Mortality In African Americans Research Articles

Microvascular vasoregulatory dysfunction in African Americans - An enhanced opportunity for early prevention and treatment of atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease and its risk factors and precursors are a major driver of disparities in cardiovascular health. This review examines reported evidence that vascular endothelial dysfunction, and its manifestation as coronary microvascular dysfunction, underlies observed excess morbidity and mortality in African Americans. Advanced imaging insights that reveal patho-mechanisms, along with population evidence from the Jackson Heart Study, and the growing evidence emanating from national and international clinical trials and registries are presented. We examine a physiological framework that recognizes insulin-resistant cardiometabolic underpinnings of the conditions of the American Heart Associations' Life's Essential Eight construct of cardiovascular health as a unifying basis that affords early prevention. Mechanistic-based therapeutic approaches, can subsequently be implemented to interrupt progression to adverse outcomes employing layered, or personalized, treatment strategies of a well-defined set of conditions or diseases. Remaining knowledge gaps are acknowledged.

Abstract 17200: PAD Raising Awareness in Sacred Environments “Praise”

Introduction: Atherosclerotic peripheral artery disease (PAD) leads to a great burden of cardiovascular and limb-related morbidity and mortality in African Americans (AA) compared to White Americans. Medical center partnerships with churches may be an effective method to improve PAD awareness and detection in the AA community. Hypotheses: We hypothesized that implementing a medical educational program in partnership with churches would increase PAD familiarity and identify participants with undiagnosed PAD. Aims: To determine (1) PAD familiarity before and after a one-time educational intervention and (2) the prevalence of PAD in older, church-going Nashville residents. Methods: Using a community-engaged research (CER) model, we partnered with 5 churches to enroll participants ≥ 50 years of age. Participants were given a 16-point pre- and post-educational program assessment to determine baseline and post-intervention PAD knowledge. Pre- and post-intervention scores were compared using Wilcoxon signed-rank test. Ankle-brachial index (ABI) testing was used to screen for PAD (ABI < 0.9). Results: We enrolled 120 participants (mean age [SD]: 64.67 [8.33] years, 74% women, 80% AA). The prevalence of PAD was 10.83%. Pre-intervention PAD awareness was low (mean score (MS): 10.89 [4.24]) and improved significantly post-intervention in all participants (MS: 13.88 [2.76; p=2 x 10 -12 ). Participants without PAD (ABI ≥ 0.9-1.39) (MS: 10.81 [4.28] vs. 13.91 [2.79]; p= p=4 x 10 -11 ) and with indeterminate status (ABI>1.4) (MS [SD]: 10.00 [5.03] vs. 14.10 [1.73; p=0.01) showed significant improvement in PAD awareness pre vs post intervention. Participants with PAD (ABI <0.9) (MS: 12.15 [3.26] vs. 13.46 [3.26; p=0.40) did not have significant improvement in their awareness scores. Conclusions: The PRAISE study demonstrates an effective CER partnership with churches as a method to increase PAD awareness and early detection of PAD, specifically among AAs.

Abstract 12617: Predictors of Mortality in African Americans Requiring Intra-Aortic Balloon Pump for Cardiogenic Shock Following Acute Myocardial Infarction

Introduction: Past studies have linked African Americans(AA) to disparities in care and outcome. We aim to improve the care of AA by evaluating the predictors of mortality in AA requiring an intra-aortic balloon pump(IABP) for cardiogenic shock(CS) following acute myocardial infarction (AMI). Methods: Variables influencing mortality among AA adults with CS from AMI using intra-aortic balloon pump (IABP), were studied via the 2016-2020 National Inpatient Sample. Results: Our study found 9050 cases of AMI with CS among AA that required IABP and 3100 (34.3%) of them died. Odds of mortality were higher in those ages ≥60(aOR 1.356, p<0.01), using mechanical ventilation (aOR 2.725, p<0.01), with ventricular tachycardia (aOR 1.231, p<0.01), ventricular fibrillation (aOR 2.215, p<0.01), prior stroke (aOR 1.319, p<0.01), Chronic Kidney Disease (aOR 1.387, p<0.01), cirrhosis (aOR 2.581, p<0.01), hypertension (aOR 1.29, p<0.01), peripheral vascular disease (aOR 1.218, p =0.031), acute kidney injury (aOR 1.281, p<0.01), and females (aOR 1.111, p=0.042). Lower odds were reported in those with lipid disorders (aOR 0.713, p<0.01), alcohol abuse (aOR 0.549, p<0.01), depression (aOR 0.676, p<0.01), drug abuse (aOR 0.483, p<0.01), events of supraventricular tachycardia (0.438, p<0.01), atrial fibrillation (aOR 0.88, p=0.042), smoking (aOR 0.727, p<0.01), obesity (aOR 0.843, p=0.011), and weekend admissions (aOR 0.867, p<0.01). Furthermore, Medicaid (aOR 0.705, p<0.01) and Private Insurers (aOR 0.550, p<0.01) showed reduced risk compared to Medicare-covered patients. Urban non-teaching (aOR 0.52, p<0.01) and Urban teaching(aOR 0.526, p<0.01) centers also had reduced mortality rates (vs. Rural hospitals). Conclusions: We found several patient and hospital characteristics that can influence the survival of AA using IABP for CS following AMI. Further research to improve the impact of these factors and alleviate their negative roles on survival should be encouraged.

Abstract 1907: Unique and novel deleterious MSH6 mutation among African American patients with colorectal cancer

Abstract Background: Colorectal cancer (CRC) incidence and mortality in African Americans (AA) is higher compared to Caucasians (CAU). It has also been reported that the disparity is due to differences in the mutation spectrum particularly germline mutations in the DNA mismatch repair (MMR) genes (such as hMSH6). Aim: We aimed to determine MSH6 mutation profile in AAs with CRC. Methods: We performed RNA sequencing in 8 paired CRC samples (AA, n=4 and CAU, n=4) to identify the unique transcript and novel pathogenic mutation in AA compared to CAU by comparing CRC matched to corresponding normal epithelia. In silico analysis of TCGA COAD RNA sequencing data was performed. Results: We found non-synonymous germline mutations (p.G1139S) in exon 5 of MSH6 gene (one of the MMR genes) in AA CRC samples. Interestingly, this mutation is present in the active site of ATP binding (1135 to 11442 residue) motif of MSH6 protein. In silico analysis was used to determine the novelty and pathogenicity of this mutation by comparison to various publicly available databases. Also, the deleterious effect of p.G1139S missense mutation on the structure of MSH6 protein revealed that p.G1139S is destabilizing MSH6 protein. Based on Ramachandran plot analysis, we found lot of clash and outliers in the mutant type compared to wild type MSH6 protein. Structural analysis revealed that serine substitution results in a wide ATP binding site compared to glycine present in wild-type MSH6. In addition, we found a loss of hydrogen bonding or gain of ionic interaction between wild-type and mutant MSH6 protein. Conclusion: Based on our in silico analysis, the deleterious effect of the detected missense mutation in the active site of ATP binding motif of MSH6 affects the structure and function of MSH6. This may result in the accumulation of mono-, or di-nucleotide repeats instability in the genome, leading to genomic alterations that associate with carcinogenesis in African American CRC patients. Citation Format: Mudasir Rashid, Rumaisa Rashid, Sudhir Varma, Zaki Sherif, John Carethers, Hassan Brim, Hassan Ashktorab. Unique and novel deleterious MSH6 mutation among African American patients with colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1907.

Contributors to Early Mortality in African Americans, the Jackson Heart Study.

In recent years, premature "deaths of despair" (ie, due to alcohol, drug use, and suicide) among middle-aged White Americans have received increased attention in the popular press, yet there has been less discussion on what explains premature deaths among young African Americans. In this study, we examined factors related to deaths of despair (alcohol use, drug use, smoking) and contextual factors (perceived discrimination, socioeconomic status, neighborhood conditions) as predictors of premature deaths before the age of 65 years among African Americans. The Jackson Heart Study (JHS) is a longitudinal cohort study of African Americans in the Jackson, Mississippi, metropolitan statistical area. We included participants younger than 65 years at baseline (n=4000). Participant enrollment began in 2000 and data for these analyses were collected through 2019. To examine predictors of mortality, we calculated multivariable adjusted hazard ratios (HRs; 95% CI), using Cox proportional hazard models adjusted for age, sex, ideal cardiovascular health metrics, drug use, alcohol intake, functional status, cancer, chronic kidney disease, asthma, waist circumference, depression, income, education, health insurance status, perceived neighborhood safety, and exposure to lifetime discrimination. There were 230 deaths in our cohort, which spanned from 2001-2019. After adjusting for all covariates, males (HR, 1.50; 95% CI, 1.11-2.03), participants who used drugs (HR, 1.53; 95% CI, 1.13-2.08), had a heavy alcohol drinking episode (HR, 1.71; 95% CI, 1.22-2.41), reported 0-1 ideal cardiovascular health metrics (HR, 1.78; 95% CI, 1.06-3.02), had cancer (HR, 2.38; 95% CI, 1.41-4.01), had poor functional status (HR, 1.68; 95% CI, 1.19-2.37), or with annual family income less than $25,000 (HR, 1.63; 95% CI, 1.02-2.62) were more likely to die before 65 years of age. In our large cohort of African American men and women, clinical predictors of premature death included poor cardiovascular health and cancer, and social predictors included low income, drug use, heavy alcohol use, and being a current smoker. Clinical and social interventions are warranted to prevent premature mortality in African Americans.

Clinical outcomes and echocardiographic characteristics between African American and Caucasian patients with acute pulmonary embolism.

Despite socioeconomic disparities, no association between clinical presentation and poor outcomes explains a higher mortality in African Americans with pulmonary embolism (PE). The objective is to identify the co-morbidities and echocardiographic characteristics associated with increased mortality in African American patients. This is a cross-sectional study of Caucasian or African American patients with PE diagnosed between October 2015 and December 2017 at University of Maryland Medical Center. The outcomes were in-hospital death, length of stay, and bleeding. There were 303 African Americans and 343 Caucasians. Caucasians were older (p = 0.007), males (p = 0.01) with history of coronary artery revascularization (CABG (p = 0.001), coronary stents (p = 0.001)), trauma (p = 0.007), and/or recent surgeries (p = 0.0001). African Americans exhibited higher rates of diabetes (p = 0.01), chronic kidney disease (p = 0.0005), and smoking (p = 0.04). Severity of PE was similar between groups and there was no difference in clot burden size. African Americans had more right ventricular strain on Computer Tomography (p = 0.001) and echocardiogram (p = 0.004); also, underfilled left ventricles (p = 0.02) and higher right ventricular systolic pressures (p = 0.001). There was no difference in hospital mortality (7.1% vs. 7.9%, p = 0.71), length of stay (13.1 ± 16.7 vs 12.8 ± 14.9, p = 0.80) and bleeding (9.0% vs.8.3%. p = 0.72). Mortality was higher in African Americans who received advanced therapies (3.8% vs. 18.8%, p = 0.02). The risk of death increased with age (OR 1.04; 95%CI 1.020-1.073) and with advanced therapies (OR 2.43; 95%CI 1.029-5.769). Differences in co-morbidities, radiologic findings, and echocardiographic characteristics that may contribute to higher mortality in African American patients, specifically those receiving advanced therapies.

The Effects of Residential Segregation on Black and White Mortality in the United States

Higher rates of black mortality compared to whites in the United States are longstanding and well documented. Wide variation across racial and socioeconomic groups suggests that many deaths may be preventable. We hypothesize that higher mortality for African Americans is due to the fundamental causes of structural racism and poverty. We developed a new index, the Racial Isolation of Poverty (RIP), to examine how the race/class nexus of disadvantage is associated with higher rates of mortality for African Americans. A wide range of policies has isolated black people into areas with poorer-quality schools and fewer jobs, where over-policing substitutes for community resources. Geographic isolation by race and income has enabled sub-standard resource distribution to African Americans. Geographic isolation also allowed us to measure the effects of racism in US counties. Two main effects, Racial Isolation (RI), and the interaction of RI with economic deprivation, or RIP, were tested in a cross-sectional fixed-effects model. Both RIP and RI increased mortality for blacks while only RIP increased mortality for whites. Universal policies to promote economic security for all and reparations especially designed to promote economic security and wealth for African Americans are proposed.

Abstract P051: Hypertension Is Associated With All-cause Mortality In Caucasians But Not African Americans With Suspected Cardiac Amyloidosis

Background: Diagnostic delay is common among patients with cardiac amyloidosis. Hypertensive heart disease is a known echocardiographic mimic of cardiac amyloidosis, with greater prevalence among African Americans than among Caucasians. The association between hypertension and clinical outcomes in patients with suspected cardiac amyloidosis is not known. Objective: We sought to determine the association between a known diagnosis of hypertension and all-cause mortality in African Americans and Caucasians with suspected cardiac amyloidosis. Methods: We identified 230 patients who underwent cardiac biopsy for suspected cardiac amyloidosis at our institution between 2000-2018. Clinical and demographic data were obtained from the medical record. Echocardiograms performed at the time of cardiac biopsy were interpreted by study personnel. All-cause mortality was assessed using the Social Security Death Index. Results: Among 230 patients with suspected cardiac amyloidosis, hypertension was more common among African Americans (71 of 91, 78%) than among Caucasians (73 of 139, 52%). Over a median follow-up period of 4.5 months, the all-cause mortality rate was higher among Caucasians with hypertension (67%) than Caucasians without hypertension (42%, p= 0.048). There was no difference in all-cause mortality rate among African Americans with and without hypertension (47.8% vs. 50%, p=0.903). Among Caucasians, those with hypertension had increased posterior wall thickness, relative wall thickness, and interventricular septal thickness as compared to those without hypertension (p<0.01 for all). There were no significant differences in these parameters among African Americans with and without hypertension (p>0.05). Conclusions: Hypertension and the hypertensive echocardiographic phenotype are associated with all-cause mortality in Caucasians but not African Americans with suspected cardiac amyloidosis. Additional study is needed to understand the differential effects of hypertension on clinical outcomes by racial category in patients with suspected cardiac amyloidosis.

Relative impact of genetic ancestry and neighborhood socioeconomic status on all-cause mortality in self-identified African Americans

Self-identified race/ethnicity is a correlate of both genetic ancestry and socioeconomic factors, both of which may contribute to racial disparities in mortality. Investigators often hold a priori assumptions, rarely made explicit, regarding the relative importance of these factors. We studied 2,239 self-identified African Americans (SIAA) from the Prostate, Lung, Colorectal and Ovarian screening trial enrolled from 1993–1998 and followed prospectively until 2019 or until death, whichever came first. Percent African genetic ancestry was estimated using the GRAF-Pop distance-based method. A neighborhood socioeconomic status (nSES) index was estimated using census tract measures of income, housing, and employment and linked to participant residence in 2012. We used Directed Acyclic Graphs (DAGs) to represent causal models favoring (1) biomedical and (2) social causes of mortality. Hazard ratios were estimated using Cox models adjusted for sociodemographic, behavioral, and neighborhood covariates guided by each DAG. 901 deaths occurred over 40,767 person-years of follow-up. In unadjusted (biomedical) models, a 10% increase in percent African ancestry was associated with a 7% higher rate of all-cause mortality (HR: 1.07, 95% CI: 1.02, 1.12). This effect was attenuated in covariate adjusted (social) models (aHR: 1.01, 95% CI: 0.96, 1.06). Mortality was lower comparing participants in the highest to lowest nSES quintile following adjustment for covariates and ancestry (aHR: 0.74, 95% CI: 0.57, 0.98, Ptrend = 0.017). Higher African ancestry and lower nSES were associated with higher mortality, but African ancestry was not associated with mortality following covariate adjustment. Socioeconomic factors may be more important drivers of mortality in African Americans.

Significant improvements, but consistent disparities in survival for African Americans after liver transplantation.

Despite improvements in survival across races in the past 20 years, African Americans have worse liver transplant outcomes after orthotopic liver transplantation (OLT). This study aims at quantifying the change in disparities between African Americans and other races in survival after OLT. We retrospectively analyzed the United Network for Organ Sharing (UNOS) database for patient data for candidates who received a liver transplant between January 1, 2007 and December 31, 2017. Multivariate Cox proportional hazards regression indicated similar decreases in mortality over time for each race with a decrease in mortality for African Americans: 2010-2012 (HR=.930), 2012-2015 (HR=.882), and 2015-2017 (HR=.883) when compared to 2007-2010. Risk of mortality for African Americans compared to Caucasians varied across the 4 eras: 2007-2010 (HR=1.083), 2010-2012 (HR=1.090), 2012-2015 (HR=1.070), and 2015-2017 (HR=1.125). While African Americans have seen increases in survival in the past decade, a similar increase in survival for other races leaves a significant survival disparity in African Americans.

Abstract P028: Do Increased Cardiovascular Comorbidities Explain Excess Covid-19 Morbidity And Mortality In African Americans?

Introduction: Racial disparities in COVID-19 incidence, severity and mortality have been widely reported, with African Americans (AA) suffering disproportionately compared to White Americans (WA), but the epidemiological basis for these observations remains poorly understood. We hypothesize that AA have an excess of comorbid cardiovascular conditions compared to WA, accounting for the disparity in COVID-19 infection and death. Methods: We examined 63545 laboratory-confirmed COVID-19 cases from the One Florida Research Consortium’s sample of recipients of healthcare in Florida from January 2020 to April 2021. We assessed the prevalence of preexisting comorbid conditions, behavioral risk factors, and outcomes of AA, WA, and Hispanic patients testing positive for COVID-19. Outcomes were defined as admission to ICU or all-cause death in the index admission. Associations between risk factors and outcomes were evaluated using multivariate logistic regression analysis. Results: Compared to WA, Hispanic and AA COVID-19 patients were younger, more females, and more uninsured. AA patients with COVID-19 had the highest burden of comorbidities (especially cardiovascular), and worse combined comorbidity scores. They also had a higher rate of ICU admission and death. After adjustment for multiple variables, AA patients continued to have the highest adverse outcomes risk (OR=1.44; P < 0.001; Figure 1). Other significant predictors in the model included age, sex, poverty, cardiovascular comorbidities, cancer, and mental health disorders. Conclusions: Excess comorbidities from cardio-metabolic diseases exist in AA patients with COVID-19, who also suffer excess COVID-19 outcomes. However, these cardiovascular comorbidities did not account for all the risk of adverse COVID-19 outcomes. Reasons for the excess residual risk of in AA even after adjusting for comorbidities and other risk factors require further investigation, such as mediation analyses.

Abstract WP201: Increasing Mortality From Ischemic Stroke In The US, Racial And Etiological Analysis

Background: Ischemic stroke is the fifth leading cause of death in the United States. In spite of the recent advances in the management of ischemic stroke, mortality rates remain high and have increased in recent years. Importantly, mortality differs by race, with African Americans more likely to die from stroke. To better understand stroke mortality we examined data from 1999 through 2018 with respect to both race and stroke subtype. Methods: Using the Multiple Cause Of Death Database, we identified all patients who died of cerebral infarction (CI) using the International Classification of Diseases, 10th revision code I63. Age-adjusted mortality rates (AAMR) standardized to the 2000 US census data were used. Data for continuous variables were examined using simple linear regression models and multivariable linear regression models controlling for relevant covariates. All tests were two-tailed and p < 0.05 was considered significant. Results: A total of 201,157 CI deaths were identified between 1999 and 2018. AAMR showed a U-shaped trend, such that compared to 1999-2004 (4.52±0.60) AAMR decreased from 2005-2014 (2.06±0.20), p < 0.001, and increased from 2015-2018 (3.63±1.32), p < 0.001. AAMR differed significantly by race, p = 0.045. Rates were 3.05+1.26 for Caucasians and 4.04+1.74 for African Americans. AAMR decreased between 1999 and 2018 for thrombotic strokes, p < 0.001, while AAMR increased over this time for embolic stroke, p < 0.001. Amongst Caucasians, there was no significant differences in AAMR for each stroke subtype from 1999 to 2018, p = 0.081. However, for African Americans, there was a significantly higher AAMR for thrombotic strokes (0.56±0.33) compared to embolic strokes (0.33±0.15), p = 0.006. Conclusion: Despite recent advances in ischemic stroke management, AAMR has increased in the last 4 years by 1.8 times. AAMR in African Americans is 1.3 times that of Caucasians with African American mortality from thrombotic stroke being 1.7 times higher than from embolic stroke. Mortality from CI caused by embolism increased by 2.8 times over the study period while that due to thrombosis decreased by 5 times. Further studies are needed to clarify the reasons behind the recent increase in AAMR.

Plant-based diets and incident cardiovascular disease and all-cause mortality in African Americans: A cohort study.

BackgroundPrior studies have documented lower cardiovascular disease (CVD) risk among people with a higher adherence to a plant-based dietary pattern. Non-Hispanic black Americans are an understudied group with high burden of CVD, yet studies of plant-based diets have been limited in this population.Methods and findingsWe conducted an analysis of prospectively collected data from a community-based cohort of African American adults (n = 3,635) in the Jackson Heart Study (JHS) aged 21–95 years, living in the Jackson, Mississippi, metropolitan area, US, who were followed from 2000 to 2018. Using self-reported dietary data, we assigned scores to participants’ adherence to 3 plant-based dietary patterns: an overall plant-based diet index (PDI), a healthy PDI (hPDI), and an unhealthy PDI (uPDI). Cox proportional hazards models were used to estimate associations between plant-based diet scores and CVD incidence and all-cause mortality. Over a median follow-up of 13 and 15 years, there were 293 incident CVD cases and 597 deaths, respectively. After adjusting for sociodemographic characteristics (age, sex, and education) and health behaviors (smoking, alcohol intake, margarine intake, physical activity, and total energy intake), no significant association was observed between plant-based diets and incident CVD for overall PDI (hazard ratio [HR] 1.06, 95% CI 0.78–1.42, p-trend = 0.72), hPDI (HR 1.07, 95% CI 0.80–1.42, p-trend = 0.67), and uPDI (HR 0.95, 95% CI 0.71–1.28, p-trend = 0.76). Corresponding HRs (95% CIs) for all-cause mortality risk with overall PDI, hPDI, and uPDI were 0.96 (0.78–1.18), 0.94 (0.76–1.16), and 1.06 (0.86–1.30), respectively. Corresponding HRs (95% CIs) for incident coronary heart disease with overall PDI, hPDI, and uPDI were 1.09 (0.74–1.61), 1.11 (0.76–1.61), and 0.79 (0.52–1.18), respectively. For incident total stroke, HRs (95% CIs) for overall PDI, hPDI, and uPDI were 1.00 (0.66–1.52), 0.91 (0.61–1.36), and 1.26 (0.84–1.89) (p-trend for all tests > 0.05). Limitations of the study include use of self-reported dietary intake, residual confounding, potential for reverse causation, and that the study did not capture those who exclusively consume plant-derived foods.ConclusionsIn this study of black Americans, we observed that, unlike in prior studies, greater adherence to a plant-based diet was not associated with CVD or all-cause mortality.

HOME DM-BAT: home-based diabetes-modified behavioral activation treatment for low-income seniors with type 2 diabetes\u2014study protocol for a randomized controlled trial

BackgroundAbout 13% of African Americans and 13% of Hispanics have diabetes, compared to 8% of non-Hispanic Whites (NHWs). This is more pronounced in the elderly where about 25–30% of those aged 65 and older have diabetes. Studies have found associations between social determinants of health (SDoH) and increased incidence, prevalence, and burden of diabetes; however, few interventions have accounted for the context in which the elderly live by addressing SDoH. Specifically, psychosocial factors (such as cognitive dysfunction, functional impairment, and social isolation) impacting this population may be under-addressed due to numerous medical concerns addressed during the clinical visit. The long-term goal of the project is to identify strategies to improve glycemic control and reduce diabetes complications and mortality in African Americans and Hispanics/Latinos with type 2 diabetes.MethodsThis is a 5-year prospective, randomized clinical trial, which will test the effectiveness of a home-based diabetes-modified behavioral activation treatment for low-income, minority seniors with type 2 diabetes mellitus (T2DM) (HOME DM-BAT). Two hundred, aged 65 and older and with an HbA1c ≥8%, will be randomized into one of two groups: (1) an intervention using in-home, nurse telephone-delivered diabetes education, and behavioral activation or (2) a usual care group using in-home, nurse telephone-delivered, health education/supportive therapy. Participants will be followed for 12 months to ascertain the effect of the intervention on glycemic control, blood pressure, and low-density lipoprotein (LDL) cholesterol. The primary hypothesis is low-income, minority seniors with poorly controlled type 2 diabetes randomized to HOME DM-BAT will have significantly greater improvements in clinical outcomes at 12 months of follow-up compared to usual care.DiscussionResults from this study will provide important insight into the effectiveness of a home-based diabetes-modified behavioral activation treatment for low-income, minority seniors with uncontrolled type 2 diabetes mellitus and inform strategies to improve glycemic control and reduce diabetes complications in minority elderly with T2DM.Trial registrationClinicalTrials.govNCT04203147). Registered on December 18, 2019, with the National Institutes of Health Clinical Trials Registry.

Abstract P111: Ischemic Stroke Associated With Covid-19 and Racial Outcome Disparity in North America

Introduction: Underlying biological, genetic, or epigenetic characteristics may predispose to health differences and outcomes with COVID-19 associated stroke. Social determinants of health, access and geographical differences pertaining both to population density and other location-based factors may also be important. Methods: We report 69 cases of acute stroke in patients positive for SARS-CoV-2, in a dichotomized analysis of ischemic stroke outcomes between patients of African American background versus all other backgrounds. All patients presented to 14 major hospitals in the United States and Canada, from March 14-April 14, 2020. All patients had nasopharyngeal swab samples that were positive for SARS-CoV-2 on qualitative RT-PCR assays. Results: We found no significant difference in age (64.4 versus 62.9 years) or the proportion of females (51.9% versus 38.1%) (table 1). Diabetes mellitus was present significantly less in African American cases versus others (37% vs. 66.7%). The African American cohort had a similar mean NIHSS score of 16.3 compared with 14.9 in other races (p=0.63). The door-to-CT time was also similar (23 versus 19 minutes). The proportion of patients presenting with a large vessel occlusion was not significantly different (40.7% versus 47%). We noted 14.8% of African American cases received intravenous tPA compared to 31% in other races but was not significantly different. The proportion of thrombectomy cases mirrored this (14.8% versus 31%). Regarding stroke functional outcomes, there was no difference between African Americans and other races with respect to discharge mRS or proportion of favorable outcome (mRS 0-2). Symptomatic intracranial hemorrhage (sICH) was significantly higher for African Americans (11.1% versus 3%, p<0.001). Mortality was significantly higher in African Americans compared to other races (51.9% vs. 28.6%, p=0.03). Discussion: The reasons for increased mortality in African Americans with COVID-19-associated stroke are unknown. The finding in this study that mortality rate of COVID-19 positive stroke patients is greater than that previously reported in either COVID-19 respiratory infection alone or acute ischemic stroke alone, suggests an interaction that also warrants further study.

A Retrospective Analysis of the Performance of Intensive Care Unit Severity Scoring Systems across Different Ethnicities

Background: Despite wide utilisation of severity scoring systems for case-mix determination and benchmarking in the intensive care unit, the possibility of scoring bias across ethnicities has not been examined. Recent guidelines on the use of illness severity scores to inform triage decisions for allocation of scarce resources such as mechanical ventilation during the current COVID-19 pandemic warrant examination for possible bias in these models. We investigated the performance of three severity scoring systems (APACHE IVa, OASIS, SOFA) across ethnic groups in two large ICU databases in order to identify possible ethnicity-based bias.Method: Data from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care were analysed for score performance in Asians, African Americans, Hispanics and Whites after appropriate exclusions. Discrimination and calibration were determined for all three scoring systems in all four groups. Findings: While measurements of discrimination - area under the receiver operating characteristic curve (AUROC) - were significantly different among the groups, they did not display any discernible systematic patterns of bias. In contrast, measurements of calibration - standardised mortality ratio (SMR) - indicated persistent, and in some cases significant, patterns of difference between Hispanics and African Americans versus Asians and Whites. The differences between African Americans and Whites were consistently statistically significant. While calibrations were imperfect for all groups, the scores consistently demonstrated a pattern of over-predicting mortality for African Americans and Hispanics. Interpretation: The systematic differences in calibration across ethnic groups suggest that illness severity scores reflect bias in their predictions of mortality.

COVID-19 vasculitis and novel vasculitis mimics.

COVID-19 has been occasionally linked to histologically confirmed cutaneous vasculitis and a Kawasaki-like vasculitis, with these entities generally having minimal or no lung involvement and a good prognosis. Unlike these vasculitis types, patients with severe COVID-19 pneumonia can develop cutaneous vasculitis-like lesions and systemic arterial and venous thromboemboli, including cryptogenic strokes and other vasculopathy features. Proposed underlying mechanisms for these severe manifestations have encompassed immune dysregulation, including an anti-phospholipid syndrome-like state, complement activation, viral dissemination with direct systemic endothelial infection, viral RNAaemia with immunothrombosis, clotting pathway activation mediated by hypoxaemia, and immobility. In this Viewpoint, we highlight how imaging and post-mortem findings from patients with COVID-19 indicate a novel thrombosis in the pulmonary venous territory distal to the alveolar capillary bed, a territory that normally acts as a clot filtration system, which might represent an unappreciated nidus for systemic microembolism. Additionally, we suggest that this mechanism represents a novel vasculitis mimic related to COVID-19 that might lead to cryptogenic strokes across multivessel territories, acute kidney injury with haematuria, a skin vasculitis mimic, intestinal ischaemia, and other organ ischaemic manifestations. This finding is supported by pathological reports of extensive pulmonary venular thrombosis and peripheral organ thrombosis with pauci-immune cellular infiltrates. Therefore, severe COVID-19 pneumonia with extensive pulmonary intravascular coagulopathy might help to explain the numerous systemic complications of COVID-19, in which the demonstration of direct organ infection has not adequately explained the pathology.

High Consumption of Red Meat Is Associated with Excess Mortality Among African-American Women

Red meat is a rich source of nutrients but is typically high in saturated fats. Carcinogenic chemicals can be formed during cooking and processing. Little is known about the relation of red meat consumption to mortality in African Americans (AAs), a group with excess mortality and high consumption of red meat relative to whites. Our objective was to assess the association between red meat consumption and mortality in AA women. The Black Women's Health Study (BWHS) is a prospective cohort study of AA women across the USA who completed health questionnaires at enrollment in 1995 (median age 38 y, median BMI 27.9kg/m2) and every 2 y thereafter. The analyses included 56,314 women who completed a validated FFQ and were free of cardiovascular disease and cancer at baseline in 1995. Exposures were total red meat, processed red meat, and unprocessed red meat consumption. Outcomes were all-cause and cause-specific mortality. Cox proportional hazards models with control for age, socioeconomic status, lifestyle factors, medical history, and dietary factors were used to estimate HRs with 95% CIs. During 22 y of follow-up through to 2017, we identified 5054 deaths, which included 1354 cardiovascular deaths and 1801 cancer deaths. The HR for all-cause mortality was 1.47 (95% CI: 1.33, 1.62) for the highest quintile of total red meat consumption relative to the lowest. Each 1 serving/d increase in red meat consumption was associated with a 7% (95% CI: 5%, 9%) increased risk of all-cause mortality. Red meat consumption was also associated with increased cardiovascular mortality, but not with cancer mortality. Results were similar for the consumption of processed and unprocessed red meat. Red meat consumption is associated with increased all-cause and cardiovascular mortality among AA women.

Performance of Intensive Care Unit Severity Scoring Systems Across Different Ethnicities

Background: Despite wide utilisation of severity scoring systems for case-mix determination and benchmarking in the intensive care unit, the possibility of scoring bias across ethnicities has not been examined. Recent guidelines on the use of illness severity scores to inform triage decisions for allocation of scarce resources such as mechanical ventilation during the current COVID-19 pandemic warrant examination for possible bias in these models. We investigated the performance of three severity scoring systems (APACHE IVa, OASIS, SOFA) across ethnic groups in two large ICU databases in order to identify possible ethnicity-based bias.Method: Data from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care were analysed for score performance in Asians, African Americans, Hispanics and Whites after appropriate exclusions. Discrimination and calibration were determined for all three scoring systems in all four groups.Finding: While measurements of discrimination - area under the receiver operating characteristic curve (AUROC) - were significantly different among the groups, they did not display any discernible systematic patterns of bias. In contrast, measurements of calibration - standardised mortality ratio (SMR) - indicated persistent, and in some cases significant, patterns of difference between Hispanics and African Americans versus Asians and Whites. The differences between African Americans and Whites were consistently statistically significant. While calibrations were imperfect for all groups, the scores consistently demonstrated a pattern of over-predicting mortality for African Americans and Hispanics.Interpretation:The systematic differences in calibration across ethnic groups suggest that illness severity scores reflect bias in their predictions of mortality.Funding Statement: Funding: LAC is funded by the National Institute of Health through NIBIB R01 EB017205. There was no specific funding for this study.Declaration of Interests: RS received writing fees for healthcare reports from Crystallise UK Ltd. None of the other authors declare any conflict of interest.Ethics Approval Statement: Research using the eICU-CRD is exempt from institutional review board (IRB) approval due to the retrospective design, lack of direct patient intervention, and the security schema, for which the re-identification risk was certified as meeting safe harbour standards by an independent privacy expert (Privacert, Cambridge, MA) (Health Insurance Portability and Accountability Act Certification no. 1031219-2). The data in MIMIC-III has been previously de-identified, and the IRBs of the Massachusetts Institute of Technology (No. 0403000206) and BIDMC (2001-P-001699/14) both approved the use of the database for research.

Clinical characteristics and predictors of mortality in African-Americans with COVID-19 from an inner-city community teaching hospital in New York.

There is limited data on the clinical presentation and predictors of mortality in the African‐American (AA) patients hospitalized with coronavirus disease 2019 (COVID‐19) despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID‐19 infection. In this retrospective cohort review, we included all AA patients with confirmed COVID‐19 infection admitted to an inner‐city teaching community hospital in New York city. Demographics, clinical presentation, baseline co‐morbidities, and laboratory data were compared between survivors and non‐survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Of the 408 (median age, 67 years) patients included, 276 (66.65%, median age 63 years) survived while 132 (33.35%, median age 71 years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (odds ratio [OR], 1.06; confidence interval [CI], 1.04‐1.08; P < .001), body mass index (OR, 1.07; CI, 1.04‐1.11; P < .001), elevated serum ferritin (OR, 1.99; CI, 1.08‐3.66; P < .02), C‐reactive protein (OR, 2.42; CI, 1.36‐4.33; P < .01), and D‐dimers (OR, 3.79; CI, 2.21‐6.50; P < .001) at the time of presentation were identified as the independent predictors of mortality. Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among AAs hospitalized with COVID‐19 infection. Advanced age, higher body mass index, elevated serum ferritin, C‐reactive protein, and D‐dimers are independent predictors of mortality among hospitalized AAs with COVID‐19 infection.