Social vulnerability and traumatic brain injury hospitalizations from sports and recreation among pediatric patients in the United States

PURPOSE

This study examined the associations between individual as well as neighborhood social vulnerability and sports and recreation-related traumatic brain injury (SR-TBI) hospitalizations among pediatric patients in the U.S.

METHODS

We obtained 2009, 2010 and 2011 hospitalization data in the U.S. from the National Inpatient Sample (NIS) database, linked it to 2010 neighborhood social vulnerability index (SVI) data from the Centers for Disease Prevention and Control (CDC), and assigned U.S. hospitals to one of four SVI quartiles. SR-TBI outcomes studied include: odds of hospitalization, length of stay (LOS), and discharge to post-acute care (DTPAC).

RESULTS

We found associations between race/ethnicity and all SR-TBI outcomes; however, sex, primary payer, and neighborhood overall SVI were only associated with LOS. Compared to White children, Native American children had almost three times higher odds of hospitalization for SR-TBI (OR: 2.82, 95% CI: 1.30, 6.14), 27% longer LOS (β: 27.06, 95% CI: 16.56, 38.51), but 99.9% lower odds of DTPAC (OR: 0.001, 95% CI: 0.00, 0.01). Compared to children with private insurance, children with public insurance had 11% longer LOS (β: 10.83, 95% CI: 8.65, 13.05). Hospitalization in neighborhood with higher overall SVI was associated with longer LOS (p < 0.0001).

CONCLUSIONS

These findings suggest that individual and neighborhood social vulnerability can have a significant impact on the health outcomes of children, especially in the context of SR-TBI.

Prospective evaluation of patient-reported outcomes of invisible ink tattoos for the delivery of external beam radiation therapy: the PREFER trial

Introduction

Invisible ink tattoos (IITs) avoid cosmetic permanence of visible ink tattoos (VITs) while serving as more reliable landmarks for radiation setup than tattooless setups. This trial evaluated patient-reported preference and feasibility of IIT implementation.

Methods and materials

In an IRB-approved, single institution, prospective trial, patients receiving proton therapy underwent IIT-based treatment setup. A survey tool assessed patient preference on tattoos using a Likert scale. Matched patients treated using our institutional standard tattooless setup were identified; treatment times and image guidance requirements were evaluated between tattooless and IIT-based alignment approaches. Distribution differences were estimated using Wilcoxon rank-sum tests or Chi-square tests.

Results

Of 94 eligible patients enrolled, median age was 58 years, and 58.5% were female. Most common treatment sites were breast (18.1%), lung (17.0%) and pelvic (14.9%). Patients preferred to receive IITs versus VITs (79.8% pre-treatment and 75.5% post-treatment, respectively). Patients were willing to travel farther from home to avoid VITs versus IITs (p<0.01). Females were willing to travel (45.5% vs. 23.1%; p=0.04) and pay additional money to avoid VITs (34.5% vs. 5.1%; p<0.01). Per-fraction average +treatment time and time from on table/in room to first beam were shorter with IIT-based vs. tattooless setup (12.3min vs. 14.1min; p=0.04 and 24.1min vs. 26.2min; p=0.02, respectively).

Discussion

In the largest prospective trial on IIT-based radiotherapy setup to date, we found that patients prefer IITs to VITs. Additionally, IIT-based alignment is an effective and efficient strategy in comparison with tattooless setup. Standard incorporation of IITs for patient setup should be strongly considered.

Safety and feasibility of destination care for bariatric surgery: a single institution retrospective study

INTRODUCTION

Increasing emphasis on value-based healthcare has prompted both employers and healthcare organizations to develop innovative strategies to supply high quality care to patients. One such strategy is through the bundled care payment model (BCPM). Through this model, our institution partnered with employers from across the country to provide quality care for their members. Patients traveling greater than 2 h driving time from the bariatric center were considered "destination" patients. To properly care for our destination patients, our institution created a "destination bariatric program." We sought to investigate comparative outcomes for the first 100 patients who completed the program. We hypothesized that there would be no difference in patient outcomes or complications between destination and local patient groups undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).

METHODS AND PROCEDURES

A retrospective cohort analysis of patients undergoing bariatric surgery at a MBSAQIP-accredited bariatric surgery center between May 2019 and October 2021 was conducted. Patients were divided into destination or local patient groups based on participation in the established destination surgery program. Patient demographics, perioperative clinical outcomes, and complications were compared and statistically analyzed using two-sample t-tests, Chi-square tests, Fisher's exact tests, and univariate logistic regressions.

RESULTS

This study identified 296 patients, which consisted of destination (n = 110) and local (n = 186) patient cohorts. Patients in the destination group had higher rates of diabetes mellitus (29.1% vs 24.2%, p = 0.029), but otherwise cohorts had similar basic demographics and comorbidities. Outcomes revealed no statistically significant associations between patient cohort (destination versus local) and ED admission (p = 0.305), hospital readmission (p = 0.893), surgical reintervention (p = 0.974), endoscopic-reintervention (p = 0.714), and patient complications in the postoperative period (30 days).

CONCLUSION

Participation in destination care programs for bariatric surgery was found to be both safe and feasible. These destination programs represent an opportunity to provide a broader patient population access to complex surgical care.

The Safety and Efficacy of SCART for Bulky Metastatic or Recurrent Cancer, a Phase I Study

PURPOSE/OBJECTIVE(S)

We are proposing a new treatment methodology, (called Stereotactic Centralized Ablative Radiation Therapy, (SCART), for bulky or metastatic tumors, which is based on the principles of SFRT, by using SBRT methods to deliver an ablative radiation dose to the central portion of the target while keeping the dose to surrounding normal tissue to a relatively low level. We performed a prospective dose escalation study of SCART for bulky metastatic or recurrent cancer. The purpose of the study was to determine dose-limiting toxicities (DLTs) and the Maximum Tolerated Dose (MTD) of SCART.

MATERIALS/METHODS

This study was registered at ClinicalTrials.gov Identifier: NCT0488198, and approved at Foshan Chancheng Hospital. Patients with unresectable solid "bulky" nonhematological malignancies with limited treatment options were enrolled and received SCART with a prescription to the central spot in the tumor with a peripheral dose to the tumor edge at around 20% isodose line of the prescription dose. Five dose levels were proposed. The primary endpoint was the maximum tolerated dose (MTD), defined as the highest dose where zero of three or one of six patients experienced grade 3 dose-limiting toxicity (DLT), scored according to the Common Toxicity Criteria for Adverse Events v. 4.03, up to 6 months after SCART.

RESULTS

A total of 21 patients received SCART and have eligible data for study follow-up. The dose was escalated for two patients to 24 GyX3. No grade 3 toxicity was observed in any of the enrolled patients. The median SCART dose was 18 Gy (range: 15 - 24). Six out of the 18 patients with data for overall survival (OS) died, and the median time to death was 16.29 months (range: 0.99 - 25.58). Three patients out of the 15 patients with available data for local recurrence (LR) were found to have an LR and the median time to LR was 16.01 months (range: 0.99 - 25.58). There appears to be a trend of tumors decreasing from the patient's first visit date, or pre-SCART, to their final volume post-SCART. The mean percent change for tumor shrinkage between first visit volumes and post-SCART volumes was 49.49% (SD: 40.89, p-value:0.009). Of 15 patients with available data for progression free survival, 9 had a local recurrence or were deceased. Estimated median survival (i.e., when survival is 50%) was equal to16.80 months (95% CI = 13.90, NA). The survival rate at 12 months and 24 months were72.22% and 24.07%, respectively. Of 15 patients with available data for time to local recurrence, 3 people had a local recurrence. The percent of patients that were free from local recurrence at one and two years after the beginning of SCART treatment was 85.56% for both.

CONCLUSION

Despite the high dose delivered and the excellent local control achieved; the incidence of Any toxicity was unexpectedly low. Multiple courses of SCART are possible. The optimal dose, volume and timing of SCART still need more study.

Prospective Evaluation of Patient-Reported Outcomes of Invisible Ink Tattoos for the Delivery of External Beam Radiation Therapy: The PREFER Trial

PURPOSE/OBJECTIVE(S)

Invisible ink tattoos allow for setup accuracy while avoiding the cosmetic permanence of visible ink tattoos. The goal of this trial was to evaluate patient-reported preference for the use of invisible ink tattoos in a radiation oncology clinic.

MATERIALS/METHODS

In an IRB-approved, prospective, feasibility trial, patients at a single institution receiving pencil beam scanning proton therapy to the thorax, abdomen, or pelvis underwent invisible ink tattoo-based treatment setup. Patient preference surveys comparing visible and invisible ink tattoos were completed prior to simulation (17 questions), immediately following simulation (5 questions), and at the end of treatment (18 questions), with preference scored on a 5-point Likert scale from strongly disagree to strongly agree, and cosmesis scored on a 4-point Likert scale of excellent-good-fair-poor. Differences in distributions were examined using Wilcoxon rank-sum tests, Fisher's exact tests, or chi-square tests, where statistical significance was considered at p<0.05.

RESULTS

Of 107 patients screened, 102 were enrolled and 94 completed all surveys. Mean age was 55.0 years, and 58.5% were female. Most patients were white (79.1%) and non-Hispanic (92.6%). Patients most commonly had breast (34.0%), prostate (16.0%), and lung (9.6%) cancer. An average of 5 (range 3-8) invisible ink tattoos were placed per patient. Overall, 75.5% of patients reported that they would prefer to receive invisible tattoos vs. visible tattoos, and 88.3% rated the overall cosmetic outcome of invisible ink tattoo marks as excellent or good. Compared to males, females were more willing to travel farther from their home in order to avoid receiving visible tattoos (45.4% vs. 23.1%, p = 0.035) and would pay additional money to avoid receiving visible tattoos (34.5% vs. 5.1%, p = 0.002). Patients who had previously received any tattoo (cosmetic or visible RT tattoos) were more satisfied with the appearance of their invisible ink tattoos compared to those who had never previously received tattoos (82.9% vs. 61.5%, p = 0.022). Patients receiving definitive intent RT were more satisfied with the appearance of the tattoos compared to those receiving palliative intent RT (67.1% vs. 38.9%, p = 0.011). Patients with at least a college education were less satisfied with the appearance of tattoos compared to those without a college education (67.0% vs. 95.0% p = 0.018).

CONCLUSION

These findings demonstrate stronger avoidance of visible tattoos and patient preference for invisible tattoos. The standard incorporation of invisible ink tattoos for patient setup should be strongly considered.

High Risk Prognostic Factors Predictive of Outcome Following Stereotactic Body Radiation Therapy (SBRT) for Early-Stage Lung Cancer

PURPOSE/OBJECTIVE(S)

High risk prognostic factors for outcomes following SBRT for early-stage lung cancer per SWOG/NRG 1914 include: tumor size > 2cm; moderately/poorly/undifferentiated histology; or high metabolic activity on PET/CT defined as SUV > 6.2. The purpose of this IRB approved retrospective study is to assess outcome for stage I lung cancer and to validate SWOG risk stratification in a single community-based radiation department.

MATERIALS/METHODS

A total of 132 patients with 139 tumors treated with SBRT between 2014 and 2019 were stratified by SWOG risk group (high vs. low). To assess differences by risk group in estimated overall survival (OS) at the patient level, as well as Freedom from Local Failure (FFLF), Freedom from Regional Failure (FFRF) and Freedom from Distant Failure (FFDF) at the tumor level, Kaplan-Meier methodology and Cox proportional hazards (PH) modeling for correlated data were used. Statistical significance was concluded at the 0.05 level.

RESULTS

Median follow-up for the entire group is 56 months. 77% of patients had high risk tumors. The median patient age was 75 years with 57% female. Patients with high-risk tumors were older (p = 0.023) compared to patients with low-risk tumors. At the tumor level, high risk tumors were more likely to have biopsies performed (91% vs 57% p = 0.002) and more likely to experience regional failure (28% vs 7% p = 0.005). High risk tumors were more likely to experience local failure (8% vs 0% p = NS) and distant failure (27% vs 14% p = NS). Median survival was 49 months for the whole group (46.0 months high risk, 65.1 months low risk). Actuarial OS at 5 years is 38% (35% high risk, 51% low risk). Actuarial FFLF at 5 years is 94% (93% high risk, 100% low risk). Actuarial FFRF at 5 years is 77% (72% high risk, 93% low risk). Actuarial FFDF at 5 years is 74% (70% high risk, 88% low risk). Cox PH models revealed no statistically significant differences in FFRF by risk group (p = 0.08).

CONCLUSION

Excellent local control but higher regional and distant failure was demonstrated for high-risk lung tumors as defined by SWOG/NRG 1914. Clinically important decrement in outcomes were consistently noted for high-risk tumors in this sample which did not demonstrate statistical significance due to lack of events and statistical power. However, our data supports the prognostic importance of tumor size/grade and SUV for identifying patients at high risk. Further validation with larger sample sizes would contribute to our knowledge regarding risk stratification for early-stage lung cancer treated with SBRT.

Extracellular Perinexal Separation Is a Principal Determinant of Cardiac Conduction

BACKGROUND

Cardiac conduction is understood to occur through gap junctions. Recent evidence supports ephaptic coupling as another mechanism of electrical communication in the heart. Conduction via gap junctions predicts a direct relationship between conduction velocity (CV) and bulk extracellular resistance. By contrast, ephaptic theory is premised on the existence of a biphasic relationship between CV and the volume of specialized extracellular clefts within intercalated discs such as the perinexus. Our objective was to determine the relationship between ventricular CV and structural changes to micro- and nanoscale extracellular spaces.

METHODS

Conduction and Cx43 (connexin43) protein expression were quantified from optically mapped guinea pig whole-heart preparations perfused with the osmotic agents albumin, mannitol, dextran 70 kDa, or dextran 2 MDa. Peak sodium current was quantified in isolated guinea pig ventricular myocytes. Extracellular resistance was quantified by impedance spectroscopy. Intercellular communication was assessed in a heterologous expression system with fluorescence recovery after photobleaching. Perinexal width was quantified from transmission electron micrographs.

RESULTS

CV primarily in the transverse direction of propagation was significantly reduced by mannitol and increased by albumin and both dextrans. The combination of albumin and dextran 70 kDa decreased CV relative to albumin alone. Extracellular resistance was reduced by mannitol, unchanged by albumin, and increased by both dextrans. Cx43 expression and conductance and peak sodium currents were not significantly altered by the osmotic agents. In response to osmotic agents, perinexal width, in order of narrowest to widest, was albumin with dextran 70 kDa; albumin or dextran 2 MDa; dextran 70 kDa or no osmotic agent, and mannitol. When compared in the same order, CV was biphasically related to perinexal width.

CONCLUSIONS

Cardiac conduction does not correlate with extracellular resistance but is biphasically related to perinexal separation, providing evidence that the relationship between CV and extracellular volume is determined by ephaptic mechanisms under conditions of normal gap junctional coupling.

Multidisciplinary Inflammatory Bowel Disease Conference: The Impact of the Expert Pathologist on Patient Care

BACKGROUND

Multidisciplinary teams (MDT) aid the diagnosis and management of patients with inflammatory bowel disease (IBD) and improve patient outcomes. The direct impact of a gastrointestinal expert pathologist on MDT care of IBD patients is unknown.

METHODS

A retrospective chart review was conducted evaluating all cases (N = 289) discussed at the IBD MDT conference at Carilion Roanoke Memorial Hospital from June 1, 2013, through December 31, 2019. Cases were discussed between 1 and 6 times at the conference. Data collected included demographics, diagnosis before and after conference, reason for diagnostic change, endoscopy findings, medications, surgeries, and clinical follow-up.

RESULTS

Approximately 15% to 42% of patients had a change in diagnosis after the first 3 conferences. The majority of diagnostic changes after the first (84%), second (73%), and third (67%) conferences were due to expert pathologist interpretation. Indeterminate colitis was the most frequently changed diagnosis, and Crohn's disease was the most common new diagnosis after conference. Among patients with a diagnostic change, 28.6% to 38.5% of patients had a change in their IBD medication regimen, and 7.7% to 10.9% had a surgical intervention after the first 2 conferences. Approximately 54.2% to 60% of patients reported clinical improvement or remission within 6 months of the first 3 conferences.

CONCLUSION

The majority of diagnostic changes made at the multidisciplinary IBD conference were due to histopathologic re-interpretation. A change in diagnosis at times led to significant modifications in medical or surgical management. An expert gastrointestinal pathologist is an essential MDT member for IBD management.

Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment

Background

Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial.

Methods

Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens.

Results

137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder.

Conclusion

Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

LESSONS FROM THE IMPLEMENTATION OF THE TRANSITIONAL CARE MODEL DURING THE COVID-19 PANDEMIC

Multiple randomized controlled trials (RCTs) evaluating the Transitional Care Model (TCM)- an advanced practice registered nurse-led (APRN), team-based, care management strategy- have shown improved outcomes for older adults transitioning from hospital to home. In the current RCT, enrollment of older adults hospitalized with heart failure, chronic obstructive pulmonary disease, or pneumonia began in February 2020, just as the COVID-19 pandemic developed across the U.S. The COVID-19 pandemic dramatically impacted healthcare delivery across diverse local contexts. This parallel convergent mixed methods study aimed to explore the implementation of the TCM intervention as intended during Year 2 of the RCT (February 2021 to January 2022). This mixed-methods analysis presents the challenges and strategies to a key TCM component, “hospital-to-home,” which focuses on delivering in-person visits to patients, as identified through a qualitative descriptive analysis of 63 clinical team and leadership meetings combined with implementation fidelity data collected simultaneously on 188 TCM participants. In Year 2 of the trial, COVID-19-specific challenges continued, including COVID-19 exposure, policy changes, patients declining services, and limited safety equipment. Some challenges to the hospital-to-home TCM component occurred regardless of COVID-19, including patient (e.g., lack of engagement), nurse provider (e.g., TCM learning curve), and system (e.g., reduced primary care access) barriers. Collectively, these challenges resulted in lower fidelity to APRNs visit patterns during TCM delivery. Strategies to address these challenges were identified. The findings provide critical insight into how to target quality improvement strategies to improve the delivery of services, such as the TCM, from hospital to home settings.

Predictive Capability of Metabolic Panels for Postoperative Atrial Fibrillation in Cardiac Surgery Patients

INTRODUCTION

Postoperative atrial fibrillation (POAF) occurs in up to 65% of cardiac surgery patients and is associated with an increased risk for stroke and mortality. Electrolyte disturbances in sodium (Na+), potassium (K+), total calcium (Ca2+), chloride (Cl-), and magnesium (Mg2+) are predisposing factors for POAF, but these imbalances are yet to be used to predict POAF. The purpose of this study is to determine whether the development of POAF can be predicted by blood plasma ionic composition.

METHODS

Metabolic panels of patients with no prior history of atrial fibrillation who did (n = 763) and did not develop POAF (n = 2144) after cardiac surgery were obtained from the Carilion Clinic electronic medical record system. We initially evaluated serum Na+, K+, Ca2+, Cl-, and Mg2+ in the two groups using descriptive statistics via scatter and spaghetti plots and then with predictive modeling via logistic regression and random forest models.

RESULTS

Neither scatter nor spaghetti plots of electrolyte data revealed a significant difference between those who did and did not develop POAF. Two logistic regression models and two random forest models with POAF status as the outcome were generated using the first observation for each electrolyte and the coefficient of the linear regression, which was obtained from a linear fit of the scatter plot. The random forest model using the first observation had a sensitivity of only 12.2%, but all four models had specificities more than 97%.

CONCLUSIONS

Neither of the two logistic regression nor two random forest models were able to effectively predict the development of POAF from plasma ionic concentrations, but the random forest models effectively classified patients who would not develop POAF.

Examination of the Moderating Effect of Race on the Relationship between Vitamin D Status and COVID-19 Test Positivity Using Propensity Score Methods

INTRODUCTION

With a well-established role in inflammation and immune function, vitamin D status has emerged as a potential factor for coronavirus disease-2019 (COVID-19).

OBJECTIVE

The purpose of this study was to evaluate the moderating effect of race on the relationship between vitamin D status and the risk of COVID-19 test positivity, and to compare propensity score (PS) model results to those obtained from classical bivariate and multivariable models, which have primarily comprised the literature to date.

METHODS

Electronic health record (EHR) data from TriNetX (unmatched n = 21,629; matched n = 16,602) were used to investigate the effect of vitamin D status, as measured by 25-hydroxyvitamin D [25(OH)D], on the odds of experiencing a positive COVID-19 test using multivariable logistic regression models with and without PS methodology.

RESULTS

Having normal (≥ 30 ng/mL) versus inadequate 25(OH)D (< 30 ng/mL) was not associated with COVID-19 positivity overall (OR = 0.913, p = 0.18), in White individuals (OR = 0.920, p = 0.31), or in Black individuals (OR = 1.006, p = 0.96). When 25(OH)D was analyzed on a continuum, a 10 ng/mL increase in 25(OH)D lowered the odds of having a positive COVID-19 test overall (OR = 0.949, p = 0.003) and among White (OR = 0.935, p = 0.003), but not Black individuals (OR = 0.994, p = 0.75).

CONCLUSIONS

Models which use weighting and matching methods resulted in smaller estimated effect sizes than models which do not use weighting or matching. These findings suggest a minimal protective effect of vitamin D status on COVID-19 test positivity in White individuals and no protective effect in Black individuals.

Caregiver Engagement Enhances Outcomes Among Randomized Control Trials of Transitional Care Interventions: A Systematic Review and Meta-analysis

BACKGROUND

Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes.

OBJECTIVE

The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects.

METHODS

Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting.

RESULTS

Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035).

DISCUSSION

Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.

The Moderating Effect of Caregiver Engagement in Transitional Care Intervention Outcomes: A Meta-Analysis

As chronically ill adults age, increased fluctuations in health status result in frequent care transitions. Caregiver engagement is often a core component of evidence-based transitional care interventions, yet little is known about the relative contribution of this element to observed outcomes. This meta-analysis aimed to synthesize evidence of caregiver engagement in randomized control trials (RCT’s) of transitional care interventions, estimate the overall intervention effects on all-cause hospital readmissions, and test caregiver engagement as a moderator of interventions’ effects. Relative risk was the effect size, and the overall effect was estimated using inverse variance weighting. Fifty-four studies met criteria, representing 31,399 participants and 65 effect sizes. The weighted sample mean age was 64 years. The majority (64%) of interventions targeted participants with specific diagnoses, such as heart disease, but more than half (54%) lacked caregiver engagement components. Among all reviewed studies of transitional care interventions, the overall effect on all-cause readmissions at 1 month was non-significant (p=.123, k=28). However, intervention effects at 2 or more months were significant (RR=0.89, 95% CI: 0.82, 0.97, p=.007, k=26), indicating a 12% reduction in the relative risk of all-cause readmissions among intervention participants compared to controls. Caregiver engagement was found to moderate intervention effects (p=.05). Specifically, interventions that included caregiver engagement produced more robust effects (RR=0.83, 95% CI: 0.75, 0.92, p=.001), than those without such engagement (RR=0.97, 95% CI: 0.87, 1.08, p=.550). Findings suggest that transitional care interventions need to more explicitly engage caregivers as active partners in order to optimize patient outcomes.

Rising incidence of interpersonal violence in Pennsylvania during COVID-19 stay-at home order

BACKGROUND

The coronavirus disease 2019 pandemic and associated policies have had important downstream consequences for individuals, communities, and the healthcare system, and they appear to have been accompanied by rising interpersonal violence. The objective of this study was to evaluate the incidence of injuries owing to interpersonal violence after implementation of a statewide stay-at-home order in Pennsylvania in March 2020.

METHODS

Using the Pennsylvania Trauma Outcome Study registry, we conducted a retrospective cohort study of patients with gunshot wounds, stab wounds, and blunt assault-related injuries attributable to interpersonal violence treated at Pennsylvania trauma centers from March 16 to July 31 of 2018, 2019, and 2020.

RESULTS

There were fewer total trauma admissions in 2020 (17,489) vs 2018 (19,290) and 2019 (19,561). Gunshot wounds increased in 2020 to 737 vs 647 for 2019 and 565 for 2018 (P = .028), whereas blunt assault injuries decreased (P = .03). In all time periods, interpersonal violence primarily impacted urban counties. African American men were predominantly affected by gunshot wounds and stab wounds, whereas Caucasian men were predominantly affected by blunt assault injuries. There were more patients with substance abuse disorders and positive drug screens during coronavirus disease than in comparison periods: (stab wound population 52.3% vs 33.9% vs 45.9%, coronavirus disease era vs 2018 vs 2019, respectively P = .0001), (blunt assault injury population 41.4% vs 33.1% vs 33.5%, coronavirus disease era vs 2018 vs 2019, respectively P < .0001). There was no correlation between the incidence of interpersonal violence and coronavirus disease 2019 rates at the county level.

CONCLUSION

The implementation of a stay-at-home order was accompanied by rising incidence of gunshot and stab wound injuries in Pennsylvania. Preparedness for future resurgences of coronavirus disease 2019 and other pandemics calls for plans to address injury prevention, recidivism, and access to mental health and substance abuse prevention services.

Breakfast Consumption Habits at Age 6 and Cognitive Ability at Age 12: A Longitudinal Cohort Study

This study aimed to assess the relationship between breakfast composition and long-term regular breakfast consumption and cognitive function. Participants included 835 children from the China Jintan Cohort Study for the cross-sectional study and 511 children for the longitudinal study. Breakfast consumption was assessed at ages 6 and 12 through parental and self-administered questionnaires. Cognitive ability was measured as a composition of IQ at age 6 and 12 and academic achievement at age 12, which were assessed by the Chinese versions of the Wechsler Intelligence Scales and standardized school reports, respectively. Multivariable general linear and mixed models were used to evaluate the relationships between breakfast consumption, breakfast composition and cognitive performance. In the longitudinal analyses, 94.7% of participants consumed breakfast ≥ 4 days per week. Controlling for nine covariates, multivariate mixed models reported that compared to infrequent breakfast consumption, regular breakfast intake was associated with an increase of 5.54 points for verbal and 4.35 points for full IQ scores (p < 0.05). In our cross-sectional analyses at age 12, consuming grain/rice or meat/egg 6-7 days per week was significantly associated with higher verbal, performance, and full-scale IQs, by 3.56, 3.69, and 4.56 points, respectively (p < 0.05), compared with consuming grain/rice 0-2 days per week. Regular meat/egg consumption appeared to facilitate academic achievement (mean difference = 0.232, p = 0.043). No association was found between fruit/vegetable and dairy consumption and cognitive ability. In this 6-year longitudinal study, regular breakfast habits are associated with higher IQ. Frequent grain/rice and meat/egg consumption during breakfast may be linked with improved cognitive function in youth.

Exploring farmers' attitudes and determinants of dairy calf welfare in an expanding dairy sector

The 2015 European Union milk quota abolition initiated considerable expansion in the dairy sector in many European Union countries, most significantly in Ireland. However, this major production increase also had wider societal implications, such as negative environmental and animal welfare consequences. In this article, we used survey data of 441 Irish dairy farmers to assess farmers' attitudes toward the welfare of farmed animals and dairy calves, as well as the reputation of the Irish dairy sector. We also explored how expansion, breeding, calf management, and farmer characteristics relate to calf welfare outcomes (i.e., calf mortality, calf export, and premature culling). In relation to attitudes, farmers expressed a general concern toward animal welfare, while views toward dairy calves and industry reputation were mixed. We used Ward's linkage hierarchical cluster analysis to group farmers based on their attitudes. The cluster analysis revealed 3 distinct groups relating to high, medium, and low animal welfare concern. Herd expansion was negatively associated with being in a higher animal welfare concern cluster, whereas beef trait-focused breeding was positively associated with it. In relation to dairy calf welfare outcomes, our econometric analyses based on multiple regression and binary choice models revealed that expansion was positively associated with calf mortality, whereas improved breeding and calf management factors had a negative association. In addition, being in the high animal welfare concern cluster was negatively associated with calf mortality. Furthermore, breeding decisions were significantly associated with whether calves were exported, and being in the high animal welfare concern cluster was negatively associated with the probability that calves were sent for live export. Finally, farmers' breeding and calf management decisions were associated with premature culling of calves. Overall, this article revealed strategies worth promoting to improve dairy calf welfare, such as beef trait-focused breeding leading to greater dairy-beef integration.

The Association Between Intimate Partner Violence and 30-Year Cardiovascular Disease Risk Among Young Adult Women

Intimate partner violence (IPV), the physical, sexual, psychological abuse or control by a former or current intimate partner, affects almost one third of women in the United States. IPV exposure can result in many negative outcomes including physical injury, increased stress, and depression. Currently, there is a growing body of literature examining the link between IPV victimization and poor heart health. However, there is little known on how IPV affects cardiovascular disease (CVD) risk among young adult women and what outcomes associated with IPV victimization may be increasing this risk. A secondary analysis of the National Longitudinal Study of Adolescent to Adult Health (Add Health) was conducted to examine the association between past-year IPV exposure and 30-year CVD risk score among a representative sample of young adult women in the United States. Regression analyses were run to examine the relationship between IPV and 30-year CVD risk score. The results of the bivariate analyses suggested that past-year IPV exposure may have a small but significant impact on 30-year CVD risk score; however, this finding becomes insignificant when important covariates are introduced into the model highlighting the complexity of IPV and its co-occurring phenomenon. The findings of this study reveal that 30-year CVD risk in the context of IPV victimization should continue to be examined in this population as CVD risk may continue to grow as one experiences IPV. Future research should examine possible mediating factors in this relationship as well as biological markers that may help better understand this relationship.

The disclosure slide-Informative or obligatory, 5 years of SSO Cancer Symposium oral presentations

BACKGROUND

Financial disclosure (FD) highlights potential conflicts of interest but is often overlooked at academic conferences.

METHODS

Retrospective review of 2015-2019 Society of Surgical Oncology Cancer Symposium oral presentation slide and/or verbal FD frequency, duration, and content.

RESULTS

Of 963 presentations, 331 (34%) omitted disclosure slide/verbalization. 575 (60%) included a slide, 551 (57%) gave verbal disclosure and 133 (14%) stated relevance. 164 presentations (17%) cited 1 + FD. 2019 had greater median FDs/talk than 2015-2018 (3.50 vs. 2.00; p = .010). Compared to 2015-2018, 2019 yielded shorter median slide display of all disclosures (2.00 s vs. 2.47 s; p = .006), median 1 + FD display (3.37 s vs. 4.81 s; p = .04) and median 1 + FD verbalization (2.81 s vs. 3.66 s; p = .54). 2019 all disclosure verbalization increased (1.97 s vs. 1.14 s; p < .001). Multivariable modeling showed longer display with 2015-2018 (+1.3 s, 95% confidence interval [CI] -0.06 to 2.5 s, p = .04), <4 authors (+3.2 s, 95% CI: 2.1-4.3 s; p < .001) and longer verbalization with 2019 (+0.8 s, 95% CI: 0.2-1.4 s; p = .01), relevance (+1.0 s, 95% CI: 0.4-1.6 s; p = .002), ≤ 4 authors (+0.8 s, 95% CI: 0.3-1.3 s, p < .001) and noncommercial FD (+3.8 s, 95% CI: 2.0-5.0 s; p < .001). The five most cited commercial entities were in 39% of talks.

CONCLUSION

Presenters' FDs were brief or omitted. Despite FD increase, disclosure time decreased. Improved FD attention will highlight potential COIs.

A Comparison of Colectomy Outcomes Utilizing Open, Laparoscopic, and Robotic Techniques

INTRODUCTION

Robotic colectomy could reduce morbidity and postoperative recovery over laparoscopic and open procedures. This comparative review evaluates colectomy outcomes based on surgical approach at a single community institution.

METHODS

A retrospective review of all patients who underwent colectomy by a fellowship-trained colon and rectal surgeon at a single institution from 2015 through 2019 was performed, and a cohort developed for each approach (open, laparoscopic, and robotic). 30-day outcomes were evaluated. For dichotomous outcomes, univariate logistic regression models were used to quantify the individual effect of each predictor of interest on the odds of each outcome. Continuous outcomes received a similar approach; however, linear and Poisson regression modeling were used, as appropriate.

RESULTS

115 patients were evaluated: 14% (n = 16) open, 44% (n = 51) laparoscopic, and 42% (n = 48) robotic. Among the cohorts, there was no statistically significant difference in operative time, rate of reoperation, readmission, or major complications. Robotic colectomies resulted in the shortest length of stay (LOS) (Kruskal-Wallis P < .0001) and decreased estimated blood loss (EBL) (Kruskal-Wallis P = .0012). Median age was 63 years (interquartile range [IQR] 53-72). 54% (n = 62) were female. Median American Society of Anesthesiologists physical status classification was 3 (IQR 2-3). Median body mass index was 28.67 (IQR 25.03-33.47). A malignant diagnosis was noted on final pathology in 44% (n = 51).

CONCLUSION

Among the 3 approaches, there was no statistically significant difference in 30-day morbidity or mortality. There was a statistically significant decreased LOS and EBL for robotic colectomies.

Favorable Biochemical Freedom From Recurrence With Stereotactic Body Radiation Therapy for Intermediate and High-Risk Prostate Cancer: A Single Institutional Experience With Long-Term Follow-Up

Purpose/Objective(s): The current study reports long-term overall survival (OS) and biochemical freedom from recurrence (BFFR) after stereotactic body radiation therapy (SBRT) for men with intermediate and high-risk prostate cancer in a single community hospital setting with early adoption.

Materials/Methods: Ninety-seven consecutive men with intermediate and high-risk prostate cancer treated with SBRT between 2007 and 2015 were retrospectively studied. Categorical variables for analysis included National Comprehensive Cancer Network risk group, race, Gleason grade group, T stage, use of androgen deprivation therapy, and planning target volume dose. Continuous variables for analysis included pretreatment prostate-specific antigen (PSA), percent cores positive, age at diagnosis, PSA nadir, prostate volume, percent prostate that received 40 Gy, and minimum dose to 0.03 cc of prostate (Dmin). BFFR was assessed using the Phoenix nadir +2 definition. OS and BFFR were estimated using Kaplan–Meier (KM) methodology with comparisons accomplished using log-rank statistics. Multivariable analysis (MVA) was accomplished with a backwards selection Cox proportional-hazards model with statistical significance taken at the p < 0.05 level.

Results: Median FU is 78.4 months. Five- and ten-year OS KM estimates are 90.9 and 73.2%, respectively, with 19 deaths recorded. MVA reveals pretreatment PSA (p = 0.032), percent prostate 40 Gy (p = 0.003), and race (p = 0.031) were predictive of OS. Five- and nine-year BFFR KM estimates are 92.1 and 87.5%, respectively, with 10 biochemical failures recorded. MVA revealed PSA nadir (p < 0.001) was the only factor predictive of BFFR. Specifically, for every one-unit increase in PSA nadir, there was a 4.2-fold increased odds of biochemical failure (HR = 4.248). No significant differences in BFFR were found between favorable intermediate, unfavorable intermediate, and high-risk prostate cancer (p = 0.054) with 7-year KM estimates of 96.6, 81.0, and 85.7%, respectively.

Conclusions: Favorable OS and BFFR can be expected after SBRT for intermediate and high-risk prostate cancer with non-significant differences seen for BFFR between favorable intermediate, unfavorable intermediate, and high-risk groups. Our 5-year BFFR compares favorably with the HYPO-RT-PC trial of 84%. PSA nadir was predictive of biochemical failure. This study is ultimately limited by the small absolute number of high-risk patients included.

Repeat Thoracic Stereotactic Body Radiation Therapy (SBRT) for Nonsmall Cell Lung Cancer: Long-Term Outcomes, Toxicity, and Dosimetric Considerations

Purpose

Lung reirradiation for nonsmall cell lung cancer (NSCLC) is common for either recurrent disease or new primary cancer. Dose volume tolerance of the lung after multiple courses of radiation therapy (RT) is unknown. We review our experience with lung reirradiation for patients with NSCLC in a single community setting using stereotactic body radiation therapy (SBRT) to report lung cumulative doses, survival, and toxicity.

Methods and Materials

Forty-four patients who received at least 2 curative courses of lung RT with the second course delivered between January 2012 and December 2017 were eligible. All patients had NSCLC and were treated with SBRT for reirradiation. Cumulative lung dose volume histograms for all courses were generated, summated, and converted into cumulative equivalent dose in 2 Gy fractions (EQD2). Actuarial overall survival (OS), local control, and toxicity is reported, including a subset of patients who received more than 2 courses of SBRT.

Results

Median age of the group was 71 years (range, 51-87). Median survival of the entire group from diagnosis, first, and second courses of RT was 3.94, 3.03, and 2.03 years. Three-year actuarial OS for the entire group was 34.1% from second course of RT. The mean EQD2 Gy₃ mean lung dose for all courses was 12.35 Gy (range, 2.7-26.52). The mean EQD2 Gy₃ V5Gy, V10Gy, V20Gy, V30Gy, and V40Gy were 40.9%, 25.5%, 14.7%, 10.2%, and 7.7%. Six-year actuarial freedom from grade ≥3 complications was 86.3%. The rate of grade ≥3 lung toxicity was 4.5% (2 of 44). Other late toxicities included grade 3 recurrent laryngeal nerve damage (n = 1) and grade 3 chest wall pain/rib fracture (n = 1). Overall, 32% of patients had more than 2 courses of RT to the lung (range, 3-7).

Conclusions

Long-term OS is possible with multiple RT courses to the lung for NSCLC with low toxicity.

Understanding the Socioeconomic and Geographical Characteristics of Beneficiaries Receiving a Comprehensive Medication Review

BACKGROUND

Medicare Part D sponsors are required to offer medication therapy management (MTM) programs to eligible beneficiaries. Recent studies have demonstrated that there have been racial/ethnic disparities in MTM eligibility criteria. For example, compared with non-Hispanic White beneficiaries, Hispanic and non-Hispanic Black beneficiaries are less likely to be eligible for MTM. However, there is limited evidence for socioeconomic and geographical characteristics of those who are eligible and receive MTM services.

OBJECTIVE

To describe the demographic, socioeconomic, and geographic characteristics of Medicare beneficiaries who received MTM services.

METHODS

As part of a previous study, a national survey evaluated a convenience sample of perspectives of Medicare beneficiaries on the MTM standardized format. The survey was distributed through Medicare Part D plans to beneficiaries receiving MTM services from 2017-2018. As part of the survey, respondents could provide their ZIP codes. Geographical variables, such as the National Center for Health Statistics (NCHS) urban-rural classification scheme and economic research service (ERS) county typology codes, were then applied to respondents' ZIP codes, allowing for the classification of counties or census tracts by urbanization and economic dependence measures. Descriptive statistics are reported for demographic, geographical, and socioeconomic information.

RESULTS

Of the 300 (of 434) respondents who provided their ZIP codes, 51.3% were aged 65-74 years; 50% were male; and 66.7% had at least a college education. There were 82.7% who self-identified as White, while only 8% self-identified as Hispanic or Black/African American. The majority of respondents (58.4%) lived in large metropolitan areas as defined by the NCHS urban-rural classification scheme. Respondents' counties were characterized by economic dependence with 14.0% of respondents living in federal/state government-dependent counties and 12.7% living in recreation-dependent counties.

CONCLUSIONS

The majority of respondents who provided their ZIP codes identified themselves as White and lived in large metropolitan areas. Respondents who identified themselves as Hispanic or Black/African American were not well represented. This study provides geographical and socioeconomic characteristics of Medicare beneficiaries who received MTM services and highlights racial/ethnic differences. Further work is needed to confirm geographical and socioeconomic disparities among beneficiaries who received MTM services.

DISCLOSURES

No outside funding supported this study. Pellegrin is a member of the AMCP MTM Advisory Group. The other authors have nothing to disclose.

Nighttime Agitation and Restless Legs Syndrome in Persons With Alzheimer's Disease: Study Protocol for a Double-Blind, Placebo-Controlled, Randomized Trial (NightRest)

Nighttime agitation is a prevalent symptom in persons with Alzheimer's disease (AD). Effective treatments are absent due to our limited knowledge of its etiology. We hypothesized that restless legs syndrome (RLS), a common neurological sensorimotor disorder of uncomfortable leg sensations that appear at night and interfere with sleep, might be a cause for nighttime agitation in persons with AD. RLS is infrequently identified in persons with AD because traditional diagnosis is dependent on patients answering complex questions about their symptoms. With a validated observational tool for RLS diagnosis, the Behavioral Indicators Test-Restless Legs, we aim to diagnose RLS and determine the effect of gabapentin enacarbil (GEn) compared to placebo on nighttime agitation, sleep, antipsychotic medications, and the mechanism for these effects. We hypothesize that frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation. This study is an 8-week, double-blind, placebo-controlled, randomized pilot clinical trial, followed by an 8-week open-label trial, that is being conducted in long-term care settings and private homes. The results of this study may shift, personalize, and improve standards of care for treatment of nighttime agitation; reduce aggression and other nighttime agitation behaviors; and improve sleep.

TARGETS

Persons with AD with nighttime agitation potentially caused by RLS.

INTERVENTION DESCRIPTION

Diagnose RLS and determine the effect of GEn.

MECHANISMS OF ACTION

The frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation.

OUTCOMES

Determine the effect of GEn on nighttime agitation, sleep, and antipsychotic medications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03082755 (Date of registration March 6, 2017). [Research in Gerontological Nursing, 13(6), 280-288.].

Venous thromboembolism after penetrating femoral and popliteal artery injuries: an opportunity for increased prevention

Background

Trauma patients with penetrating vascular injuries have a higher rate of venous thromboembolism (VTE). The objective of this study was to determine the risk of VTE formation in penetrating femoral and popliteal vascular injuries and the effects of endovascular management of these injuries.

Methods

A retrospective study of Pennsylvania Trauma Outcome Study registry was conducted during a 5-year period (2013–2017). All adult patients with a penetrating mechanism with femoral/popliteal vascular injuries were studied. Primary outcome was incidence of VTE in patients with isolated arterial injuries versus combined arterial/venous injuries. Secondary endpoints were intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality. Statistical comparisons were accomplished using Fisher’s exact tests, and parametric two-sample t-tests or non-parametric Wilcoxon rank-sum tests for categorical and continuous variables, respectively.

Results

Of the 865 patients with penetrating extremity vascular injuries, 207 had femoral or popliteal artery injuries. Patients with isolated arterial injuries (n=131) had a significantly lower deep venous thrombosis (DVT) rate compared with those with concurrent venous injuries (n=76) (3.1% vs. 13.2%, p=0.008). There were 14 patients in the study who developed DVTs. Among the four patients with isolated femoral or popliteal arterial injuries who had developed DVTs, three had an open repair. Among patients with isolated arterial injuries, those with DVT spend significantly more time on the ventilator (median=2 vs. 0, p=0.0020) compared with patients without DVT. Patients with DVT also had longer stay in the hospital (median=17.5 vs. 8, p=0.0664) and in the ICU (median=3 vs. 1, p=0.0585).

Conclusions

Risk of DVT exists in patients with penetrating isolated femoral and popliteal artery trauma. Open repair was associated with significantly higher DVT rates in isolated arterial injuries.

Level of evidence

Level IV therapeutic care/management.

0861 Age, Race, And Continuous Positive Airway Pressure (CPAP) Confidence Score At 1-week Predict 3-month CPAP Adherence In Older Adults With Amnestic Mild Cognitive Impairment And Moderate To Severe Obstructive Sleep Apnea

Introduction

Adherence to continuous positive airway pressure (CPAP) may delay cognitive decline in older adults with obstructive sleep apnea (OSA) and amnestic mild cognitive impairment (MCI), defined as deficits in memory that do not significantly impact daily functioning. The aim of this analysis was to identify predictors of CPAP adherence in this population.

Methods

Data are from Memories 2, an ongoing multisite clinical trial on the effect of treatment of moderate to severe OSA on cognitive decline in older adults 65-85 years of age who have amnestic MCI. Unadjusted and adjusted linear models were used to examine predictors of mean hours of CPAP use at 3 months. Predictors were age, sex (male/female), race (White/Non-White), education (more than high school, less than high school), Apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and CPAP Comfort and Confidence scores at 7 days. Collinearity in the adjusted model for CPAP use at 3 months was examined using the variance inflation factor.

Results

Of 57 participants, most were male (54%), White (72%), with a mean age of 66.3 years (SD: 6.1). Mean AHI in this sample was 35.1 (SD: 19.9), with mean daily hours of CPAP use at 3 months 5.3 hours (SD: 2.3). Adjusted linear model results demonstrated that younger age (β=-0.13, SE=0.04, p=0.0032), White race (β=2.56, SE=0.58, p&lt;0.0001), and higher 7-day CPAP Confidence score (β=0.48, SE=0.17, p=0.0086) were significantly associated with CPAP use at 3 months. Sex, education, AHI, ESS, and CPAP comfort were not statistically significant predictors of adherence.

Conclusion

Tailored interventions to increase self-efficacy during the first 7 days of CPAP treatment, especially in Non-Whites and those older than 74 years, may improve long-term CPAP adherence in older adults with amnestic MCI.

Support

R01AG054435

Relationships Between Race/Ethnicity and Health Care Utilization Among Older Post-Acute Home Health Care Patients

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 (N = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use. Overall rates of rehospitalization and ER visits were 10% and 13%, respectively. African American and Hispanic patients experienced higher odds of ER visits or rehospitalization during their HHC episode. Racial/ethnic differences in utilization were mediated by enabling factors, such as caregiver availability, and illness-level factors, such as illness severity, functional status, and symptoms. Intervention targets may include early risk assessment, proactive management of clinical conditions, rehabilitative therapy, and caregiver training.

Estimating Human Exposure to Rat Lungworm (Angiostrongylus cantonensis) on Hawai'i Island: A Pilot Study

Angiostrongylus cantonensis is a zoonotic, parasitic nematode causing angiostrongyliasis or rat lungworm disease. Clinical diagnosis in humans is currently confirmed by detection of parasite DNA in cerebrospinal fluid. This study estimated human exposure to A. cantonensis in volunteer participants solicitated via public venues on east Hawai'i Island using blood-based tests. Antibodies were screened in sera by crude antigen ELISA, followed by a 31-kDa dot-blot test developed and validated in Thailand. Human participants (n = 435) donated blood samples and completed a questionnaire to self-report relevant symptomology or clinical diagnosis. Among symptoms reported by participants diagnosed by licensed clinicians, headaches, high eosinophil counts, stiff neck, fatigue, and joint pain were most severe during the initial 3 months of infection. ELISA results revealed 22% of the serum samples as positive, 46% as equivocal, and 32% as negative. A subset of 186 samples was tested by dot blot, with 30% testing positive and 70% testing negative. A significantly higher mean ELISA value was found among recently (2014-2015) clinically diagnosed participants as than among those with a diagnosis before 2010 (P = 0.027). All dot-blot positives were also ELISA positive and were significantly associated with higher ELISA values compared with dot-blot negatives (P = 0.0001). These results suggest that an ELISA using crude antigen isolated from adult A. cantonensis from Hawai'i may be an effective initial screening method for estimating exposure to A. cantonensis in Hawai'i and likewise suggest that dot-blot tests using the 31-kDa antigen exhibit efficacy as a diagnostic for exposure.

A Comparison of Missing-Data Imputation Techniques in Exploratory Factor Analysis

BACKGROUND AND PURPOSE

To compare the effects of missing-data imputation techniques, mean imputation, group mean imputation, regression imputation, and multiple imputation (MI), on the results of exploratory factor analysis under different missing assumptions.

METHODS

Missing data with different missing assumptions were generated from true data. The quality of imputed data was examined by correlation coefficients. Factor structures were compared indirectly by coefficients of congruence and directly by factor structures.

RESULTS

MI had the best quality and matching factor structure to the true data for all missing assumptions with different missing rates. Mean imputation had the least favorable results in factor analysis. The imputation techniques revealed no important differences with 10% of data missing.

CONCLUSION

MI showed the best results, especially with larger proportions of missing data.

P53 Alteration in Oral Tongue Cancer is Not Significantly Associated with Age at Diagnosis or Tobacco Exposure

Aims and background

The tumor suppressor gene P53 is mutated in almost half of head and neck cancers. The current work assessed the prognostic significance of P53 alteration in patients with squamous cell carcinoma of the oral tongue treated with a curative intent, its association with age at diagnosis (using 45 years as a cut point), and risk exposure as defined by tobacco and/or alcohol consumption.

Methods

P53 alteration was determined immunohistochemically in 45 patients with tongue cancer treated with a curative intent.

Results

P53 alteration occurred in 20 of 45 tumors (44%) and was more common among younger patients (58% versus 36% for younger versus older patients, respectively) and those lacking tobacco/alcohol exposure (53% versus 40% for “no-risk” and “risk” groups, respectively), but the differences were not statistically significant. With a median follow-up of 56 months, 5-year progression-free survival rates were 48% and 66% in patients with and without P53 detection, respectively (P = 0.22).

Conclusions

Despite a trend of a younger age at diagnosis in P53-altered tumors, results did not reach statistically significant differences. A trend of a worse clinical outcome with P53 alteration was noted.

Effect of a Breakfast in the Classroom Initiative on Obesity in Urban School-aged Children: A Cluster Randomized Clinical Trial

IMPORTANCE

Serving breakfast in the classroom is promoted to increase participation in the federal School Breakfast Program. However, little is known about the effect of breakfast in the classroom on children's weight status.

OBJECTIVE

To evaluate the effect of a breakfast in the classroom initiative, which combined breakfast in the classroom with breakfast-specific nutrition education, on overweight and obesity among urban children in low-income communities.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized clinical trial among 1362 fourth- through sixth-grade students from low-income urban communities across 2.5 years. Sixteen kindergarten through eighth grade Philadelphia public schools with universal breakfast participated. Participants were recruited in September 2013, and the intervention began in January 2014. Data analysis took place from April 1, 2018, to August 30, 2018.

INTERVENTIONS

Intervention schools received a program that included breakfast in the classroom and breakfast-specific nutrition education. Control schools continued breakfast before school in the cafeteria and standard nutrition education.

MAIN OUTCOMES AND MEASURES

The primary outcome was the combined incidence of overweight and obesity. Secondary outcomes included the combined prevalence of overweight and obesity, incidence and prevalence of obesity, changes in body mass index (BMI) z score, and School Breakfast Program participation.

RESULTS

Among the 1362 students, mean (SD) age was 10.8 (0.96) years and 700 (51.4%) were female; 907 (66.6%) were black, 233 (17.1%) were Hispanic, 100 (7.3%) were white, 83 (6.1%) were Asian, and 39 were of multiple or other race/ethnicity. After 2.5 years, students in intervention schools had participated in the School Breakfast Program 53.8% of days, compared with 24.9% of days among students in control schools (β = 0.33; 95% CI, 0.22-0.42). There was no difference between intervention and control schools in the combined incidence of overweight and obesity after 2.5 years (11.7% vs 9.3%; odds ratio [OR] 1.31; 95% CI, 0.85-2.02; P = .22). However, the incidence (11.6% vs 4.4%; OR, 2.43; 95% CI, 1.47-4.00) and prevalence (28.0% vs 21.2%; OR, 1.46; 95% CI, 1.11-1.92) of obesity were higher in intervention schools than in control schools after 2.5 years.

CONCLUSIONS AND RELEVANCE

A breakfast in the classroom initiative increased participation in the School Breakfast Program and did not affect the combined incidence of overweight and obesity. However, the initiative had an unintended consequence of increasing incident and prevalent obesity. Further research is needed to identify approaches to increase participation in the School Breakfast Program that do not increase obesity among students.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01924130.

CPAP Adherence May Slow 1-Year Cognitive Decline in Older Adults with Mild Cognitive Impairment and Apnea

BACKGROUND/OBJECTIVES

Obstructive sleep apnea (OSA) has been linked to an increased risk for Alzheimer's disease (AD), but little prospective evidence exists on the effects of OSA treatment in preclinical AD. The objective was to determine if continuous positive airway pressure (CPAP) treatment adherence, controlling for baseline differences, predicts cognitive and everyday function after 1 year in older adults with mild cognitive impairment (MCI) and to determine effect sizes for a larger trial.

DESIGN

Quasi-experimental pilot clinical trial with CPAP adherence defined as CPAP use 4 hours or more per night over 1 year.

SETTING

Sleep and geriatric clinics and community.

PARTICIPANTS

Older adults, aged 55 to 89 years, with an apnea-hypopnea index of 10 or higher participated: (1) MCI, OSA, and CPAP adherent (MCI +CPAP), n = 29; and (2) MCI, OSA, CPAP nonadherent (MCI -CPAP), n = 25.

INTERVENTION

CPAP.

MEASUREMENTS

The primary cognitive outcome was memory (Hopkins Verbal Learning Test-Revised), and the secondary cognitive outcome was psychomotor/cognitive processing speed (Digit Symbol subtest from the Wechsler Adult Intelligence Scale Substitution Test). Secondary function and progression measures were the Everyday Cognition, Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change Scale, and Clinical Dementia Rating.

RESULTS

Statistically significant improvements in psychomotor/cognitive processing speed in the MCI +CPAP group vs the MCI -CPAP group were observed at 1 year after adjustment for age, race, and marital status (parameter estimate = 1.68; standard error = 0.47; 95% confidence interval = 0.73-2.62), with a 6-month effect size (ES) of 0.46 and a 1-year ES of 1.25. There were small to moderate ESs for memory (ES 0.20, 6 mo), attention (ES 0.25, 1 y), daytime sleepiness (ES 0.33, 6 mo and ES 0.22, 1 y), and everyday function (ES 0.50, 6 mo) favoring the MCI +CPAP group vs the MCI -CPAP group.

CONCLUSION

Controlling for baseline differences, 1 year of CPAP adherence in MCI +OSA significantly improved cognition, compared with a nonadherent control group, and may slow the trajectory of cognitive decline.

TRIAL REGISTRATION NUMBER

Memories; NCT01482351; https://clinicaltrials.gov/ct2/show/NCT01482351?cond=MCI+and+OSA&rank=1 J Am Geriatr Soc 67:558-564, 2019.

Interactive effects of sleep duration and morning/evening preference on cardiovascular risk factors

Background

Sleep duration and morningness/eveningness (circadian preference) have separately been associated with cardiovascular risk factors (i.e. tobacco use, physical inactivity). Interactive effects are plausible, resulting from combinations of sleep homeostatic and circadian influences. These have not been examined in a population sample.

Methods

Multivariable regression models were used to test the associations between combinations of sleep duration (short [≤6 h], adequate [7-8 h], long [≥9 h]) and morning/evening preference (morning, somewhat morning, somewhat evening, evening) with the cardiovascular risk factors of tobacco use, physical inactivity, high sedentary behaviour, obesity/overweight and eating fewer than 5 daily servings of fruit and vegetables, in a cross-sectional sample of 439 933 adults enrolled in the United Kingdom Biobank project.

Results

Participants were 56% female, 95% white and mean age was 56.5 (SD = 8.1) years. Compared with adequate sleep with morning preference (referent group), long sleep with evening preference had a relative odds of 3.23 for tobacco use, a 2.02-fold relative odds of not meeting physical activity recommendations, a 2.19-fold relative odds of high screen-based sedentary behaviour, a 1.47-fold relative odds of being obese/overweight and a 1.62-fold relative odds of <5 fruit and vegetable daily servings. Adequate sleep with either morning or somewhat morning preference was associated with a lower prevalence and odds for all cardiovascular risk behaviours except fruit and vegetable intake.

Conclusions

Long sleepers with evening preference may be a sleep phenotype at high cardiovascular risk. Further work is needed to examine these relationships longitudinally and to assess the effects of chronotherapeutic interventions on cardiovascular risk behaviours.

Testing the Efficacy of a Web-Based Parent-Adolescent Sexual Communication Intervention Among Puerto Ricans

This randomized controlled trial tested the efficacy of a Web-based intervention to increase sexual communication between parents and adolescents. Parent/adolescent dyads (n = 660) were recruited from communities in the San Juan area and randomly assigned to the Cuídalos sexual communication or physical activity program. Parent assessments were obtained preintervention and at 3-, 6-, and 12-month follow-up. Parents in the experimental group reported significantly more sexual communication (ie, peer pressure, sexual prevention, protection, risk) over time than parents in the control group. Results support the efficacy of the Cuídalos Web-based format and provide insight into future Web-based sexual health interventions for this population.

Predicting cervical cancer screening among sexual minority women using Classification and Regression Tree analysis

Cervical cancer screening is a critical preventive healthcare service for all women. Sexual minority women (SMW) in the United States experience multiple health disparities including decreased access to and use of cervical cancer screening. The mechanisms driving these disparities are not clear and SMW with multiple marginalized identities may be more likely to miss recommended cervical cancer screening. This study aimed to identify subgroups of SMW that are more and less likely to be screened for cervical cancer according to American Cancer Society guidelines. We used cross-sectional data from the latest (2010-2012) wave of the Chicago Health and Life Experiences of Women (CHLEW) Study (N = 691). Informed by intersectionality theory, we performed classification and regression tree (CART) modeling to construct a data-driven, predictive model of subgroups of SMW who were more and less likely to receive guideline-recommended screening. Notably, the CART model did not include commonly tested variables such as race/ethnicity or level of income or education. The model did identify subgroups with low likelihood of receiving screening and several novel variables that may be important in understanding SMW's use of cervical cancer screening; lifetime number of sexual partners, age at drinking onset, childhood physical abuse, and internalized homonegativity. Our results point to the importance of early life experiences and identity development processes in shaping patterns of preventive healthcare use among adult SMW. Our analysis also demonstrated the potential value of CART modeling techniques for evaluating how multiple variables interact in complex ways to predict cervical cancer screening.

Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention

Background

We previously reported reduction in the rate of hospitalisations with medication harm among older adults with our ‘Pharm2Pharm’ intervention, a pharmacist-led care transition and care coordination model focused on best practices in medication management. The objectives of the current study are to determine the extent to which medication harm among older inpatients is ‘community acquired’ versus ‘hospital acquired’ and to assess the effectiveness of the Pharm2Pharm model with each type.

Methods

After a 3-year baseline, six non-federal general acute care hospitals with 50 or more beds in Hawaii implemented Pharm2Pharm sequentially. The other five such hospitals served as the comparison group. We measured frequencies and quarterly rates of admissions among those aged 65 and older with ‘community-acquired’ (International Classification of Diseases-coded as present on admission) and ‘hospital-acquired’ (coded as not present on admission) medication harm per 1000 admissions from 2010 to 2014.

Results

There were 189 078 total admissions from 2010 through 2014, 7% of which had one or more medication harm codes. There were 16 225 medication harm codes, 70% of which were community-acquired, among these 13 795 admissions. The varied times when the intervention was implemented across hospitals were associated with a significant reduction in the rate of admissions with community-acquired medication harm compared with non-intervention hospitals (p=0.001), and specifically harm by anticoagulants (p<0.0001) and by medications in therapeutic use (p<0.001). The hospital-acquired medication harm rate did not change. The rate of admissions with community-acquired medication harm was reduced by 4.28 admissions per 1000 admissions per quarter in the Pharm2Pharm hospitals relative to the comparison hospitals.

Conclusion

The Pharm2Pharm model is an effective way to address the growing problem of community-acquired medication harm among high-risk, chronically ill patients. This model demonstrates the importance of deploying specially trained pharmacists in the hospital and in the community to systematically identify and resolve drug therapy problems.

Attrition in NRG Oncology's Radiation-Based Clinical Trials

PURPOSE

To determine individual, organizational, and protocol-specific factors associated with attrition in NRG Oncology's radiation-based clinical trials.

METHODS AND MATERIALS

This retrospective analysis included 27,443 patients representing 134 NRG Oncology's radiation-based clinical trials .trials with primary efficacy results published from 1985-2011. Trials were separated on the basis of the primary endpoint (fixed time vs event driven). The cumulative incidence approach was used to estimate time to attrition, and cause-specific Cox proportional hazards models were used to assess factors associated with attrition.

RESULTS

Most patients (69%) were enrolled in an event-driven trial (n = 18,809), while 31% were enrolled in a fixed-time trial (n = 8634). Median follow-up time for patients enrolled in fixed-time trials was 4.1 months and 37.2 months for patients enrolled in event-driven trials. Fixed time trials with a duration < 6 months had a 5 month attrition rate of 4.3% (95% confidence interval [CI]: 3.4%, 5.5%) and those with a duration ≥ 6 months had a 1 year attrition rate of 1.6% (95% CI: 1.2, 2.1). Event-driven trials had 1- and 5-year attrition rates of 0.5% (95% CI: 0.4%, 0.6%) and 13.6% (95% CI: 13.1%, 14.1%), respectively. Younger age, female gender, and Zubrod performance status >0 were associated with greater attrition as were enrollment by institutions in the West and South regions and participation in fixed-time trials.

CONCLUSIONS

Attrition in clinical trials can have a negative effect on trial outcomes. Data on factors associated with attrition can help guide the development of strategies to enhance retention. These strategies should focus on patient characteristics associated with attrition in both fixed-time and event-driven trials as well as in differing geographic regions of the country.