson), and Mailman School of Public Health (Cournos), Columbia University, New York City; Institute for Health, Health Care Policy and Aging Research (Walkup) and Center for Health Services Research (Crystal), Rutgers University, New Brunswick, New Jersey; Kaiser Family Foundation, HIV Policy, Washington, D.C. (Dawson).

Objective: The objective of this study was to determine the availability and national distribution of HIV testing and counseling at substance use treatment facilities in the United States.

Methods: Analyses of data from the 2018 National Survey of Substance Abuse Treatment Services assessed HIV testing and counseling availability in U.S. substance use treatment facilities (excluding those in U.S. territories). Facilities were subcategorized by availability of mental health services and medication for opioid use disorders and compared by using logistic models. Descriptive statistics were calculated to characterize the availability of HIV testing and counseling by state, state HIV incidence, and facility characteristics.

Results: Among U.S. substance use treatment facilities (N=14,691), 29% offered HIV testing, 53% offered HIV counseling, 23% offered both, and 41% offered neither. Across states, the proportions of facilities offering HIV testing ranged from 9.0% to 62.8%, and the proportion offering counseling ranged from 19.2% to 83.3%. In only three states was HIV testing offered by at least 50% of facilities. HIV testing was significantly more likely to be offered in facilities that offered medication for opioid use disorder (48.0% versus 16.0% in those not offering such medication) or mental health services (31.2% versus 24.1% in those not offering such services). Higher state-level HIV incidence was related to an increased proportion of facilities offering HIV testing.

Conclusions: Only three in 10 substance use treatment facilities offered HIV testing in 2018. This finding represents a missed opportunity for early identification of HIV among people receiving treatment for substance use disorders.
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http://dx.doi.org/10.1176/appi.ps.202000524DOI Listing
June 2021

Electrophysiologic and imaging evidence for an occult myopathic substrate in patients with idiopathic ventricular arrhythmias.

Int J Cardiol 2021 08 26;336:60-66. Epub 2021 May 26.

Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia. Electronic address:

Background: Idiopathic VA are traditionally considered benign, although occasional patients develop an ectopy-mediated cardiomyopathy (EMC). It is unclear whether patients with idiopathic VA in the absence of left ventricular (LV) dysfunction harbor a subclinical cardiomyopathy. We aim to assess for cardiomyopathic substrate in patients with idiopathic ventricular arrhythmias (VA) using imaging and electrophysiologic markers of early fibrosis.

Methods: Cardiac magnetic resonance (CMR) imaging and ventricular electroanatomic mapping was performed in 3 groups: patients undergoing ablation for idiopathic VA without (Group 1, n = 17) and with LV dysfunction (Group 2 [presumed EMC], n = 12) plus a control group undergoing ablation of supraventricular tachycardia (Group 3, n = 16). Global LV strain, T1 mapping and extended electrogram (EGM) characteristics were compared.

Results: Global strain was impaired in patients with presumed EMC (Group 2, p < 0.001). Native T1 times did not differ between groups, however patients in both idiopathic VA groups (Groups 1 and 2) had shorter post-contrast T1 times at 8 min compared to SVT controls (Group 3, p = 0.04). Similarly, the duration of the bipolar EGM was subtly prolonged in both Group 1 and 2 compared to Group 3 (p = 0.002). There were no between group differences in unipolar or bipolar voltage, the no. of bipolar EGM deflections or the maximal unipolar EGM dV/dt.

Conclusion: Patients with idiopathic VAs and apparently structurally normal hearts may have subtle CMR and electrophysiologic changes similar in magnitude to that seen in frank presumed EMC, possibly suggestive of an occult cardiomyopathic process.
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http://dx.doi.org/10.1016/j.ijcard.2021.05.041DOI Listing
August 2021

Factors Predisposing to Survival After Resuscitation for Sudden Cardiac Arrest.

J Am Coll Cardiol 2021 May;77(19):2353-2362

Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA. Electronic address:

Background: In the POST SCD study, the authors autopsied all World Health Organization (WHO)-defined sudden cardiac deaths (SCDs) and found that only 56% had an arrhythmic cause; resuscitated sudden cardiac arrests (SCAs) were excluded because they did not die suddenly. They hypothesized that causes underlying resuscitated SCAs would be similarly heterogeneous.

Objectives: The aim of this study was to determine the causes and outcomes of resuscitated SCAs.

Methods: The authors identified all out-of-hospital cardiac arrests (OHCAs) from February 1, 2011, to January 1, 2015, of patients aged 18 to 90 years in San Francisco County. Resuscitated SCAs were OHCAs surviving to hospitalization and meeting WHO criteria for suddenness. Underlying cause was determined by comprehensive record review.

Results: The authors identified 734 OHCAs over 48 months; 239 met SCA criteria, 133 (55.6%) were resuscitated to hospitalization, and 47 (19.7%) survived to discharge. Arrhythmic causes accounted for significantly more resuscitated SCAs overall (92 of 133, 69.1%), particularly among survivors (43 of 47, 91.5%), than WHO-defined SCDs in POST SCD (293 of 525, 55.8%; p < 0.004 for both). Among resuscitated SCAs, arrhythmic cause, ventricular tachycardia/fibrillation initial rhythm, and white race were independent predictors of survival. None of the resuscitated SCAs due to neurologic causes survived.

Conclusions: In this 4-year countywide study of OHCAs, only one-third were sudden, of which one-half were resuscitated to hospitalization and 1 in 5 survived to discharge. Arrhythmic cause predicted survival and nearly one-half of nonsurvivors had nonarrhythmic causes, suggesting that SCA survivors are not equivalent to SCDs. Early identification of nonarrhythmic SCAs, such as neurologic emergencies, may be a target to improve OHCA survival.
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http://dx.doi.org/10.1016/j.jacc.2021.03.299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167892PMC
May 2021

Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse.

Am J Obstet Gynecol 2021 May 10. Epub 2021 May 10.

Department of Obstetrics, Gynecology, and Reproductive Science, University of California, San Francisco, CA.

Background: There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery.

Objective: This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity.

Study Design: This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity.

Results: A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02).

Conclusion: There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.
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http://dx.doi.org/10.1016/j.ajog.2021.05.002DOI Listing
May 2021

Body mass index in early adulthood and dementia in late life: Findings from a pooled cohort.

Alzheimers Dement 2021 May 13. Epub 2021 May 13.

Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.

Introduction: To examine the independent association of body mass index (BMI) in early adulthood with dementia incidence among men and women.

Methods: We studied 5104 older adults from the Cardiovascular Health Study (CHS) and the Health, Aging, and Body Composition (Health ABC) study. We imputed early adulthood and midlife BMI using a pooled parent cohort with complete adult lifespan coverage and previously established methods. Dementia was ascertained using criteria such as neuropsychological test battery, medical records, and dementia-related drug use. Pooled logistic regression (PLR) models were used.

Results: Compared to women with normal BMI in early adulthood, the odds of dementia were higher among both overweight (odds ratio [OR] = 1.8; 95% confidence interval [CI] = 1.31 to 2.54) and obese (OR = 2.45; 95% CI = 1.47 to 4.06) women, independent of mid- and late-life BMI. Similar relationship was observed in men.

Conclusions: With the growing obesity epidemic among US adults, efforts aimed at reducing dementia may need to begin obesity prevention and treatment early in the life course.
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http://dx.doi.org/10.1002/alz.12367DOI Listing
May 2021

Factors Associated With Access to and Timing of Coronavirus Testing Among US Adults After Onset of Febrile Illness.

JAMA Netw Open 2021 05 3;4(5):e218500. Epub 2021 May 3.

Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco.

Importance: Active SARS-CoV-2 (coronavirus) transmission continues in the US. It is unclear whether better access to coronavirus testing and more consistent use of testing could substantially reduce transmission.

Objective: To describe coronavirus testing in persons with new onset of febrile illness and analyze whether there are changes over time and differences by race and ethnicity.

Design, Setting, And Participants: This cohort study used data from the COVID-19 Citizen Science Study, launched in March 2020, which recruited participants via press release, word-of-mouth, and partner organizations. Participants completed daily surveys about COVID-19 symptoms and weekly surveys about coronavirus testing. All adults (aged at least 18 years) with a smartphone were eligible to join. For this analysis, US participants with new onset of febrile illness from April 2020 to October 2020 were included. Data analysis was performed from November 2020 to March 2021.

Main Outcomes And Measures: Receipt of a coronavirus test result within 7 days of febrile illness onset.

Results: Of the 2679 participants included in this analysis, the mean (SD) age was 46.3 (13.4) years, 1983 were female (74%), 2017 were college educated (75%), and a total of 3865 distinct new febrile illness episodes were reported (300 episodes [7.8%] from Hispanic participants, 71 episodes [1.8%] from Black participants, and 3494 episodes [90.4%] from not Black, not Hispanic participants) between April 2 and October 23, 2020. In weekly surveys delivered during the 14 days after fever onset, 12% overall (753 participants) indicated receipt of a test result. Using serial survey responses and parametric time-to-event modeling, it was estimated that by 7 days after onset of febrile illness, a total of 20.5% (95% CI, 19.1%-22.0%) had received a test result. This proportion increased from 9.8% (95% CI, 7.5%-12.0%) early in the epidemic to 24.1% (95% CI, 21.5%-26.7%) at the end of July, but testing rates did not substantially improve since then, increasing to 25.9% (95% CI; 21.6%-30.3%) in late October at the start of the winter surge. Black participants reported receiving a test result about half as often as others (7% [7 of 103] of survey responses vs 12% [53 of 461] for Hispanic vs 13% [693 of 5516] for not Black, not Hispanic; P = .03). This association was not statistically significant in adjusted time-to-event models (hazard ratio = 0.59 vs not Black, not Hispanic participants; 95% CI, 0.26-1.34).

Conclusions And Relevance: Systematic underuse of coronavirus testing was observed in this cohort study through late October 2020, at the beginning of the winter COVID-19 surge, which may have contributed to preventable coronavirus transmission.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.8500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094007PMC
May 2021

Weight Goals, Disordered Eating Behaviors, and BMI Trajectories in US Young Adults.

J Gen Intern Med 2021 Apr 19. Epub 2021 Apr 19.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.

Background: Community sample data indicate that weight control efforts in young adulthood may have associations with greater increases in body mass index (BMI) over time.

Objective: To determine the prospective associations between weight goals and behaviors in young adults and BMI trajectories over 15-year follow-up using a nationally representative sample.

Design: Longitudinal cohort data collected from 2001 to 2018 of the National Longitudinal Study of Adolescent to Adult Health.

Participants: Young adults aged 18-26 years old at baseline stratified by gender and BMI category.

Main Measures: Predictors: weight goals, any weight loss/maintenance behaviors, dieting, exercise, disordered eating behaviors.

Outcomes: BMI at 7- and 15-year follow-up.

Key Results: Of the 12,155 young adults in the sample (54% female, 32% non-White), 33.2% reported a goal to lose weight, 15.7% to gain weight, and 14.6% to maintain weight. In unadjusted models, all groups have higher mean BMI at 7- and 15-year follow-up. In mixed effect models, goals to lose weight in men with BMI < 18.5 (5.94 kg/m; 95% CI 2.58, 9.30) and goals to maintain weight in men with BMI ≥ 25 (0.44; 95% CI 0.15, 0.72) were associated with greater BMI increase compared to no weight goal. Engaging in disordered eating behaviors was associated with greater BMI increase in men with BMI < 18.5 (5.91; 2.96, 8.86) and women with 18.5 ≤ BMI < 25 (0.40; 0.16, 0.63). Dieting (- 0.24; - 0.41, - 0.06) and exercise (- 0.31; - 0.45, - 0.17) were associated with lower BMI increase in women with 18.5 ≤ BMI < 25. In women with BMI < 18.5, dieting was associated with greater BMI increase (1.35; 0.33, 2.37).

Conclusions: Weight control efforts may have variable effects on BMI over time by gender and BMI category. These findings underscore the need to counsel patients on the effectiveness of weight control efforts and long-term weight management.
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http://dx.doi.org/10.1007/s11606-021-06702-yDOI Listing
April 2021

Physical Activity and Hypertension From Young Adulthood to Middle Age.

Am J Prev Med 2021 06 15;60(6):757-765. Epub 2021 Apr 15.

Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California.

Introduction: The optimum physical activity dose to achieve during young adulthood to prevent hypertension using the 2017 American College of Cardiology/American Heart Association guidelines remains undefined. This study aims to determine the association between level and change in physical activity through the adult life course and the onset of hypertension using these 2017 definitions.

Methods: In 2020, prospective community-based cohort data of 5,115 Coronary Artery Risk Development in Young Adults study participants were analyzed. The cohort included Black and White men and women aged 18-30 years at baseline (1985-1986) at 4 urban sites, collected through 30 years of follow-up (2015-2016). Individualized physical activity trajectories were developed for each participant using linear mixed models.

Results: Black women reported the lowest physical activity levels from young adulthood through middle age. Lower physical activity score (per 100 units) at age 18 years was associated with 4% (95% CI=1%, 7%, p=0.002) higher odds of hypertension incidence. Each additional 1-unit reduction per year in physical activity score was associated with 2% (95% CI=1%, 3%, p=0.001) higher annual odds of hypertension incidence. Meeting approximately the current minimum physical activity guideline levels at age 18 years and through follow-up was not protective of hypertension incidence; however, meeting approximately twice the current minimum physical activity guideline level at age 18 years and through follow-up was protective of hypertension incidence.

Conclusions: Moderate physical activity levels may need to exceed current minimum guidelines to prevent hypertension onset using 2017 American College of Cardiology/American Heart Association definitions.
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http://dx.doi.org/10.1016/j.amepre.2020.12.018DOI Listing
June 2021

Validation of an algorithm for continuous monitoring of atrial fibrillation using a consumer smartwatch.

Heart Rhythm 2021 Apr 8. Epub 2021 Apr 8.

Division of Cardiology, University of California San Francisco, San Francisco, California. Electronic address:

Background: Consumer devices with broad reach may be useful in screening for atrial fibrillation (AF) in appropriate populations. However, currently no consumer devices are capable of continuous monitoring for AF.

Objective: The purpose of this study was to estimate the sensitivity and specificity of a smartwatch algorithm for continuous detection of AF from sinus rhythm in a free-living setting.

Methods: We studied a commercially available smartwatch with photoplethysmography (W-PPG) and electrocardiogram (W-ECG) capabilities. We validated a novel W-PPG algorithm combined with a W-ECG algorithm in a free-living setting, and compared the results to those of a 28-day continuous ECG patch (P-ECG).

Results: A total of 204 participants completed the free-living study, recording 81,944 hours with both P-ECG and smartwatch measurements. We found sensitivity of 87.8% (95% confidence interval [CI] 83.6%-91.0%) and specificity of 97.4% (95% CI 97.1%-97.7%) for the W-PPG algorithm (every 5-minute classification); sensitivity of 98.9% (95% CI 98.1%-99.4%) and specificity of 99.3% (95% CI 99.1%-99.5%) for the W-ECG algorithm; and sensitivity of 96.9% (95% CI 93.7%-98.5%) and specificity of 99.3% (95% CI 98.4%-99.7%) for W-PPG triggered W-ECG with a single W-ECG required for confirmation of AF. We found a very strong correlation of W-PPG in quantifying AF burden compared to P-ECG (r = 0.98).

Conclusion: Our findings demonstrate that a novel algorithm using a commercially available smartwatch can continuously detect AF with excellent performance and that confirmation with W-ECG further enhances specificity. In addition, our W-PPG algorithm can estimate AF burden. Further research is needed to determine whether this algorithm is useful in screening for AF in select at-risk patients.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.044DOI Listing
April 2021

Factors associated with phosphatidylethanol (PEth) sensitivity for detecting unhealthy alcohol use: An individual patient data meta-analysis.

Alcohol Clin Exp Res 2021 06 7;45(6):1166-1187. Epub 2021 May 7.

West Haven VA Healthcare System, United States Department of Veterans Affairs, West Haven, CT, USA.

Background: Objective measurement of alcohol consumption is important for clinical care and research. Adjusting for self-reported alcohol use, we conducted an individual participant data (IPD) meta-analysis to examine factors associated with the sensitivity of phosphatidylethanol (PEth), an alcohol metabolite, among persons self-reporting unhealthy alcohol consumption.

Methods: We identified 21 eligible studies and obtained 4073 observations from 3085 participants with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive scores (≥3 for women and ≥4 for men) and PEth measurements. We conducted 1-step IPD meta-analysis using mixed effects models with random intercepts for study site. We examined the associations between demographic (sex, race/ethnicity, and age) and biologic (body mass index-BMI, hemoglobin, HIV status, liver fibrosis, and venous versus finger-prick blood collection) variables with PEth sensitivity (PEth≥8 ng/ml), adjusting for the level of self-reported alcohol use using the AUDIT-C score.

Results: One third (31%) of participants were women, 32% were African, 28% African American, 28% White, and 12% other race/ethnicity. PEth sensitivity (i.e., ≥8 ng/ml) was 81.8%. After adjusting for AUDIT-C, we found no associations of sex, age, race/ethnicity, or method of blood collection with PEth sensitivity. In models that additionally included biologic variables, those with higher hemoglobin and indeterminate and advanced liver fibrosis had significantly higher odds of PEth sensitivity; those with higher BMI and those living with HIV had significantly lower odds of PEth sensitivity. African Americans and Africans had higher odds of PEth sensitivity than whites in models that included biologic variables.

Conclusions: Among people reporting unhealthy alcohol use, several biological factors (hemoglobin, BMI, liver fibrosis, and HIV status) were associated with PEth sensitivity. Race/ethnicity was associated with PEth sensitivity in some models but age, sex, and method of blood collection were not. Clinicians should be aware of these factors, and researchers should consider adjusting analyses for these characteristics where possible.
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http://dx.doi.org/10.1111/acer.14611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254773PMC
June 2021

Sex and Racial Differences in Autopsy-Defined Causes of Presumed Sudden Cardiac Death.

Circ Arrhythm Electrophysiol 2021 May 9;14(5):e009393. Epub 2021 Apr 9.

Office of the Chief Medical Examiner, San Francisco, CA (E.M.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCEP.120.009393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137672PMC
May 2021

Preventive Care Delivery After the Veterans Choice Program.

Am J Prev Med 2021 07 2;61(1):55-63. Epub 2021 Apr 2.

Department of Medicine, University of California San Francisco, San Francisco, California; San Francisco VA Health Care System, San Francisco, California.

Introduction: The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program.

Methods: The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011-October 2014 and November 2015-December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre-post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019.

Results: Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre-post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits.

Conclusions: Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.
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http://dx.doi.org/10.1016/j.amepre.2021.01.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217145PMC
July 2021

Characteristics and Behaviors Associated with Prevalent SARS-CoV-2 Infection.

Int J Gen Med 2021 25;14:1063-1067. Epub 2021 Mar 25.

Division of Cardiology, University of California, San Francisco, San Francisco, CA, USA.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (Covid-19), has been a serious threat to global health. Previous work has focused primarily on hospitalized patients or on identifying risk factors for disease severity and mortality once the infection has taken place. We sought to leverage the ubiquity of smartphones and mobile applications to study risk factors for Covid-19 infection in a large, geographically heterogenous cohort.

Methods: We analyzed data obtained from the Covid-19 Citizen Science (CCS) Study, a worldwide, mobile application-based cohort. After employing forward selection to identify variables with p values < 0.1, multivariable logistic regression models were utilized to identify independent risk factors associated with prevalent SARS-CoV-2 infection.

Results: Among 36,041 participants in 113 countries and all 50 states in the US, 484 participants had prevalent SARS-CoV-2 infection. After multivariable adjustment, being a healthcare worker, living with at least one school-aged child, having pets at home, and having immunodeficiency were each associated with an increased odds of SARS-CoV-2. The association between pets and prevalent SARS-CoV-2 was driven by dog ownership. After adjustment for the same covariates, Asian or Pacific Islander race, receiving a flu shot within the past year, increased level of education, and smoking or vaping marijuana within the last 30 days were each associated with a lower odds of SARS-CoV-2.

Conclusion: We identified various characteristics and behaviors, many of which are potentially modifiable, associated with prevalent SARS-CoV-2 infection in a world-wide mobile application-based cohort.
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http://dx.doi.org/10.2147/IJGM.S305990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006955PMC
March 2021

Body Weight Changes During Pandemic-Related Shelter-in-Place in a Longitudinal Cohort Study.

JAMA Netw Open 2021 03 1;4(3):e212536. Epub 2021 Mar 1.

Division of Cardiology, Department of Medicine, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.2536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985720PMC
March 2021

Cardiovascular Risk Factors Across the Life Course and Cognitive Decline: A Pooled Cohort Study.

Neurology 2021 04 17;96(17):e2212-e2219. Epub 2021 Mar 17.

From the Departments of Psychiatry and Neurology (K.Y.) and Epidemiology & Biostatistics (K.Y., E.V.), University of California San Francisco; San Francisco Veterans Affairs Medical Center (K.Y.); Northern California Institute Research for Research and Education (T.H.), San Francisco; Department of Psychiatry (K.M.), University of Pittsburgh, PA; Department of Medicine (S.H.G.), Johns Hopkins University School of Medicine; Department of Epidemiology (S.H.G.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Epidemiology (A.Z.A.H.), Mailman School of Public Health, Columbia University, New York, NY.

Objective: Cardiovascular risk factors (CVRFs) are associated with increased risk of cognitive decline, but little is known about how early adult CVRFs and those across the life course might influence late-life cognition. To test the hypothesis that CVRFs across the adult life course are associated with late-life cognitive changes, we pooled data from 4 prospective cohorts (n = 15,001, ages 18-95).

Methods: We imputed trajectories of body mass index (BMI), fasting glucose (FG), systolic blood pressure (SBP), and total cholesterol (TC) for older adults. We used linear mixed models to determine the association of early adult, midlife, and late-life CVRFs with late-life decline on global cognition (Modified Mini-Mental State Examination [3MS]) and processing speed (Digit Symbol Substitution Test [DSST]), adjusting for demographics, education, and cohort.

Results: Elevated BMI, FG, and SBP (but not TC) at each time period were associated with greater late-life decline. Early life CVRFs were associated with the greatest change, an approximate doubling of mean 10-year decline (an additional 3-4 points for 3MS or DSST). Late-life CVRFs were associated with declines in early late life (<80 years) but with gains in very late life (≥80 years). After adjusting for CVRF exposures at all time periods, the associations for early adult and late-life CVRFs persisted.

Conclusions: We found that imputed CVRFs across the life course, especially in early adulthood, were associated with greater late-life cognitive decline. Our results suggest that CVRF treatment in early adulthood could benefit late-life cognition, but that treatment in very late life may not be as helpful for these outcomes.
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http://dx.doi.org/10.1212/WNL.0000000000011747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166431PMC
April 2021

Effect of preload reducing therapy on right ventricular size and function in patients with arrhythmogenic right ventricular cardiomyopathy.

Heart Rhythm 2021 Jul 17;18(7):1186-1191. Epub 2021 Mar 17.

Department of Cardiology, University of California San Francisco, San Francisco, California.

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an important cause of sudden cardiac death in young people and athletes. To date, no treatment has proven to slow the progression of the disease. Preload reducing agents such as nitrates and diuretics have shown promising results in preventing training-induced development of ARVC in a murine model.

Objective: The purpose of this study was to describe our experience with preload reducing therapy in patients with ARVC and symptomatic right ventricular (RV) dysfunction.

Methods: We performed retrospective chart review of prospectively collected registry data and included 20 patients with definite ARVC who had serial echocardiographic measurements and an implantable cardioverter-defibrillator. Six of the 20 patients with RV end-diastolic area (RVEDA) above median (>25 cm) and New York Heart Association functional class II-IV symptoms were successfully treated with long-term isosorbide dinitrate 5-40 mg tid (at maximum tolerated dose) and hydrochlorothiazide-spironolactone 25-25 mg daily. The main outcomes of interest were RVEDA, RV fractional area change (FAC), and RV outflow tract measurements. Generalized estimating equations with repeated measures were used to identify the association between preload reducing agents and echocardiographic structural progression.

Results: Patients who received preload reducing agents (n = 6) were older and had larger RVs with lower FAC at baseline. However, treatment with preload reducing agents was associated with less RVEDA enlargement during mean 3.3 (range 1-6.7) years of treatment in multivariate analysis (% change in RVEDA associated with treatment -7.71; 95% confidence interval -13.29 to -2.13; P = .007).

Conclusion: Preload reducing agents show promising results in slowing RV enlargement in patients with ARVC and show possible disease-modifying potential.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.018DOI Listing
July 2021

Differences in objectively measured daily physical activity patterns related to depressive symptoms in community dwelling women - mPED trial.

Prev Med Rep 2021 Jun 4;22:101325. Epub 2021 Feb 4.

Department of Physiological Nursing, School of Nursing, University of California, San Francisco, United States.

Physical activity (PA) is an effective depression treatment. However, knowledge on how variation in day-to-day PA relates to depression in women is lacking. The purposes of this study were to 1) compare overall objectively measured baseline daily steps and duration of moderate to vigorous PA (MVPA) and 2) examine differences in steps and MVPA on days of the week between women aged 25-65 years, who were physically inactive, with high and low depressive symptoms, enrolled in a run-in period of the obile phone based hysical activity ucation (mPED) trial. The Center for Epidemiological Studies Depression Scale was used to categorize low/high depressive symptom groups. We used linear mixed-effects models to examine the associations between steps and MVPA and depression-status overall and by day of the week, adjusting for selected demographic variables and their interactions with day of the week. 274 women were included in the final analysis, of which 58 had high depressive symptoms. Overall physical activity levels did not differ. However, day of the week modified the associations of depression with MVPA (p = 0.015) and daily steps (p = 0.08). Women with high depression were characterized by reduced activity at the end of the week (Posthoc: Friday: 791 fewer steps, 95% CI: 73-1509, p = 0.03; 8.8 lower MVPA, 95% CI: 2.16-15.5, p = 0.0098) compared to women with low depression, who showed increased activity. Day of the week might be an important target for personalization of physical activity interventions. Future work should evaluate potential causes of daily activity alterations in depression in women.
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http://dx.doi.org/10.1016/j.pmedr.2021.101325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890210PMC
June 2021

Incident Strokes Among American Indian Individuals With Atrial Fibrillation.

J Am Heart Assoc 2021 Mar 2;10(6):e019581. Epub 2021 Mar 2.

The Section of Cardiac Electrophysiology Division of Cardiology University of California San Francisco CA.

BACKGROUND American Indian individuals experience a relatively high risk for cardiovascular disease and have exhibited a higher risk of stroke compared with other racial and ethnic minorities. Although this population has the highest incidence of atrial fibrillation (AF) compared with other groups, the relationship between AF and nonhemorrhagic stroke among American Indian individuals compared with other groups has not been thoroughly studied. METHODS and RESULTS We used the Healthcare Cost and Utilization Project to evaluate risk of nonhemorrhagic stroke among American Indian individuals, with comparisons to White, Black, Hispanic, and Asian individuals, among all adult California residents receiving care in an emergency department, inpatient hospital unit, or ambulatory surgery setting from 2005 to 2011. Of 16 951 579 patients followed for a median 4.1 years, 105 822 (0.6%) were American Indian. After adjusting for age, sex, income level, insurance payer, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cardiac surgery, valvular heart disease, chronic kidney disease, smoking, obstructive sleep apnea, pulmonary disease, and alcohol use, American Indian individuals with AF exhibited the highest risk of nonhemorrhagic stroke when compared with either non-American Indian individuals with AF (hazard ratio, 1.38; 95% CI, 1.23-1.55; <0.0001) or to each race and ethnicity with AF. American Indian individuals also experienced the highest overall risk for stroke, with no evidence that AF disproportionately heightened that risk in interaction analyses. CONCLUSIONS American Indian individuals experienced the highest risk of nonhemorrhagic stroke, whether in the presence or absence of AF. Our findings likely suggest an opportunity to further study, if not immediately address, guideline-adherent anticoagulation prescribing patterns among American Indian individuals with AF.
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http://dx.doi.org/10.1161/JAHA.120.019581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174189PMC
March 2021

Antemortem and Post-Mortem Characteristics of Lethal Mitral Valve Prolapse Among All Countywide Sudden Deaths.

JACC Clin Electrophysiol 2021 Feb 19. Epub 2021 Feb 19.

Department of Medicine (Cardiovascular Division), University of California-San Francisco, San Francisco, California, USA.

Objectives: The goal of this study was to investigate the characteristics of mitral valve prolapse (MVP) in a post-mortem study of consecutive sudden cardiac deaths (SCDs) in subjects up to 90 years of age.

Background: Up to 2.3% of subjects with MVPs experience SCD, but by convention SCD is rarely confirmed by autopsy. In a post-mortem study of persons <40 years of age, 7% of SCDs were caused by MVP; bileaflet involvement, mitral annular disjunction (MAD), and replacement fibrosis were common.

Methods: In the San Francisco POST SCD (Postmortem Systematic Investigation of Sudden Cardiac Death) study, autopsies have been performed on >1000 consecutive World Health Organization-defined (presumed) cases of SCD in subjects aged 18 to 90 years since 2011; a total of 603 were adjudicated. Autopsy-defined sudden arrhythmic death (SAD) required absence of nonarrhythmic cause; MVP diagnosis required leaflet billowing. One hundred antemortem echocardiograms were revised to identify additional MVPs missed on autopsy.

Results: Among the 603 presumed SCDs, 339 (56%) were autopsy-defined SADs, with MVP identified in 7 (1%). Six additional MVPs were identified by review of echocardiograms, for a prevalence of at least 2% among 603 presumed SCDs and 4% among 339 SADs (vs. 264 non-SADs; p = 0.02). All 6 additional MVPs had monoleaflet rather than bileaflet involvement and mild mitral regurgitation, ruling out hemodynamic cause. Less than one-half had MAD with replacement fibrosis, but all had multisite interstitial fibrosis.

Conclusions: In a countywide post-mortem study of all adult cases of SCD, MVP prevalence was at least 4% of SADs, but one-half were missed on autopsy. Monoleaflet MVP was often underdiagnosed post-mortem. Compared with young cases of SCD, lethal MVP in older cases of SCD did not consistently have bileaflet anatomy, replacement fibrosis, or MAD.
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http://dx.doi.org/10.1016/j.jacep.2021.01.007DOI Listing
February 2021

Caution Against Overinterpreting Time-Restricted Eating Results-Reply.

JAMA Intern Med 2021 Jun;181(6):878

University of California-San Francisco Cardiology Division, San Francisco.

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http://dx.doi.org/10.1001/jamainternmed.2020.8928DOI Listing
June 2021

Heart Failure, Atrioventricular Block, and Ventricular Tachycardia in Sarcoidosis.

J Am Heart Assoc 2021 Feb 18;10(5):e017692. Epub 2021 Feb 18.

Division of Cardiology, Electrophysiology Section University of California, San Francisco CA.

Background Sarcoidosis is a granulomatous disease usually affecting the lungs, although cardiac morbidity may be common. The risk of these outcomes and the characteristics that predict them remain largely unknown. This study investigates the epidemiology of heart failure, atrioventricular block, and ventricular tachycardia among patients with and without sarcoidosis. Methods and Results We identified California residents aged ≥21 years using the Office of Statewide Health Planning and Development ambulatory surgery, emergency, or inpatient databases from 2005 to 2015. The risk of sarcoidosis on incident heart failure, atrioventricular block, and ventricular tachycardia were each determined. Linkage to the Social Security Death Index was used to ascertain overall mortality. Among 22 527 964 California residents, 19 762 patients with sarcoidosis (0.09%) were identified. Sarcoidosis was the strongest predictor of heart failure (hazard ratio [HR], 11.2; 95% CI, 10.7-11.7), atrioventricular block (HR, 117.7; 95% CI, 103.3-134.0), and ventricular tachycardia (HR, 26.1; 95% CI, 24.2-28.1) identified among all risk factors. The presence of any cardiac involvement best predicted each outcome. Approximately 22% (95% CI, 18%-26%) of the relationship between sarcoidosis and increased mortality was explained by the presence of at least 1 of these cardiovascular outcomes. Conclusions The magnitude of risk associated with sarcoidosis as a predictor of heart failure, atrioventricular block, and ventricular tachycardia, exceeds all established risk factors. Surveillance for and anticipation of these outcomes among patients with sarcoidosis is indicated, and consideration of a sarcoidosis diagnosis may be prudent among patients with heart failure, atrioventricular block, or ventricular tachycardia.
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http://dx.doi.org/10.1161/JAHA.120.017692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174291PMC
February 2021

A Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Alcohol to Assess Changes in Atrial Electrophysiology.

JACC Clin Electrophysiol 2021 05 27;7(5):662-670. Epub 2021 Jan 27.

Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.

Objectives: This study sought to identify acute changes in human atrial electrophysiology during alcohol exposure.

Background: The mechanism by which a discrete episode of atrial fibrillation (AF) occurs remains unknown. Alcohol appears to increase the risk for AF, providing an opportunity to study electrophysiologic effects that may render the heart prone to arrhythmia.

Methods: In this randomized, double-blinded, placebo-controlled trial, intravenous alcohol titrated to 0.08% blood alcohol concentration was compared with a volume and osmolarity-matched, masked, placebo in patients undergoing AF ablation procedures. Right, left, and pulmonary vein atrial effective refractory periods (AERPs) and conduction times were measured pre- and post-infusion. Isoproterenol infusions and burst atrial pacing were used to assess AF inducibility.

Results: Of 100 participants (50 in each group), placebo recipients were more likely to be diabetic (22% vs. 4%; p = 0.007) and to have undergone a prior AF ablation (36% vs. 22%; p = 0.005). Pulmonary vein AERPs decreased an average of 12 ms (95% confidence interval: 1 to 22 ms; p = 0.026) in the alcohol group, with no change in the placebo group (p = 0.98). Whereas no statistically significant differences in continuously assessed AERPs were observed, the proportion of AERP sites tested that decreased with alcohol (median: 0.5; interquartile range: 0.6 to 0.6) was larger than with placebo (median: 0.4; interquartile range: 0.2 to 0.6; p = 0.0043). No statistically significant differences in conduction times or in the proportion with inducible AF were observed.

Conclusions: Acute exposure to alcohol reduces AERP, particularly in the pulmonary veins. These data demonstrate a direct mechanistic link between alcohol, a common lifestyle exposure, and immediate proarrhythmic effects in human atria. (How Alcohol Induces Atrial Tachyarrhythmias Study [HOLIDAY]; NCT01996943).
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May 2021
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