bluuebunny/crossref_metadata_2025_split huggingface dataset:
1266-P: The Risk of Major CV Events after Initiation of SGLT2i, GLP-1RA, DPP-4i, or SUs in Patients with Type 2 Diabetes and Low-to-Moderate CV Risk
Authors: PATORNO ELISABETTA , TESFAYE HELEN , ALIX CAROLINE , DICESARE ELYSE C. , JANE CROMER SARA , EVERETT BRENDAN M. , GLYNN ROBERT , WEXLER DEBORAH J. , PAIK JULIE M. 
Published: June 2024

Introduction & Objective: We assessed the risk of major CV events (MACE) after initiation of SGLT2 inhibitors (SGLT2i), GLP1 receptor agonists (GLP-1RA), DPP-4 inhibitors (DPP-4i), or sulfonylurea (SU) in patients with T2D and low-to-moderate CV risk, for whom limited guidance exists on which diabetes medications clinicians should prescribe.
Methods: Using Medicare and 2 U.S. private health plans (2013-2023), we identified six pairwise cohorts of 1:1 propensity score-matched patients aged ≥18 years (≥66 years in Medicare) with T2D and no established CV disease, initiating SGLT2i, GLP-1RA, DPP-4i, or SU (Table). Our primary outcome was MACE, i.e., myocardial infarction (MI), stroke, or mortality. We estimated HRs and 95% CIs, adjusting for 156 covariates.
Results: Compared to DPP-4i or SUs, SGLT2i and GLP-1RA were associated with 15-28% reductions in the risk of MACE (Table), over a mean follow-up of ~11 months. Compared with GLP-1RA, SGLT2i were associated with a small increase in the risk of MACE (HR=1.06; 95% CI=1.01-1.11), driven by a 13% increase in risk of MI. Compared with SUs, DPP-4i had a 10% decrease in the risk of MACE.
Conclusion: This study suggests robust reductions in rates of MACE with SGLT2i and GLP-1RA compared to DPP-4i or SUs in patients with T2D and no CV disease. Although differences were not large, the risk of MACE was lower with GLP-1RA (vs SGLT2i) and DPP-4i (vs SUs).

Disclosure
E. Patorno: Research Support; Boehringer-Ingelheim, Food and Drug Administration (FDA), National Institutes of Health, Patient-Centered Outcomes Research Institute. H. Tesfaye: None. C. Alix: None. E.C. DiCesare: None. S. Cromer: Other Relationship; Johnson & Johnson Medical Devices Companies. Advisory Panel; Alexion Pharmaceuticals, Inc. Other Relationship; Wolters Kluwer Health. B.M. Everett: Consultant; Novo Nordisk. Research Support; Novo Nordisk. Consultant; Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Ipsen Pharmaceuticals, Provention Bio, Inc. R. Glynn: Research Support; Amarin Corporation, Kowa Pharmaceuticals America, Inc., Novartis AG, Pfizer Inc. D.J. Wexler: Other Relationship; Novo Nordisk. J.M. Paik: None.

Funding
Patient Centered Outcomes Research Institute (DB-2020C2-20326)
1274-P: Evolving Burden of Stroke Attributable to High Fasting Plasma Glucose in the United States from 1990–2019—A Benchmarking Systematic Analysis
Authors: MADDINENI KAVYA , PARISAPOGU ANUSHA , TEJA CHINTHAPALLI MRUNAL , POTLURI GEETHIKA , MARKANDU KEETHANSHAN , ISLAM HAMZA , ISLAM RABIA , DEKHNE ANUSHKA , DINESHBHAI DESAI HARDIK 
Published: June 2024

Introduction: Stroke remains a leading cause of mortality and disability in the United States, presenting significant public health and economic challenges. Among the various risk factors contributing to the incidence of stroke, high fasting plasma glucose levels (FPG) have emerged as a critical element.
Method: Using Global Burden of Disease tool, deaths and disability adjusted life years (DALYs) due to stroke attributable to FPG were estimated by age, sex, year across the US from 1990-2019.
Results: From 1990-2019, the annual percentage change (APC) in deaths rose by 77% (95% UI: 52-107%), and DALYs increased by 78% (56-106%). However, the age-standardized APC saw a 3% decrease in death rates, while DALY rates increased by 3%. Nevada experienced the highest increase in death APC at 338%, followed by Alaska at 312%, whereas Pennsylvania had the lowest at 18%. The highest death toll was in the 85-89 age group, and the most DALYs were seen in the 70-74 age group in 2019. Females showed a higher APC in both deaths (83% vs 70%) and DALYs (81% vs 74%) compared to males during this period.
Conclusion: Stroke related to FPG represented 28.68% of all stroke-related deaths. This significant proportion underscores the need for public health policymakers to take decisive action to address and mitigate this growing burden.

Disclosure
K. Maddineni: None. A. Parisapogu: None. M. Chinthapalli: None. G. Potluri: None. K. Markandu: None. H. Islam: None. R. Islam: None. A. Dekhne: None. H. Desai: None.
128-OR: Investigating C-Fiber Activity Using Depolarizing Stimuli Provides Insight into the Natural Course of Diabetic Polyneuropathy
Authors: ELDESOUKY OMAR , SEEBAUER LUKAS , RUKWIED ROMAN , CARR RICHARD , ROSHAN MANI , SULAJ ALBA , TSILINGIRIS DIMITRIOS , KOPF STEFAN , FLEMING THOMAS H. , SCHMELZ MARTIN , SZENDROEDI JULIA , KENDER ZOLTAN 
Published: June 2024

Introduction: Based on quantitative sensory testing (QST) we described the progression of diabetic sensorimotor polyneuropathy (DSPN) from healthy to thermal hyperalgesia, to mechanical hyperalgesia, to sensory loss. While QST provides valuable insights, it gives less information about the level of sensory impairment (transductional vs axonal). Therefore, we performed an electrical stimulation protocol to evaluate C-nociceptor excitability in individuals with DSPN.
Methods: We examined 66 individuals with diabetes mellitus, 51 having varying stages of DSPN. Slow depolarizing transcutaneous currents of low-intensity with 4 Hz sinusoidal stimulation profile and single 500 ms half sine wave pulses were used to stimulate C-fibers. Pain perception was quantified using (0-10)-Numeric-Rating-Scale. Findings were cross-referenced with QST Z-scores and correlated to serum levels of the axonal marker neurofilament light chain (NfL).
Results: Mechanical pain scores positively correlated with electrically induced pain (r=0.757, P&lt;0.001) whereas only a weak positive correlation was found between electrical pain and thermal pain Z-scores at high stimulation intensities (r=0.403, P&lt;0.01). Increased electrical pain ratings were found in individuals with reduced heat pain but not in participants with reduced mechanical pain indicating a possible axonal degeneration in the latter. In most of our subjective sensory tests, higher NfL levels correlated with impaired sensory function (r&gt;-0.3, P&lt;0.05).
Conclusion: Loss of mechanical pain indicated axonal degeneration, while absent heat sensation with normal electrically induced pain suggested a progression involving impaired transduction or superficial degeneration of sensory endings. Hypersensitivity to weak depolarizing stimuli may offer insights into DSPN's natural course, aiding high-risk patient identification and guiding interventions.

Disclosure
O. Eldesouky: None. L. Seebauer: Other Relationship; Springer Medizin Verlag GmbH. R. Rukwied: None. R. Carr: None. M. Roshan: None. A. Sulaj: None. D. Tsilingiris: None. S. Kopf: Speaker's Bureau; Lilly Diabetes, Bayer Inc. T.H. Fleming: None. M. Schmelz: Consultant; Lilly GmbH, Merz Therapeutics, Bayer Inc., Medtronic GmbH. J. Szendroedi: None. Z. Kender: None.
1286-P: Impact of Changes in Glucose Tolerance Status on Incidence of Cardiovascular Disease in Japan—Historical Cohort Study Using a Nationwide Claims Database
Authors: SHIMAYAMA CHIHIRO , FUJIHARA KAZUYA , OE MOMOKO , UEGAMI YOHEI , TAKIZAWA HIROKI , SATO TAKAAKI , SUZUKI HIROSHI , KITAZAWA MASARU , MATSUBAYASHI YASUHIRO , YAMADA TAKAHO , KODAMA SATORU , SONE HIROHITO 
Published: June 2024

Although both glucose abnormalities and a history of cardiovascular disease such as coronary artery disease (CAD) or cerebrovascular disease (CVD) are risk factors for cardiovascular disease, few studies have examined the association of changes in glucose tolerance and subsequent CAD and CVD in those with and without a history of cardiovascular disease in the same cohort. Thus, we studied the impact of changes in glucose tolerance status over 2 years on subsequent CAD and CVD in those with and without a history of either. During a 2-year baseline period in which there was worsening, no change, or improvement in glucose tolerance according to a history or no history of CAD/CVD, 363,856 people were classified as having either normoglycemia (NGT), prediabetes (preDM), or diabetes (DM). After baseline, incident CAD and CVD were followed up. The association between changes in glucose tolerance and the incidence of CAD/CVD was analyzed by a multivariate Cox regression model. In the absence of prior CAD/CVD, hazard ratios (HR) for CAD/CVD and CAD were 0.6 to 0.7 for those with ‘DM to preDM’ compared with ‘DM to DM’. In the presence of prior CAD/CVD, the HRs for CAD/CVD, CAD, and CVD were 1.3 to 1.6 in ‘preDM to DM’ compared with ‘preDM to preDM’ (Table). Individualized treatment strategies should consider changes in glucose tolerance status and prior cardiovascular disease.

Disclosure
C. Shimayama: Employee; Kowa Company, Ltd. K. Fujihara: None. M. Oe: Employee; Kowa Company, Ltd. Y. Uegami: None. H. Takizawa: None. T. Sato: None. H. Suzuki: None. M. Kitazawa: None. Y. Matsubayashi: None. T. Yamada: None. S. Kodama: None. H. Sone: Research Support; Novo Nordisk, Astellas Pharma Inc., Kowa Company, Ltd., Kyowa Kirin Co., Ltd., Eisai Inc., Sumitomo Dainippon Pharma Co., Ltd.
1288-P: Comparison of Moderate Intensity Atorvastatin and Ezetimibe with High Intensity Atorvastatin on Cardiovascular Events and Diabetes in Patients with Angina Pectoris Undergoing Percutaneous Coronary Intervention
Authors: YOUNG SOHN SEO , WOO CHO SUNG 
Published: June 2024

Objective: This real-world large cohort study was aimed to compare effect of moderate intensity atorvastatin and ezetimibe combination therapy and high intensity atorvastatin therapy on cardiovascular events and diabetes in patients with angina pectoris undergoing percutaneous coronary intervention (PCI).
Methods: This retrospective cohort study used Korean National Health Insurance Data. Study participants underwent PCI between 2015 and 2018, and received high-intensity atorvastatin (atorvastatin 40-80 mg; n = 2,102) or moderate-intensity atorvastatin (atorvastatin 10-20 mg) plus ezetimibe (n = 4,682). The primary outcome was each cardiovascular outcome; incidence of cardiovascular death, myocardial infarction (MI) and stroke. The secondary outcome was newly developed diabetes.
Results: During a mean follow up of 4 years, there were no significant differences in the cardiovascular outcomes between high-intensity atorvastatin monotherapy and moderate-intensity atorvastatin and ezetimibe combination therapy. The adjusted hazard ratio (aHR) for cardiovascular death was 1.18 [95% confidence interval (CI): 0.87-1.61, p=0.285], MI was 0.82 (95% CI 0.67-1.01; p = 0.066). and stroke was 1.10 (95% CI: 0.86-1.39, p=0.453), respectively. The risk of new onset diabetes was not different between the two-treatment group (aHR: 0.99, 95% CI: 0.88-1.13, p=0.94).
Conclusions: There was no significant difference in the cardiovascular outcome and risk of new onset diabetes between high-intensity atorvastatin monotherapy and moderate-intensity atorvastatin and ezetimibe combination therapy, in real-world large cohort study.

Disclosure
S. Sohn: None. S. Cho: None.
1295-P: Fasting Plasma Glucose and A1C Underperform as Diagnostic Tests for Africans with Diabetes—Insight from the Africans in America Study
Authors: WORTHY CHARLITA , SAYED MARIAM , HUEFNER ELIZA A. , HURSTON JAMAIICA , DUBOSE CHRISTOPHER , SUMNER ANNE E. 
Published: June 2024

According to the International Diabetes Federation, the prevalence of type 2 diabetes (DM) in sub-Saharan Africa will increase by 134% in the next 25 years. Furthermore, recent data suggests that the most widely used diagnostic tests, fasting blood glucose (FPG) (≥126 mg/dL) and A1C (≥6.5%) underperform in Africans. Thus, rigorous testing by the OGTT for the detection of DM in Africans is critical. The OGTT allows for assessment of 2h glucose, a postprandial equivalent. Therefore, OGTT were performed in 601 African-born Blacks enrolled in the Africans in America cohort (male: 63% (377/601), age: 39±11, (mean±SD) range 20-69, BMI: 27.7±4.5, range (18.2-42.0)). DM diagnosis was based on ADA glucose criteria for the OGTT. To determine if confounding factors were present, tests were done to assess hemoglobin, hemoglobin type, nutritional status and renal and hepatic function. Assays for G6PD deficiency were performed in 228 consecutively enrolled participants. DM occurred in 7% (42/601) of participants. Sickle cell trait (SCT) or HbC Trait occurred in 17% (100/601) of participants overall and 33% (14/42) of individuals with DM. No participants (0/601) had anemia (Hgb&lt;11 g/dL), nutritional deficiencies or renal or hepatic dysfunction. G6PD deficiency was identified in 10% (22/228) of participants overall, and no one with DM (0/18). Diagnostic sensitivity of FPG for the detection of DM was 16% (7/42). Sensitivity of A1C was 28% (12/42). Sensitivity of both tests combined was 33% (14/42). When the Africans with SCT or HbC trait were excluded, sensitivity of FPG was 21% (6/28) and A1C was 29% (8/28). For both tests combined, the sensitivity increased to only 36% (10/28). In short, FPG and A1C underperform in the detection of DM in Africans even in the absence of SCT, HbC trait and metabolic disorders and nutritional deficiencies. This data raises concern that the DM epidemic in Africa may be worse than predicted.

Disclosure
C. Worthy: None. M. Sayed: None. E.A. Huefner: None. J. Hurston: None. C. DuBose: None. A.E. Sumner: None.
13-OR: Relationship between Visit-to-Visit Variability of HbA1c and Development/Progression of Diabetic Retinopathy
Authors: YUKI MASAHIRO , YAMAZAKI TSUTOMU , TOKI RYOTA , SAKAMOTO MASAYA 
Published: June 2024

Introduction: Our study is aimed to examine the relationship between visit-to-visit variability (VVV) of HbA1c and development/ progression of diabetic retinopathy (DR).
Methods: This retrospective study analyzed data on 5,898 T2DM patients that had ophthalmic follow data. The VVV of HbA1c was evaluated using the intrapersonal coefficient of variation (CV) of HbA1c during a 7-year period from 2014-2020. We divided patients as (1) diagnosed with non-DR and (2) diagnosed with DR at start of this study. DR was assessed by Davis classification. Data analyses were performed using SPSS version 29.0 software.
Results: The number of patients is as follows; (1) patients with non-DR(n=4,197), (2) patients with DR(n=1,701). Multivariate logistic regression analyses indicated there is no significant association with CV of HbA1c and development of DR. There are, however, significant increase risks of development of DR with HbA1c level (OR=1.37), pulse pressure (OR=1.04) and diabetic duration (OR=1.02). Interestingly, there is significant association with CV of HbA1c and progression of DR (OR=1.04, Figure).
Conclusion: This study suggests that development of DR was associated with HbA1c level, pulse pressure and diabetic duration, but not with VVV of HbA1c. Progression of DR was associated with VVV of HbA1c. Thus, the VVV of HbA1c might be a new marker of progression of diabetic retinopathy.

Disclosure
M. Yuki: None. T. Yamazaki: None. R. Toki: None. M. Sakamoto: None.
1317-P: Novel Clusters of Prediabetes Help to Better Identify People at Risk for Diabetes-Associated Complications
Authors: ANSMANN MALIN , KLIEMANK ELISABETH , RAUCHHAUPT EKATERINA V. , SCHIMPFLE LUKAS , SEEBAUER LUKAS , ROSHAN MANI , KENDER ZOLTAN , KOPF STEFAN , SZENDROEDI JULIA , SULAJ ALBA 
Published: June 2024

Introduction & Objective:The description of prediabetes subphenotypes could improve the detection of individuals at increased risk for the onset of diabetes and/or related complications. The aim of this study was to assess the prevalence of diabetes-associated complications in newly established clusters of prediabetes and to compare them with the current classification of prediabetes.
Methods: People with prediabetes (n=118: 57/61 women/men, HbA1c 5.6±0.3%, age 57.4±9.8 y, BMI 29.7±5.7 kg/m2) were identified either using classical clinical parameters (increased HbA1c levels: HbA1c, impaired fasting glucose: IFG, impaired glucose tolerance: IGT) or using a novel pathophysiology-based subphenotyping of prediabetes (cluster 1-6, according to Wagner et al., Nature medicine 2021 ). Study participants were screened for diabetes-associated complications such as nephropathy, neuropathy, retinopathy, and pneumopathy, with a focus on liver steatosis and fibrosis according to liver stiffness measurement.
Results: Individuals allocated to the new prediabetes clusters 5 and 6 showed more often at least 2 diabetes-associated complications (70.6% vs. 52.2%) compared to prediabetes individuals identified using the classical parameters HbA1c, IFG and IGT (44.3% vs. 37.3% vs. 16.7%), all p=0.026. Elevated markers for liver steatosis were more common in cluster 3, 4, 5 and 6 (76% vs. 91% vs. 100% vs. 83%) compared to classical cluster HbA1c (74%), whereas for liver fibrosis in cluster 5 and 6 (50% vs. 41%) compared to 26% in the IFG cluster. Further analyses showed that 83% and 73% of people in cluster 5 and 6 with liver steatosis had at least one additional diabetes-associated complication compared to 63%/56% in cluster HbA1c/IFG.
Conclusion: The novel pathophysiology-based clusters of prediabetes help to better identify people with increased risk of diabetes-associated complications, allowing the design of early targeted preventive measures.

Disclosure
M. Ansmann: None. E. Kliemank: None. E.V. Rauchhaupt: None. L. Schimpfle: None. L. Seebauer: Other Relationship; Springer Medizin Verlag GmbH. M. Roshan: None. Z. Kender: None. S. Kopf: Speaker's Bureau; Lilly Diabetes, Bayer Inc. J. Szendroedi: None. A. Sulaj: None.
1320-P: Raising Prediabetes Awareness and Reducing Type 2 Diabetes Risk through Virtual Care for Overweight and Obesity
Authors: BROFFMAN LAUREN , FEIFEL NATHAN , HANSEN STEPHANIE , QUALLIOTINE KERRY , MA YING , STERN KEVIN , BARNES MELYNDA , SCHMIDT ERIKA 
Published: June 2024

Introduction & Objective: A third of the U.S. population has prediabetes but most are unaware. Knowing one’s status can reduce risk of future Type II Diabetes (T2D); current demand for anti-obesity medication is an opportunity to screen for prediabetes, offer counseling, and, when appropriate, initiate weight loss treatment to prevent T2D. We explored characteristics and outcomes of individuals with prediabetic HbA1C values and no prior diagnosis who sought weight management care on a direct-to-patient (DTP) digital health platform.
Methods: Using EMR data from a random sample of 25,000 DTP patients who completed blood work in early 2023, we assessed characteristics of those with prediabetic HbA1C levels and no diagnosis and evaluated the impact of GLP-1 use on the risk of developing T2D in 3 years via a validated algorithm and t-test.
Results: About a fifth (17.6%) of sampled patients had HbA1C levels of 5.7-6.4. Of those, 73.9% had no prior diagnosis. Undiagnosed patients who started GLP-1 therapy and had a 12 week follow-up weight reduced their risk of developing T2D by a mean of 3.3 percentage points (CI = 2.9-3.7, p &lt;.01).
Conclusion: A substantial number of DTP patients had HbA1C levels indicating prediabetes and no prior diagnosis, benefitting from counseling. Those who started GLP-1 therapy meaningfully reduced their body weight and significantly reduced their risk of future T2D after 12 weeks.

Disclosure
L. Broffman: Employee; Ro Health Ventures. N. Feifel: Employee; Ro. S. Hansen: Employee; Ro. K. Qualliotine: Employee; Ro. Y. Ma: Employee; Roman Health Ventures Inc. K. Stern: None. M. Barnes: Employee; Ro. E. Schmidt: None.
1325-P: Applications of Artificial Intelligence–Machine Learning by Using Spectral Analysis of Arterial Pulse to Discriminate the Vascular Effects of Metabolic Syndrome and Prediabetes
Authors: WU LI-WEI 
Published: June 2024

Introduction & Objective: Preventing type 2 diabetes and managing its complications is very important because of the many complications it causes and the high cost of treating it. Metabolic syndrome (MetS) and impaired fasting glucose (IFG) represent interrelated risk factors for developing type 2 diabetes and cardiovascular diseases. Alterations in the cardiovascular system can affect the characteristics of peripheral blood vessels in MetS and IFG. The present study aimed to use only noninvasive arterial pulse signals and combine machine-learning-based and self-developed pulse-distribution analysis (PDA) to discriminate the MetS and IFG-induced effects on vascular properties.
Methods: Divided into three groups categorized according to the five MetS factors (Control, Pre-MetS, and MetS), 113 participants receiving geriatric health checkups with standard medical inspection at Tri-Service General Hospital (TSGH) in Taiwan were enrolled in this study. The participants' radial blood pressure waveform (BPW) signal was measured, to which frequency-domain analysis (FDA) was applied. Two classification methods were used and the features of each pulse signal were collected from 40 spectral indices.
Results: BPW signal differed significantly among the three groups. Several pulse waveform indices were significantly lower in Pre-MetS and MetS than in Control. The AUC of PDA (0.83) was better than that of machine learning (AUC=0.66) in discriminating MetS. IFG and MetS factors were verified as having no obvious interference effect on the PDA classification.
Conclusion: Using pulse indices without other clinical parameters performs well discrimination in detecting MetS and IFG. The present findings facilitate a noninvasive, easy-to-use, and objective evaluation technique for the vascular properties, and could hence aid in reducing the cardiovascular risk associated with MetS and IFG.

Disclosure
L. Wu: None.
133-OR: Efficacy of a Culturally Tailored Mediterranean-Like Diet Intervention on Cardiometabolic Risk Factors
Authors: MATTEI JOSIEMER , CHENG CHAO , RODRIGUEZ JOSE F. 
Published: June 2024

Introduction & Objective: To determine if adults in Puerto Rico improved cardiometabolic risk factors on a 4-months culturally-tailored Mediterranean-like intervention (vs. standard nutritional advice).
Methods: The Puerto Rican Optimized Mediterranean-like Diet (PROMED) parallel pilot trial randomized 44 adults (25-65y) in Puerto Rico with at least 2 cardiometabolic risk factors to either an intervention (individual nutritional advice for a portion-controlled Mediterranean diet adapted for Puerto Ricans and a supply of vegetable oils and legumes for 2 months) or control group (standard portion-control nutritional advice and cooking utensils). Daily text messages emphasized each group’s nutritional advice for 4 months. Clinical assessments were done at baseline, 2 months, and 4 months. Mean changes per protocol (n=15 intervention; n=13 control) were estimated for the primary outcome of a cardiometabolic improvement score (range 0-10; higher score denotes more improved factors) and secondary outcomes.
Results: At 2 and 4 months, the cardiometabolic improvement score increased from baseline for the intervention (mean±SD: 2.0±1.4 and 1.8±1.5 points) and control groups (1.1±1.5 and 1.1±1.6 points), with no significant differences between groups. At 4 months, the intervention vs. control group had significantly greater decrease in systolic (-8.8±8.5 vs. 5.4±9.2 mmHg; p=0.02) and diastolic blood pressure (-4.4±5.4 vs. 2.7±2.9 mmHg; p= 0.02), non-significant greater decrease in waist circumference (-2.54±2.51 vs. 0.03±0.23 cm; p=0.16) and depressive symptoms score (-8.3±10.2 vs. -0.56±0.8 points; p=0.24), and non-significant greater increase in diet quality score (1.8±2.7 vs. 1.3±2.4 points; p=0.11) at 4 months. Study satisfaction was &gt;90% at 2 months at 100% at 4 months.
Conclusion: PROMED was efficacious in decreasing blood pressure in 4 months. The program’s potential of improving cardiometabolic health and high satisfaction supports its enhancement.

Disclosure
J. Mattei: None. C. Cheng: None. J.F. Rodriguez: None.

Funding
American Diabetes Association (11-22-ICTSN-33); NIH-National Institute of Minority Health and Health Disparities (R01-MD018750)