Cardiac Autonomic Neuropathy in Type 1 and 2 Diabetes: Epidemiology, Pathophysiology, and Management.

PURPOSE: Cardiac autonomic neuropathy (CAN) is a serious complication of type 1 and type 2 diabetes and is independently associated with major cardiovascular events, morbidity, and mortality. This narrative review examines the epidemiology, pathophysiology, and management and identifies areas of future research to address the challenge posed by CAN. METHODS: We conducted a comprehensive literature search using a range of sources, including the electronic databases PubMed Central, Google Scholar, OVID, and Open Athens, to search for studies on CAN, diabetes mellitus, lifestyle intervention, and cardiovascular risk. We set inclusion criteria to consider review articles or original research published in peer-reviewed journals that examined CAN in diabetes. FINDINGS: Epidemiologic data indicate a varied prevalence of CAN in type 1 and 2 diabetes, with prevalences of 17% to 73%) depending on clinical and demographic factors. Indeed, duration of diabetes and hyperglycemia are the strongest risk factors for CAN development in type 1 diabetes. However, in type 2 diabetes, multifactorial risk factors, including obesity, hypertension, and hyperlipidemia, are associated with the development of CAN. Insulin resistance, which underpins type 2 diabetes and metabolic syndrome, has a direct role in the pathogenesis of CAN. Lifestyle interventions, including dietary measures and tailored exercise programs, have been beneficial in improving cardiac autonomic function primarily measured through heart rate variability. In addition, weight loss through bariatric surgery also improves heart rate variability and may prevent or reduce CAN progression in people living with obesity and concomitant type 2 diabetes. For optimization in type 2 diabetes, both lifestyle and targeted pharmacologic interventions are required to achieve glycemic/metabolic targets, and weight loss is required to prevent or reverse early CAN or prevent the progression to definite and severe CAN. IMPLICATIONS: The focused use of diagnostic testing for CAN, including cardiac autonomic reflex testing in those at high risk of CAN, will enable earlier diagnosis. This testing will allow timely interventions at a reversible stage. Future research should examine targeted early diagnostic testing with subsequent intervention with a combination of lifestyle measures and newer pharmacotherapeutics (eg, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists), which have produced significant cardiovascular benefit in diabetes.

Racism in child welfare: Ethical considerations of harm.

Racism has resulted in significant disproportionality and disparity in the US child welfare system. Being Black is not an inherent risk factor for child abuse and neglect yet Black children are almost twice as likely to be victims of substantiated abuse and neglect claims compared to other racial groups. Addressing the disproportionality within the child welfare system due to systemic racism falls squarely under the purview of bioethics. In this paper, we briefly review the impact of racism on child welfare. We then discuss some ethical considerations that mandatory healthcare reporters should think through when determining whether to report potential abuse and neglect. Specifically, we discuss the need for a broader consideration of what constitutes harm. We then present a hypothetical composite case to illuminate where and how bias can enter the process of referral to child protective services (CPS). We encourage thoughtful reporting with consideration of social and historical context and alternative explanations for worrisome findings. We recommend using evidence, avoiding assumptions by seeking clarification from families and ensuring internal consistency. When contemplating CPS referral, medical providers should feel empowered to ask questions if there is concern for potential bias. The ultimate goal is to protect children from harm. If there are clear safety concerns-they must be addressed. However, in the many cases where the safety concern is less tangible, we need to expand our considerations of the harms that can befall children, especially children of color.

Food Insecurity in the Food Allergic Population: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee.

Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.

Engaging School and Family in Navajo Gardening for Health: Development of the Yéego Intervention to Promote Healthy Eating among Navajo Children.

OBJECTIVE: Navajo children are at increased risk for obesity, in part due to limited access to healthy foods. School garden interventions have been shown to increase access to fresh fruit and vegetables and consumption of healthy foods. Our study describes the development and pilot testing of a school garden intervention for Navajo elementary school children. METHODS: We reviewed existing school garden interventions and conducted formative research with students, caregivers, and school staff to inform the intervention. The intervention consisted of a garden built at the school and a yearlong curriculum on gardening and healthy eating. We pilot tested the intervention in an elementary school on the Navajo Nation. RESULTS: Formative research revealed the importance of incorporating Diné culture, including traditional growing practices and the preparation of traditional foods into the curriculum. School staff also stressed the value of tying the curriculum to state and Diné educational standards. Students enjoyed opportunities for hands-on activities and snack preparation. CONCLUSIONS: Schools have a meaningful role to play in addressing childhood obesity disparities among Navajo children. School-based interventions that draw on cultural strengths and include healthy traditional practices can be a promising strategy for increasing fruit and vegetable consumption.

Evidence-Based Assessment of Genes in Dilated Cardiomyopathy.

BACKGROUND: Each of the cardiomyopathies, classically categorized as hypertrophic cardiomyopathy, dilated cardiomyopathy (DCM), and arrhythmogenic right ventricular cardiomyopathy, has a signature genetic theme. Hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy are largely understood as genetic diseases of sarcomere or desmosome proteins, respectively. In contrast, >250 genes spanning >10 gene ontologies have been implicated in DCM, representing a complex and diverse genetic architecture. To clarify this, a systematic curation of evidence to establish the relationship of genes with DCM was conducted. METHODS: An international panel with clinical and scientific expertise in DCM genetics evaluated evidence supporting monogenic relationships of genes with idiopathic DCM. The panel used the Clinical Genome Resource semiquantitative gene-disease clinical validity classification framework with modifications for DCM genetics to classify genes into categories on the basis of the strength of currently available evidence. Representation of DCM genes on clinically available genetic testing panels was evaluated. RESULTS: Fifty-one genes with human genetic evidence were curated. Twelve genes (23%) from 8 gene ontologies were classified as having definitive (BAG3, DES, FLNC, LMNA, MYH7, PLN, RBM20, SCN5A, TNNC1, TNNT2, TTN) or strong (DSP) evidence. Seven genes (14%; ACTC1, ACTN2, JPH2, NEXN, TNNI3, TPM1, VCL) including 2 additional ontologies were classified as moderate evidence; these genes are likely to emerge as strong or definitive with additional evidence. Of these 19 genes, 6 were similarly classified for hypertrophic cardiomyopathy and 3 for arrhythmogenic right ventricular cardiomyopathy. Of the remaining 32 genes (63%), 25 (49%) had limited evidence, 4 (8%) were disputed, 2 (4%) had no disease relationship, and 1 (2%) was supported by animal model data only. Of the 16 evaluated clinical genetic testing panels, most definitive genes were included, but panels also included numerous genes with minimal human evidence. CONCLUSIONS: In the curation of 51 genes, 19 had high evidence (12 definitive/strong, 7 moderate). It is notable that these 19 genes explain only a minority of cases, leaving the remainder of DCM genetic architecture incompletely addressed. Clinical genetic testing panels include most high-evidence genes; however, genes lacking robust evidence are also commonly included. We recommend that high-evidence DCM genes be used for clinical practice and that caution be exercised in the interpretation of variants in variable-evidence DCM genes.

Effects of a trauma-informed curriculum on depression, self-efficacy, economic security, and substance use among TANF participants: Evidence from the Building Health and Wealth Network Phase II.

RATIONALE: Integrating trauma-informed peer support curriculum into the Temporary Assistance for Needy Families (TANF) program can help address caregiver trauma symptoms (e.g., depression, low self-efficacy, economic hardship) caused by exposures to violence and adversity that negatively impact one's ability to maintain employment and improve earnings; yet, it is unclear if trauma-informed peer support interventions designed for TANF impact co-occurring disorders, such as depression and substance use, that inhibit resiliency in the labor market. OBJECTIVE: The aim of this study is to examine whether integrating trauma-informed peer support curriculum into the TANF program is associated with reductions in co-occurring depression and substance use, and improvements in self-efficacy and economic security. METHOD: From October 2015 to May 2018, 369 caregivers were enrolled in the 16-week Building Wealth and Health Network Phase II single-group cohort study. Participants responded to questions regarding their socio-demographic characteristics, mental health, economic security, and use of drugs and alcohol at baseline and four three-month follow-up surveys. Associations between the trauma-informed peer support curriculum and health outcomes were assessed using maximum likelihood estimation. RESULTS: Using class attendance records, participants were separated into a low-exposure group (

Multilevel Barriers to Engagement in the HIV Care Continuum Among Residents of the State of Rhode Island Living with HIV.

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression-all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18-29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18-29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum.

State Legislators' Opinions About Adverse Childhood Experiences as Risk Factors for Adult Behavioral Health Conditions.

OBJECTIVES: Adverse childhood experiences (ACEs) increase risk of adult behavioral health conditions. State legislators are an important audience to target with evidence about ACEs because they make policy decisions that can prevent ACE exposure and enhance resilience. This study sought to describe state legislators' opinions about ACEs as risk factors for adult behavioral health conditions and identify how opinions vary between legislators with different characteristics. METHODS: A multimodal survey was conducted in 2017 (response rate, 16.4%; N=475). Dependent variables were the extent to which legislators thought that four ACEs-sexual abuse, physical abuse, witnessing domestic violence, and childhood neglect-increase risk of adult behavioral health conditions. Independent variables were legislator characteristics (e.g., ideology and gender). Rao-Scott chi-square tests and multivariable logistic regression were conducted. RESULTS: Childhood sexual abuse was identified as a major risk factor by the largest proportion of respondents (77%), followed by childhood physical abuse (59%), witnessing domestic violence (39%), and childhood neglect (38%). The proportion identifying each ACE as a major risk factor was significantly higher among Democrats than among Republicans, liberals than among conservatives, and women than among men. For example, 56% of liberals identified witnessing domestic violence as a major risk factor, compared with 29% of conservatives (p<.001). CONCLUSIONS: Opinions about ACEs as risk factors for adult behavioral health conditions varied between legislators with different characteristics, especially liberals and conservatives. To enhance the policy impact of evidence about ACEs, advocates might consider developing multiple versions of ACE evidence summaries that are tailored on the basis of these characteristics.

Assessment of Rates of Child Maltreatment in States With Medicaid Expansion vs States Without Medicaid Expansion.

Importance: Physical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care. Objective: To determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates. Design, Setting, and Participants: This ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019. Exposures: State-level Medicaid expansion status. Main Outcomes and Measures: Incidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state. Results: Data were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates. Conclusions and Relevance: Medicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.

Hospital Variation in Child Protection Reports of Substance Exposed Infants.

OBJECTIVE: To examine whether hospital-level factors contribute to discrepancies in reporting to Child Protective Services (CPS) of infants diagnosed with prenatal substance exposure. STUDY DESIGN: We used a linked dataset of birth, hospital, and CPS records using diagnostic codes (International Classification of Diseases, Ninth Revision) to identify infants diagnosed with prenatal substance exposure. Using multilevel models, we examined hospital-level and individual birth-level factors in relation to a report to CPS among those infants prenatally exposed to substances. RESULTS: Of the 760 863 infants born in Washington State between 2006 and 2013, 12 308 (1.6%) were diagnosed with prenatal substance exposure. Infants born at hospitals that served larger populations of patients with Medicaid (OR, 1.25; 95% CI, 1.07-1.45) and hospitals with higher occupancy rates (OR, 1.43; 95% CI, 1.15-1.77) were more likely to be reported to CPS. Infants exposed to amphetamines (OR, 2.58; 95% CI, 2.31-2.90) and cocaine (OR, 2.33; 95% CI-1.92, 2.83) were more likely to be reported and infants exposed to cannabis (OR, 0.62; 95% CI-0.55, 0.70) were less likely to be reported to CPS than infants exposed to opioids. Infants with Native American mothers were more likely to be reported to CPS than infants with white mothers (OR, 1.47; 95% CI, 1.27-1.70). CONCLUSIONS: Hospital-level and individual birth-level factors impact the likelihood of infants prenatally exposed to substances being reported to CPS, providing additional knowledge about which infants are reported to CPS. Targeted education and improved policies are necessary to ensure more standardized approaches to CPS reporting of prenatal substance exposure.

Energy Expenditure in Critically Ill Adult Patients With Acute Brain Injury: Indirect Calorimetry vs. Predictive Equations.

Introduction: Predictive equations (PE) are used in lieu of indirect calorimetry (IC) due to cost and limited resources; however, these equations may not be as accurate as IC in estimating resting energy expenditure (REE) in critically ill patients, putting them at risk of malnutrition. The purpose of this study is to compare predicted and measured energy expenditure (MEE) in critically ill adults with acute brain injury. Materials and Methods: This was a retrospective review of adult patients admitted to the Neurosciences ICU with acute brain injury between May 1st, 2014 and April 1st, 2016 who had IC performed. The Harris Benedict (HBE), Penn State University, and Mifflin St Jeor (MSJ) PE were used in comparison to IC results. Subgroup analyses stratified patients based on BMI and type of acute brain injury. Results: One hundred and forty-four patients met inclusion criteria. Comparing predicted and MEE found no significant difference (p = 0.1). High degrees of interpatient variability were discovered, with standard deviations ranging from 17 to 29% of each PE. Pearson's correlations indicated weak associations when HBE, Penn State, and MSJ were individually compared to MEE (r = 0.372, 0.409, and 0.372, respectively). A significant difference was found between predicted and MEE in patients with a BMI < 30 kg/m2 (p < 0.01) and in those with aneurysmal subarachnoid hemorrhage (p < 0.01). Discussion: Due to interpatient variability that exists among REE of critically ill patients with acute brain injury, IC should be used when feasible.

An assessment of domain-general metacognitive responding in rhesus monkeys.

Metacognition is the ability to monitor and control one's cognition. Monitoring may involve either public cues or introspection of private cognitive states. We tested rhesus monkeys (Macaca mulatta) in a series of generalization tests to determine which type of cues control metacognition. In Experiment 1, monkeys learned a perceptual discrimination in which a "decline-test" response allowed them to avoid tests and receive a guaranteed small reward. Monkeys declined more difficult than easy tests. In Experiments 2-4, we evaluated whether monkeys generalized this metacognitive responding to new perceptual tests. Monkeys showed a trend toward generalization in Experiments 2 & 3, and reliable generalization in Experiment 4. In Experiments 5 & 6, we presented the decline-test response in a delayed matching-to-sample task. Memory tests differed from perceptual tests in that the appearance of the test display could not control metacognitive responding. In Experiment 6, monkeys made prospective metamemory judgments before seeing the tests. Generalization across perceptual tests with different visual properties and mixed generalization from perceptual to memory tests provide provisional evidence that domain-general, private cues controlled metacognition in some monkeys. We observed individual differences in generalization, suggesting that monkeys differ in use of public and private metacognitive cues.

The Role of Care Management as a Population Health Intervention to Address Disparities and Control Hypertension: A Quasi-Experimental Observational Study.

OBJECTIVE: We studied whether care management is a pragmatic solution for improving population blood pressure (BP) control and addressing BP disparities between Blacks and Whites in routine clinical environments. DESIGN: Quasi-experimental, observational study. SETTING AND PARTICIPANTS: 3,964 uncontrolled hypertensive patients receiving primary care within the last year from one of six Baltimore clinics were identified as eligible. INTERVENTION: Three in-person sessions over three months with registered dietitians and pharmacists who addressed medication titration, patient adherence to healthy behaviors and medication, and disparities-related barriers. MAIN MEASURES: We assessed the population impact of care management using the RE-AIM framework. To evaluate effectiveness in improving BP, we used unadjusted, adjusted, and propensity-score matched differences-in-differences models to compare those who completed all sessions with partial completers and non-participants. RESULTS: Of all eligible patients, 5% participated in care management. Of 629 patients who entered care management, 245 (39%) completed all three sessions. Those completing all sessions on average reached BP control (mean BP 137/78) and experienced 9 mm Hg systolic blood pressure (P<.001) and 4 mm Hg DBP (P=.004) greater improvement than non-participants; findings did not vary in adjusted or propensity-score matched models. Disparities in systolic and diastolic BP between Blacks and Whites were not detectable at completion. CONCLUSIONS: It may be possible to achieve BP control among both Black and White patients who participate in a few sessions of care management. However, the very limited reach and patient challenges with program completion should raise significant caution with relying on care management alone to improve population BP control and eliminate related disparities.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial.

INTRODUCTION: Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension. DESIGN: We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013. SETTING/PARTICIPANTS: We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes. INTERVENTION: Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group. MAIN OUTCOME MEASURES: The primary outcome was blood pressure change. Analyses were conducted in January to October 2014. RESULTS: Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure. CONCLUSIONS: A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

Assessment of the Readability of Genetic Counseling Patient Letters.

Patient letters are a powerful tool that genetic counselors use to communicate with their patients. Patient letters are often sent to provide information on a new diagnosis, reiterate test results, and to serve as a permanent record of the visit. Patient letters, however, are only helpful if the patients can understand them. More than 50 % of the US population reads below a 9th grade reading level and over one-third of the population has low health literacy skills. In this study we evaluate the readability of genetic counseling patient letters by assessing reading level, image use, and terminology use. One hundred forty-nine genetic counselors participated in the survey and of these, 79 submitted a sample patient letter. Analyses of the letters revealed a mean reading level of 10.93. On average, 6 genetic terms were included in each letter, and only 25 % of these terms were defined. Analyses of survey responses revealed over 75 % of the genetic counselors did not include images in their patient letters. These results indicate there is room for improvement in order to make genetic counseling patient letters more accessible to the general population.