Projected Outcomes of Optimized Statin and Ezetimibe Therapy in US Military Veterans with Coronary Artery Disease.

Importance: Many patients with coronary artery disease (CAD) do not achieve the guideline-directed goals for low-density lipoprotein cholesterol (LDL-C) levels. Objective: To estimate reductions in the rates of adverse events associated with CAD in a large US military veteran population that may be achieved through use of optimized statin therapy alone or with ezetimibe compared with the prevailing lipid-lowering therapy (LLT). Design, Setting, and Participants: In this observational cohort study, US military veterans with CAD were identified by coronary angiography between June 2015 and September 2020 across 82 US Department of Veterans Affairs health care facilities. Exposures: The exposures were observed LLT, LLT with an optimized statin regimen, and LLT with optimized statin and ezetimibe. Main Outcomes and Measures: Observed rates of death, myocardial infarction, stroke, and coronary revascularization, and potential reductions in those outcomes with optimized LLT based on expected further reductions in LDL-C levels and application of formulas from The Cholesterol Treatment Trialists' Collaboration. Results: The analysis cohort comprised 111 954 veterans (mean [SD] age, 68.4 [8.8] years; 109 390 men [97.7%]; 91 589 White patients [81.8%]; 17 592 Black patients [15.7%]). The median (IQR) observation period for this study was 3.4 (2.1-4.0) years. At the time of index angiography, 66 877 patients (59.7%) were treated with statin therapy, and 623 patients (0.6%) were treated with ezetimibe. At 6 months, the number of patients with statin prescriptions increased to 74 400 (68.7%), but the number of patients with high-intensity statin prescriptions was only 57 297 (52.9%). At 6 months, ezetimibe use remained low (n = 1168 [1.1%]), and LDL-C levels were 70 mg/dL or more in 56 405 patients (52.1%). At 4 years, observed incidences of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (95% CI, 21.3%-21.8%), 5.0% (95% CI, 4.9%-5.2%), 2.2% (95% CI, 2.1%-2.3%), and 15.4% (95% CI, 15.2%-15.7%), respectively. With optimized statin treatment, projected absolute reductions in these incidences were 1.3% (95% CI, 0.9%-1.7%), 0.8% (95% CI, 0.7%-1.0%), 0.2% (95% CI, 0.1%-0.3%), and 2.3% (95% CI, 2.0%-2.7%), respectively. With optimized statin and ezetimibe treatment, projected absolute reductions were 1.8% (95% CI, 1.2%-2.4%), 1.1% (95% CI, 0.9%-1.3%), 0.3% (95% CI, 0.2%-0.4%), and 3.1% (95% CI, 2.6%-3.6%), respectively. Conclusions and Relevance: In this cohort study of veterans with CAD, suboptimal LLT was prevalent in the clinical setting. Optimization of statin therapy was projected to produce clinically relevant reductions in the risks of death and cardiovascular events. Despite a lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level in conjunction with optimized statin therapy may be associated with further meaningful reductions in cardiovascular risk.

Urine tungsten and chronic kidney disease in rural Colorado.

BACKGROUND: Chronic kidney disease (CKD) is a cause of global morbidity and mortality in agricultural communities. The San Luis Valley (SLV) is a rural agricultural community in southern Colorado with geographic and sociodemographic risk factors for CKD, including a water supply contaminated by heavy metals. METHODS: We obtained pre-existing sociodemographic, clinical, and urine trace metal data for 1659 subjects from the San Luis Valley Diabetes Study, a prospective cohort study. We assessed prospective associations between urine tungsten (W) and time-to-CKD using accelerated failure time models (n = 1659). Additionally, logistic models were used to assess relationships between urine W and renal injury markers (NGAL, KIM1) using Tobit regression (n = 816), as well as epidemiologically-defined CKD of unknown origin (CKDu) using multiple logistic regression (n = 620). RESULTS: Elevated urine W was strongly associated with decreased time-to-CKD, even after controlling for hypertension and diabetes. Depending on how CKD was defined, a doubling of urine W was associated with a 27% (95% CI 11%, 46%) to 31% (14%, 51%) higher odds of developing CKD within 5 years. The relationship between urine W and select renal injury markers was not significant, although urine NGAL was modified by diabetes status. Elevated (>95%ile) urinary W was significantly associated with CKDu (OR 5.93, 1.83, 19.21) while adjusting for known CKD risk factors. CONCLUSIONS: Our data suggest that increased exposure to W is associated with decreased time-to-CKD and may be associated with CKDu. Given persistence of associations after controlling for diabetes and hypertension, W may exert a primary effect on the kidney, although this needs to be evaluated further in future studies.

Prices, peers, and perceptions (P3): study protocol for improved biomass cookstove project in northern Ghana.

BACKGROUND: Despite their potential health and social benefits, adoption and use of improved cookstoves has been low throughout much of the world. Explanations for low adoption rates of these technologies include prices that are not affordable for the target populations, limited opportunities for households to learn about cookstoves through peers, and perceptions that these technologies are not appropriate for local cooking needs. The P3 project employs a novel experimental design to explore each of these factors and their interactive effects on cookstove demand, adoption, use and exposure outcomes. METHODS: The P3 study is being conducted in the Kassena-Nankana Districts of Northern Ghana. Leveraging an earlier improved cookstove study that was conducted in this area, the central design of the P3 biomass stove experiment involves offering stoves at randomly varying prices to peers and non-peers of households that had previously received stoves for free. Using household surveys, electronic stove use monitors, and low-cost, portable monitoring equipment, we measure how prices and peers' experience affect perceptions of stove quality, the decision to purchase a stove, use of improved and traditional stoves over time, and personal exposure to air pollutants from the stoves. DISCUSSION: The challenges that public health and development communities have faced in spreading adoption of potentially welfare-enhancing technologies, like improved cookstoves, have highlighted the need for interdisciplinary, multisectoral approaches. The design of the P3 project draws on economic theory, public health practice, engineering, and environmental sciences, to more fully grasp the drivers and barriers to expanding access to and uptake of cleaner stoves. Our partnership between academic institutions, in the US and Ghana, and a local environmental non-governmental organization creates unique opportunities to disseminate and scale up lessons learned. TRIAL REGISTRATION: ClinicalTrials.gov NCT03617952 7/31/18 (Retrospectively Registered).

Liquified Petroleum Gas (LPG) Supply and Demand for Cooking in Northern Ghana.

Like many other countries, Ghana relies on biomass (mainly wood and charcoal) for most of its cooking needs. A national action plan aims to expand liquefied petroleum gas (LPG) access to 50% of the country's population by 2020. While the country's southern urban areas have made progress toward this goal, LPG use for cooking remains low in the north. The aim of this cross-sectional study was to characterize the current state of the LPG market in this area and examine opportunities and barriers to scale up LPG adoption. We interviewed 16 LPG suppliers (stove, cylinder, and fuel vendors) as well as 592 households in the Kassena-Nankana Districts (KND) of Ghana. We find large rural-urban differences in LPG uptake: less than 10% of rural households own LPG stoves compared with over half of urban households. Awareness of LPG is high across the region, but accessibility of fuel supply is highly limited, with just one refilling station located in the KND. Affordability is perceived as the main barrier to LPG adoption, and acceptability is also limited by widespread concerns about the safety of cooking with LPG. Transitioning to a cylinder recirculation model, and providing more targeted subsidies and credit options, should be explored to expand access to cleaner cooking in this region.