Prospective transitions in hemoglobin A1c following gestational diabetes using Multistate Markov Models.

OBJECTIVE: We characterized the state-to-state transitions in postpartum A1c levels after gestational diabetes, including remaining in a state of normoglycemia or transitions between prediabetes or diabetes states of varying severity. METHODS: We used data from the APPLE Cohort, a postpartum population-based cohort of individuals with gestational diabetes between 2009-2011and linked HbA1c data with up to 9 years follow-up (N=34,171). We examined maternal sociodemographic and perinatal characteristics as predictors of transitions in A1c progression using Markov multistate models. RESULTS: In the first-year postpartum following gestational diabetes, 45.1% of people had no-diabetes, 43.1% had prediabetes, 4.6% had controlled diabetes and 7.2% had uncontrolled diabetes. Roughly two-thirds of individuals remained in same state in the next year. Black individuals were more likely to transition from pre-diabetes to uncontrolled diabetes (aHR: 2.32 95% CI: 1.21 ,4.47) than White persons. Perinatal risk factors were associated with disease progression and lower likelihood of improvement. For example, hypertensive disorders of pregnancy were associated with a stronger transition (aHR: 2.06 95% CI: 1.39, 3.05) from prediabetes to uncontrolled diabetes. CONCLUSIONS: We illustrate factors associated with adverse transitions in incremental A1c stages and describe patient profiles who may warrant enhanced postpartum monitoring.

Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study.

BACKGROUND: Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes. OBJECTIVE: To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings. PARTICIPANTS: Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data. MAIN MEASURES: Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome. KEY RESULTS: Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2. CONCLUSIONS: Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.

Predictors and Trends in First-Trimester Hemoglobin A1c Screening in New York City, 2009 to 2017.

Glycated hemoglobin is an adjunct tool in early pregnancy to assess glycemic control. We examined trends and maternal predictors for those who had A1c screening in early pregnancy using hospital discharge and vital registry data between 2009 and 2017 linked with the New York City A1C Registry (N = 798,312). First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017. The likelihood of screening became less targeted to high-risk patients over time, with a decrease in mean A1c values from 5.8% (95% confidence interval [CI]: 5.8, 5.9) to 5.3 (95% CI: 5.3, 5.4). The prevalence of gestational diabetes mellitus increased while testing became less discriminate for those with high-risk factors, including pregestational type 2 diabetes, chronic hypertension, obesity, age over 40 years, as well as Asian or Black non-Hispanic race/ethnicity. KEY POINTS: · First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017 in New York City.. · The likelihood of screening became less targeted to high-risk patients over time.. · The prevalence of gestational diabetes mellitus increased, while testing became less discriminate..

Trends and disparities in diabetes and prediabetes among adults in the United States, 1999-2018.

OBJECTIVE: The aims of the study were to describe the up-to-date trend of total, diagnosed, and undiagnosed diabetes and prediabetes, assess their associated disparities among population subgroups, and examine their relationship with sociodemographic factors among adults in the United States. STUDY DESIGN: This was a cross-sectional study from a nationally representative sample of US adults (aged ≥20 years) who participated in the National Health and Nutrition Examination Survey. METHODS: Diagnosed diabetes was defined as a self-reported previous diagnosis of diabetes by a physician or any other health professionals (other than during pregnancy). Undiagnosed diabetes was defined as elevated levels of fasting plasma glucose (≥126 mg/dL) or HbA1c (≥6.5%). Total diabetes included those who had either diagnosed or undiagnosed diabetes. Prediabetes was defined as an HbA1c level of 5.7%-6.4% or a fasting plasma glucose level of 100-125 mg/dL. All estimates were age standardized to the 2010 US census population for age groups 20-44, 45-64, and 65+ years. All analyses accounted for the complex survey design. Logistic regressions were used to conduct the analyses. RESULTS: A total of 21,600 (mean, 47.2 years [SD, 14.7]) individuals were analyzed. From 1999 to 2018, the age-standardized prevalence increased significantly from 9.17% to 14.7% (difference, 5.52%; 95% confidence interval [CI], 2.69%-8.35%; P-trend <0.001) for total diabetes, increased from 6.15% to 11.0% (difference, 4.79%; 95% CI, 2.27%-7.32%; P-trend<0.001) for diagnosed diabetes and remained stable from 3.01% to 3.73% (difference, 0.72%; 95% CI, -0.47% to 1.91%; P-trend = 0.19) for undiagnosed diabetes. The age-standardized prevalence of prediabetes increased significantly from 29.5% to 48.3% (difference, 18.8%; 95% CI, 13.3%-24.4%; P-trend<0.001). Disparities persisted with higher prevalence among adults with obesity and populations that have been marginalized, including racial and ethnic minorities, low income, less educated Americans, and those living in food-insecure household. CONCLUSIONS: The prevalence of diabetes and prediabetes increased significantly from 1999 to 2018 among US adults. There are substantial and persistent disparities among racial and ethnic minorities, populations experiencing socio-economic disadvantages, and adults with obesity.

CT Angiography Clot Burden Score from Data Mining of Structured Reports for Pulmonary Embolism.

Background Many studies emphasize the role of structured reports (SRs) because they are readily accessible for further automated analyses. However, using SR data obtained in clinical routine for research purposes is not yet well represented in literature. Purpose To compare the performance of the Qanadli scoring system with a clot burden score mined from structured pulmonary embolism (PE) reports from CT angiography. Materials and Methods In this retrospective study, a rule-based text mining pipeline was developed to extract descriptors of PE and right heart strain from SR of patients with suspected PE between March 2017 and February 2020. From standardized PE reporting, a pulmonary artery obstruction index (PAOI) clot burden score (PAOICBS) was derived and compared with the Qanadli score (PAOIQ). Scoring time and confidence from two independent readings were compared. Interobserver and interscore agreement was tested by using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. To assess conformity and diagnostic performance of both scores, areas under the receiver operating characteristic curve (AUCs) were calculated to predict right heart strain incidence, as were optimal cutoff values for maximum sensitivity and specificity. Results SR content authored by 67 residents and signed off by 32 consultants from 1248 patients (mean age, 63 years ± 17 [standard deviation]; 639 men) was extracted accurately and allowed for PAOICBS calculation in 304 of 357 (85.2%) PE-positive reports. The PAOICBS strongly correlated with the PAOIQ (r = 0.94; P < .001). Use of PAOICBS yielded overall time savings (1.3 minutes ± 0.5 vs 3.0 minutes ± 1.7), higher confidence levels (4.2 ± 0.6 vs 3.6 ± 1.0), and a higher ICC (ICC, 0.99 vs 0.95), respectively, compared with PAOIQ (each, P < .001). AUCs were similar for PAOICBS (AUC, 0.75; 95% CI: 0.70, 0.81) and PAOIQ (AUC, 0.77; 95% CI: 0.72, 0.83; P = .68), with cutoff values of 27.5% for both scores. Conclusion Data mining of structured reports enabled the development of a CT angiography scoring system that simplified the Qanadli score as a semiquantitative estimate of thrombus burden in patients with pulmonary embolism. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Hunsaker in this issue.

Substance Use Disorders and Diabetes Care: Lessons From New York Health Homes.

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: Preintervention/postintervention triple difference analysis. SUBJECTS: 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: 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.

"Not Alone Anymore": The Experiences of Adults With Diabetes in New York's Medicaid Health Home Program.

BACKGROUND: New York State Medicaid's Health Home program is an example of a natural experiment that could affect individuals with diabetes. While evaluations of interventions such as the Health Home program are generally based solely on clinical and administrative data and rarely examine patients' experience, patients may add to the understanding of the intervention's implementation and mechanisms of impact. OBJECTIVE: The objective of this study was to qualitatively examine the health and nonmedical challenges faced by Medicaid-insured patients with diabetes and their experiences with the services provided by New York's Health Homes to address these challenges. RESEARCH DESIGN: We performed 10 focus groups and 23 individual interviews using a guide developed in collaboration with a stakeholder board. We performed a thematic analysis to identify cross-cutting themes. SUBJECTS: A total of 63 Medicaid-insured individuals with diabetes, 31 of whom were enrolled in New York's Health Home program. RESULTS: While participants were not generally familiar with the term "Health Home," they described and appreciated services consistent with Health Home enrollment delivered by care managers. Services addressed challenges in access to care, especially by facilitating and reminding participants about appointments, and nonmedical needs, such as transportation, housing, and help at home. Participants valued their personal relationships with care managers and the psychosocial support they provided. CONCLUSIONS: From the perspective of its enrollees, the Health Home program primarily addressed access to care, but also addressed material and psychosocial needs. These findings have implications for Health Home entities and for research assessing their impact.

Network Engagement in Action: Stakeholder Engagement Activities to Enhance Patient-centeredness of Research.

BACKGROUND: Stakeholders (ie, patients, policymakers, clinicians, advocacy groups, health system leaders, payers, and others) offer critical input at various stages in the research continuum, and their contributions are increasingly recognized as an important component of effective translational research. Natural experiments, in particular, may benefit from stakeholder feedback in addressing real-world issues and providing insight into future policy decisions, though best practices for the engagement of stakeholders in observational studies are limited in the literature. METHODS: The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) network utilizes rigorous methods to evaluate natural experiments in health policy and program delivery with a focus on diabetes-related outcomes. Each of the 8 partnering institutions incorporates stakeholder engagement throughout multiple study phases to enhance the patient-centeredness of results. NEXT-D2 dedicates a committee to Engagement for resource sharing, enhancing engagement approaches, and advancing network-wide engagement activities. Key stakeholder engagement activities include Study Meetings, Proposal Development, Trainings & Educational Opportunities, Data Analysis, and Results Dissemination. Network-wide patient-centered resources and multimedia have also been developed through the broad expertise of each site's stakeholder group. CONCLUSIONS: This collaboration has created a continuous feedback loop wherein site-level engagement approaches are informed via the network and network-level engagement efforts are shaped by individual sites. Emerging best practices include: incorporating stakeholders in multiple ways throughout the research, building on previous relationships with stakeholders, enhancing capacity through stakeholder and investigator training, involving stakeholders in refining outcome choices and understanding the meaning of variables, and recognizing the power of stakeholders in maximizing dissemination.

Diabetes Risk and Control in Multi-ethnic US Immigrant Populations.

PURPOSE OF REVIEW: The goal of this review is to assess current evidence on diabetes risk and control among adult immigrants in the USA. RECENT FINDINGS: Patterns of diabetes risk in US immigrants may reflect global diabetes trends. Asian, Black, and Latinx immigrants all see a diabetes disadvantage relative to US-born Whites. Diabetes risk in Asian immigrants also surpasses US-born Asians. Relative diabetes risk among all groups increases with time in the USA. Research to explain patterns in diabetes risk and control among immigrants has broadened from lifestyle factors to include multi-level, life course influences on trajectories of risk. Some determinants are shared across groups, such as structural racism, healthcare access, and migration stress, whereas others such as diet are embedded in sending country culture. Current literature on diabetes in immigrant populations suggests a need to shift towards a transnational lens and macro-level social determinants of health framework to understand diabetes risk and potential prevention factors.

Associations of Residential Socioeconomic, Food, and Built Environments With Glycemic Control in Persons With Diabetes in New York City From 2007-2013.

In the present study, we examined the longitudinal associations between residential environmental factors and glycemic control in 182,756 adults with diabetes in New York City from 2007 to 2013. Glycemic control was defined as a hemoglobin A1c (HbA1c) level less than 7%. We constructed residential-level measures and performed principle component analysis to formulate a residential composite score. On the basis of this score, we divided residential areas into quintiles, with the lowest and highest quintiles reflecting the least and most advantaged residential environments, respectively. Several residential-level environmental characteristics, including more advantaged socioeconomic conditions, greater ratio of healthy food outlets to unhealthy food outlets, and residential walkability were associated with increased glycemic control. Individuals who lived continuously in the most advantaged residential areas took less time to achieve glycemic control compared with the individuals who lived continuously in the least advantaged residential areas (9.9 vs. 11.5 months). Moving from less advantaged residential areas to more advantaged residential areas was related to improved diabetes control (decrease in HbA1c = 0.40%, 95% confidence interval: 0.22, 0.55), whereas moving from more advantaged residential areas to less advantaged residential areas was related to worsening diabetes control (increase in HbA1c = 0.33%, 95% confidence interval: 0.24, 0.44). These results show that residential areas with greater resources to support healthy food and residential walkability are associated with improved glycemic control in persons with diabetes.

Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications.

PURPOSE OF REVIEW: Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS: NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.

Food insecurity, coping strategies and glucose control in low-income patients with diabetes.

OBJECTIVE: To examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes. DESIGN: Using a cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies. SETTING: An urban medical centre, between June and December 2013. SUBJECTS: Four hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes. RESULTS: Of respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80). CONCLUSIONS: While food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.

Perspectives of Urban Corner Store Owners and Managers on Community Health Problems and Solutions.

INTRODUCTION: Urban corner store interventions have been implemented to improve access to and promote purchase of healthy foods. However, the perspectives of store owners and managers, who deliver and shape these interventions in collaboration with nonprofit, government, and academic partners, have been largely overlooked. We sought to explore the views of store owners and managers on the role of their stores in the community and their beliefs about health problems and solutions in the community. METHODS: During 2013 and 2014, we conducted semistructured, in-depth interviews in Philadelphia, Pennsylvania, and Camden, New Jersey, with 23 corner store owners/managers who participated in the Healthy Corner Store Initiative spearheaded by The Food Trust, a nonprofit organization focused on food access in low-income communities. We oversampled high-performing store owners. RESULTS: Store owners/managers reported that their stores served multiple roles, including providing a convenient source of goods, acting as a community hub, supporting community members, working with neighborhood schools, and improving health. Owners/managers described many challenging aspects of running a small store, including obtaining high-quality produce at a good price and in small quantities. Store owners/managers believed that obesity, diabetes, high cholesterol, and poor diet are major problems in their communities. Some owners/managers engaged with customers to discuss healthy behaviors. CONCLUSION: Our findings suggest that store owners and managers are crucial partners for healthy eating interventions. Corner store owners/managers interact with community members daily, are aware of community health issues, and are community providers of access to food. Corner store initiatives can be used to implement innovative programs to further develop the untapped potential of store owners/managers.

Food insecurity, neighborhood food access, and food assistance in Philadelphia.

An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7% reported food insecurity; 79.4% of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6% reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95% CI 0.43-0.90, 0.33: 95% CI 0.23-0.47, and 0.28: 95% CI 0.20-0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95% CI 0.60-1.08, 0.58: 95% CI 0.43-0.78, and 0.43: 95% CI 0.31-0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95% CI 1.11-1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95% CI 0.77-1.78) and those receiving both SNAP and WIC (OR 0.84: 95% CI 0.61-1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability.

Incomplete sensorimotor paresis after upper abdominal surgery with TEA and spinal epidural lipomatosis: a case report.

INTRODUCTION: This case report documents a postoperative, incomplete sensorimotor paraparesis from thoracic vertebral body 6 (Th6) after combined anesthesia for upper abdominal surgery in a patient who had a thoracic localization of spinal epidural lipomatosis (SEL). CASE PRESENTATION: The patient was treated in our clinic with a thoracic epidural catheter (TEA) for perioperative analgesia during a partial duodenopancreatectomy. Paraparetic symptoms occurred 20 hours after surgery. Initial MRI did not show bleeding, infection or spinal cord damage and the neurosurgeon consultants recommended observation. The neurological examination and the third follow-up MRI on 15th postoperative day showed ventrolateral damage of the spinal cord at level Th6. It is possible that local anesthetic compressed the spinal cord in addition to the existing lipomatosis and the thoracic kyphosis. The paraparesis improved during follow-up paraplegiologic treatment. CONCLUSION: So far, only two uncomplicated lumbar epidural catheter anesthesias have been described in patients who had a lumbar SEL. Epidural catheter anesthesia is a safe and effective method of pain control. But it is important to carefully identify and stratify patients with risk factors during the premedication visit. In patients who had kyphosis and thoracic localization of SEL, TEA may only be used after a risk-benefit assessment.

Emotional and Financial Stressors in New York City During the COVID-19 Pandemic: A Consecutive Cross-Sectional Analysis.

Mental and financial hardship during the COVID-19 pandemic in New York City was severe, but how vulnerable groups have been disproportionately impacted is incompletely understood. In partnership with community stakeholders, we administered a web-based survey to a convenience sample of New York City residents (18 + years) from May 2020 to April 2021 to evaluate their financial and emotional stressors. We analyzed outcomes by race, ethnicity, and education level. A total of 1854 adults completed the survey across three consecutive non-overlapping samples. Fifty-five percent identified other than non-Latinx White. Sixty-four percent reported emotional stress; 38%, 32%, and 32% reported symptoms of anxiety, depression, and post-traumatic stress disorder respectively; and 21% reported a large adverse financial impact. The leading unmet needs were mental health and food services (both 19%), and health services (18%). Need for both resources grew over time. Adverse financial impact directly correlated with presence of all four adverse mental health outcomes above. In multivariate analysis, non-White race and lack of college degree were associated with adverse financial impact, whereas LGBT identity and lack of college degree were associated with mental health impact. Throughout the COVID-19 pandemic, participants in this research demonstrated a large and growing mental and financial strain, disproportionately associated with lower education level, non-White race, and LGBT status. Our findings suggest an urgent need to differentially target COVID-19 mental health and resource support in New York City to persons in these vulnerable communities.

Racial and Ethnic Inequities in Development of Type 2 Diabetes After Gestational Diabetes Mellitus.

OBJECTIVE: To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics as mediators. METHODS: We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index [BMI], chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born). RESULTS: The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals. CONCLUSION: Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.

Influence of Gestational Diabetes Mellitus on Diabetes Risk and Glycemic Control in a Retrospective Population-Based Cohort.

OBJECTIVE: Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women. RESEARCH DESIGN AND METHODS: Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity. RESULTS: The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control. CONCLUSIONS: Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities.

Child Disruptions, Remote Learning, and Parent Mental Health during the COVID-19 Pandemic.

New York City (NYC) was an epicenter of the COVID-19 pandemic, which resulted in broad economic, social, and emotional consequences in the lives of individuals. The current study examined associations between pandemic-related stressors and adverse mental health symptoms among NYC parents/caregivers. Community-based participatory research was used to develop a survey, and logistic regression models were utilized to assess associations between factors including disruptions in child routines and remote learning, and parent-reported symptoms of stress, anxiety, depression, and post-traumatic stress disorder (PTSD). Some 91.0% of parents reported stress and 41.2, 26.6, and 33.7% reported symptoms of anxiety, depression, and PTSD, respectively. Most parents (87.6%) reported cancellation of at least one child activity. Of the parents, 60.3% reported that their children participated in remote learning and the majority (70.3%) reported feeling overwhelmed by it. Having more cancelled child activities was associated with higher odds of reported mental health symptoms, with not being able to play outside associated with higher odds of anxiety (1.80 (1.26, 2.58), p = 0.001), depression (1.93 (1.29, 2.91), p = 0.002), PTSD (1.64 (1.13, 2.39), p = 0.009), and stress (2.34 (1.27, 4.44), p = 0.008). Feeling overwhelmed by remote learning was also associated with higher odds of all four outcomes. Pre-existing mental illness, lower resilience scores, and lower socioeconomic status emerged as additional factors associated with symptoms of mental illness. These findings highlight the importance of resources to minimize adverse psychological effects among vulnerable families.

Magnetic resonance imaging detects improvements of pulmonary and paranasal sinus abnormalities in response to elexacaftor/tezacaftor/ivacaftor therapy in adults with cystic fibrosis.

BACKGROUND: Therapy with Elexacaftor/Tezacaftor/Ivacaftor (ETI) was recently approved for adult cystic fibrosis (CF) patients with at least one F508del mutation. However, its effects on structural and functional lung abnormalities and chronic rhinosinusitis have not been studied by imaging. METHODS: 19 adults with CF (mean age 31±9y, range 19-55y) underwent standardized chest magnetic resonance imaging (MRI), and nine also same-session sinonasal MRI, before (MRI1) and after (MRI2) at least one month (mean duration 5 ± 3mon) on ETI. 24 control CF patients (30±7y, range 20-44y) without ETI underwent longitudinal chest MRI, and eleven also sinonasal MRI, twice (mean interval 40±15mon). MRI was assessed using the validated chest MRI score and chronic rhinosinusitis (CRS)-MRI score. Forced expiratory volume in 1 s percent predicted (FEV1%) was measured in all patients. RESULTS: In controls, the chest MRI global score and CRS-MRI sum score were stable from MRI1 to MRI2. In patients under ETI, the chest MRI global score improved (-11.4 ± 4.6, P<0.001), mainly due to reduction of bronchiectasis/wall thickening and mucus plugging subscores (-3.3 ± 2.2 and -5.2 ± 1.5, P<0.001, respectively). The improvement in chest MRI score correlated well with improved FEV1% (r=-0.703, P<0.001). The CRS-MRI sum score also improved in patients under ETI (-6.9 ± 3.0, P<0.001), mainly due to a reduction of mucopyoceles in the maxillary and ethmoid sinus (-50% and -39%, P<0.05, respectively). CONCLUSIONS: MRI detects improvements of chest MRI and CRS-MRI scores in adult CF patients who first received ETI, demonstrating reversibility of structural lung and paranasal sinus abnormalities in patients with established disease.