Differentiation latency and dormancy signatures define fetal liver HSCs at single cell resolution

Decoding the gene regulatory mechanisms mediating self-renewal of hematopoietic stem cells (HSCs) during their amplification in the fetal liver (FL) is relevant for advancing therapeutic applications aiming to expand transplantable HSCs, a long-standing challenge. Here, to explore intrinsic and extrinsic regulation of self-renewal in FL-HSCs at the single cell level, we engineered a culture platform designed to recapitulate the FL endothelial niche, which supports the amplification of serially engraftable HSCs ex vivo. Leveraging this platform in combination with single cell index flow cytometry, serial transplantation assays, and single cell RNA-sequencing, we elucidated previously unrecognized heterogeneity in immunophenotypically defined FL-HSCs and demonstrated that differentiation latency and transcriptional signatures of biosynthetic dormancy are distinguishing properties of self-renewing FL-HSCs with capacity for serial, long-term multilineage hematopoietic reconstitution. Altogether, our findings provide key insights into HSC expansion and generate a novel resource for future exploration of the intrinsic and niche-derived signaling pathways that support FL-HSC self-renewal.

Abstract 10 Interim Results of a Phase I Study Investigating a Cord Blood-Derived Natural Killer Cell Therapy for Patients Hospitalized with COVID-19

Introduction

In the setting of viral infections, including infection with SARS-CoV-2, lymphocyte exhaustion and lymphopenia are common. Patients with COVID-19 who develop lymphopenia, particularly low numbers of circulating natural killer (NK) cells, are at high risk for disease progression. Thus, strategies that overcome profound lymphopenia and restore innate immune function may reduce the severity of COVID-19. One approach is the direct infusion of an exogenous source of healthy, functional NK cells intended to boost the patient’s immune system during the viral infection, enabling elimination of infected cells. “DVX201” is a cord blood-derived allogeneic NK cell therapy that is cryopreserved and intended for “off-the-shelf use” without HLA-matching.

Objective

The primary objective of this study is to investigate the safety and to identify the recommended phase II dose and/or the maximum tolerated dose (MTD) of DVX201 in patients hospitalized with COVID-19.

Methods

We are conducting an open-label, nonrandomized phase I safety and dose-finding (modified 3+3) study of DVX201 at three dose levels in patients hospitalized with COVID-19. Adult patients with documented SARS-CoV-2 infection were eligible if they were admitted to the hospital, were receiving ≤6 L supplemental oxygen by low flow delivery, and did not have other evidence of cytokine storm based on levels of serum IL-6, C-reactive protein, and ferritin.

Results

To date, 9 patients have been enrolled: 3 subjects at each dose level. All dose levels have been well tolerated, with no dose-limiting toxicities, infusion toxicities, or cytokine release syndrome observed. All patients were discharged from the hospital at an average of 5 days post infusion. Blood samples were drawn for correlative studies including persistence of DVX201, pre- and post-infusion immune system characterization, and cytokine panels. Accrual is continuing at the MTD.

Discussion

This trial will serve as the proof of concept for the use of DVX201 as an anti-viral treatment for COVID-19. These results will inform the potential role of DVX201 for treatment of other life-threatening viral infections by harnessing NK cells’ innate function to kill virally infected cells, regardless of the etiology of the infection.

Abstract 2 Development of CAR-NK Cell Therapy for Hematologic Malignancies

Introduction

Natural killer (NK) cells can kill tumor cells without priming or prior activation through their complement of activating and inhibitory surface molecules. Chimeric antigen receptor (CAR) expression by engineered NK cells can improve both specificity and potency of the NK cells’ anti-tumor efficacy. CAR-NK cell therapy may be a safer, more clinically accessible, and cost effective allogeneic cellular therapy in comparison to autologous CAR-T cell therapy, as NK cells do not cause graft versus host disease (GvHD) or cytokine release syndrome (CRS).

Objective

We aimed to develop an allogeneic, cryopreserved, off-the-shelf CAR-NK cell product for the treatment of hematologic malignancies.

Methods

Our CD56+ NK cells are generated from cord blood-derived CD34+ cells, which undergo expansion and priming on a proprietary Notch ligand cell culture platform followed by a second culture phase of NK cell differentiation. These cells were transduced using a viral vector to express a CAR specific for an antigen expressed on the cell surface of acute lymphoblastic leukemia (ALL) cells. The CAR-NK cells were assessed for CAR expression, NK cell phenotype, and in vitro cytotoxicity both pre- and post-cryopreservation. An ALL xenograft mouse model was treated using repeat doses of cryopreserved CAR-NK cell product, with readouts of body weight, tumor growth, and survival.

Results

The transduced CAR-NK cell product displayed viability and phenotyping comparable to the untransduced control NK cell product but possessed significantly enhanced cytotoxicity against ALL target cells in vitro. Following cryopreservation and thaw, the CAR-NK cell product retained CAR expression and maintained enhanced anti-tumor function in vitro. Cryopreserved CAR-NK cell product was safely given in up to 8 repeat doses to ALL xenograft mice and significantly inhibited tumor growth as well as increased survival compared with control NK cell product.

Discussion

We have demonstrated in this proof-of-concept study that our cord blood CD34+ cell-derived CAR-NK cell product can maintain CAR expression, with specific and enhanced potency both in vitro and in vivo, following cryopreservation and thaw. Additional preclinical studies are planned to develop CAR-NK off-the-shelf cell therapy for AML and other hematologic malignancies.

Abstract 3 Generation of Myeloid Cells from Cord Blood-Derived CD34+ Cells for Therapeutic Intent

Introduction

Macrophages and monocytes traffic to and infiltrate complex solid tumor microenvironments where conditions can promote an immunosuppressive phenotype in resident tumor-associated macrophages that hinder effective anti-tumor immune responses. Ongoing advances in cell engineering are being adapted to modify monocytes and macrophages into efficacious anti-tumor cell therapies. However, a limiting factor to this promising therapy has been cell numbers, since monocytes obtained from adult peripheral blood mononuclear cells do not expand ex vivo.

Objective

We are developing an expanded allogeneic, cryopreserved, off-the-shelf myeloid cell product for the treatment of solid tumors.

Methods

CD34+ cells isolated from pooled donor cord blood are the starting material for generation of myeloid cells. The process has three phases: (1) expansion of hematopoietic stem and progenitor cells, (2) continued expansion and differentiation into monocytes, and (3) differentiation of monocytes into mature macrophages. Cells are characterized before and after cryopreservation by immune phenotyping, morphology, and phagocytic capacity.

Results

The current culture method produces several thousand HLA-DR+ CD11b+ myeloid cells at both the monocyte and macrophage stage per starting CD34+ cell. These cells make up ~70% of the final cell product along with a potentially beneficial heterogeneous mix of additional myeloid-derived cells. Immunophenotyping demonstrates expression of canonical monocyte/macrophage markers, including CD14, CD86, and CD163. Cell morphology after macrophage differentiation is similar to that of peripheral blood-derived mature adult macrophages. Importantly, the final cell product can be cryopreserved with excellent recovery of viable cells post-thaw that are functional, as demonstrated by maintenance of phagocytic potential when compared with pre-cryopreservation function.

Discussion

This proprietary CD34+ cell expansion and directed differentiation platform results in the generation of therapeutically relevant numbers of functional myeloid cells. Furthermore, the ability to cryopreserve these cells, with demonstrated viability and function upon thaw, facilitates their use as an off-the-shelf cell therapy, with potential for faster and less expensive routes to treatments for solid tumors that have proven resistant to other cell therapies. Additional work is being done toward engineering these myeloid cells to express proteins to enhance a patient’s anti-tumor immune responses, whether these cells are used alone or in combination with other therapeutics.

Infusion of Non-HLA-Matched Off-the-Shelf Ex Vivo Expanded Cord Blood Progenitors in Patients Undergoing Cord Blood Transplantation: Result of a Phase II Clinical Trial

Recipients of myeloablative cord blood transplants (CBT) are known to experience delayed hematopoietic recovery and an increased risk of transplant related mortality (TRM). We developed methods for ex vivo expansion and cryopreservation of CB stem and progenitor cells. 15 patients with hematologic malignancies were enrolled in this single center phase II trial between September 2010 and August 2012 to assess the safety of infusing a non-HLA-matched expanded CB product to bolster a conventional CBT. On the day of transplant, an infusion of the expanded CB product followed the primary graft (1 or 2 unmanipulated CB units). All patients engrafted. Median time to neutrophil and platelet recovery was 19 and 35 days, respectively. Early myelomonocytic recovery was almost entirely due to cells arising from the non-HLA-matched expansion product and were no longer detected at day 14 in all but 2 patients. The probability of 3-years disease free survival was 86%. No TRM was observed throughout the study period, and only 2 patients relapsed. All patients presented with grade II acute graft-versus-host disease (aGVHD) at a median time of 32 days, with no grade III-IV aGVHD observed. At 2 years only 2 patients remain on immunosuppressive therapy for mild chronic GVHD. This phase II safety study demonstrate that infusion of an off-the-shelf non-HLA-matched expanded CB product in addition to a conventional CB graft was safe and led to sustained myeloid recovery. Based on these encouraging results, a prospective multicenter randomized trial utilizing this product has been conducted and results will be soon released. ClinicalTrials.gov Identifier: NCT01175785.

Group Coaching Using Energy-Based Practices for Health, Healing, and Personal Growth: Program Design and Training Outcomes

An innovative training curriculum on energy-based practices for group coaching was developed and disseminated to 16 coaching students. This article describes phase 1 curriculum design and initial evaluation of the coaching program. Findings demonstrated the benefits of this course, highlighted areas for refinement, and support progression to phase 2 for wider dissemination.

High Incidence of Herpes Zoster After Cord Blood Hematopoietic Cell Transplant Despite Longer Duration of Antiviral Prophylaxis

BACKGROUND

Cord blood transplant (CBT) recipients have a high incidence of herpes zoster (HZ) in the context of short-term peritransplant antiviral prophylaxis. In 2009, international guidelines recommended HZ prophylaxis for at least 1 year after hematopoietic cell transplant. The impact of longer-term antiviral prophylaxis on HZ incidence after CBT is unknown.

METHODS

We retrospectively analyzed varicella zoster virus (VZV)-seropositive CBT recipients who were transplanted between 2006 and 2016. We abstracted HZ events and other variables for up to 5 years post-CBT. We calculated the cumulative incidence of HZ and used Cox proportional hazards regression to identify variables associated with HZ.

RESULTS

The study cohort consisted of 227 patients. Among 1-year survivors, 91% were still receiving prophylaxis, for a median duration of 20.6 months. HZ occurred in 44 patients (19%) at a median of 23.6 months. The cumulative incidence of HZ by 1 year after CBT was 1.8% (95% confidence interval [CI], .1%-4%), but increased to 26% (95% CI, 19%-33%) by 5 years. In a multivariable analysis, acute graft-vs-host disease was associated with increased risk, whereas antiviral prophylaxis was associated with reduced risk for HZ (adjusted hazard ratio, 0.19 [95% CI, .09-.4]). There was no association between CD4+ T-cell counts at 1 year post-CBT and subsequent risk for HZ.

CONCLUSIONS

We found a high incidence of HZ after CBT despite antiviral prophylaxis for > 1 year. Based on these findings, we suggest longer duration of prophylaxis for HZ after CBT. Compliance with antiviral prophylaxis, VZV-specific immune monitoring, and vaccination to mitigate HZ after CBT also require further study.

Mechanical biofilm disruption causes microbial and immunological shifts in periodontitis patients

Periodontitis is characterized by subgingival biofilm dysbiosis, inflammation and tissue destruction. Current treatment involves mechanical biofilm disruption known as non-surgical periodontal therapy (NSPT). This study sought to characterise the impact of treatment on microbial diversity and overall community, and the parallel impact on host inflammation in the oral cavity. Fourty-two periodontitis patients were included in this study, with periodontal clinical parameters, subgingival plaque and saliva samples collected at baseline and 90 days after treatment. Salivary cytokines were quantified, and subgingival plaque was analysed using 16S rRNA sequencing. After treatment, there were marked health-associated alterations in microbial composition and diversity, including differential abundance of 42 genera and 61 species. These changes were accompanied by substantial clinical improvement (pockets ≥ 5 mm, 27.50% to 9.00%, p < 0.001) and a decrease in salivary IL-1β (p < 0.001)-a putative marker of periodontal inflammation. Despite significant reductions in disease associated anaerobes, several genera (Fusobacterium, Prevotella, Tanenerella, Treponema) remained present and formed a distinct subnetwork associated with residual disease. Collectively, this study shows that current periodontal treatment results in partial restoration of a healthy microbial ecosystem, but features of biofilm dysbiosis and host inflammation remain in some patients, which were surprisingly independent of clinical response.

Needs Assessment to Inform and Improve Educational Practices Surrounding Omega-3 Consumption during Pregnancy

OBJECTIVES

Adequate dietary consumption of long chain omega-3 fatty acids (n-3 LCPUFA) during pregnancy has been associated with better maternal and infant health outcomes. Given that the primary source of n-3 LCPUFA is fish and fish oils, concerns surrounding contamination and uncertainty of safe fish intake guidelines have negatively affected consumption of fish during pregnancy. Although obstetric healthcare providers are in a unique position to influence dietary intake patterns, a gap exists in their understanding the knowledge and practices surrounding n-3 LCPUFA. This needs assessment investigation evaluated knowledge, attitudes and prescribing/recommending practices of obstetric practitioners surrounding n-3 LCPUFA consumption and/or supplementation to generate evidence supporting the development of targeted educational initiatives.

METHODS

A cross-sectional, needs assessment was conducted using anonymous online-survey of affiliate members of the American College of Nurse Midwives (N = 105). A 24-item, previously validated (α = 0.86) needs assessment survey (Obstetric Clinicians Omega-3 Survey, OCOS) was used to assess attitudes, knowledge, and prescribing practices surrounding n-3 LCPUFA.

RESULTS

The total OCOS score representing attitudes, knowledge and prescribing patterns collectively was 69.48% (Mean = 79.90(± 12.44), score range = 24-115). Scores for the sub-domains included attitude 68.33% (Mean = 20.50(± 3.64), score range = 6-30); knowledge 71.40% (Mean = 30.70(± 5.43), score range = 9-43); and prescribing patterns 68.31% (Mean = 28.69(± 5.39), score range = 9-42).

CONCLUSIONS FOR PRACTICE

Although the majority of respondents had fair-moderate n-3 LCPUFA knowledge, attitudes and prescribing/recommending, our results highlight an opportunity for additional research and educational outreach targeting improved n-3 LCPUFA knowledge and practices. Specific areas of educational interest included associated health outcomes, dosing and safe consumption guidelines.

Cord blood maternal microchimerism following unrelated cord blood transplantation

Cord blood transplantation (CBT) is associated with low risk of leukemia relapse. Mechanisms underlying antileukemia benefit of CBT are not well understood, however a previous study strongly but indirectly implicated cells from the mother of the cord blood (CB) donor. A fetus acquires a small number of maternal cells referred to as maternal microchimerism (MMc) and MMc is sometimes detectable in CB. From a series of 95 patients who underwent double or single CBT at our center, we obtained or generated HLA-genotyping of CB mothers in 68. We employed a technique of highly sensitive HLA-specific quantitative-PCR assays targeting polymorphisms unique to the CB mother to assay CB-MMc in patients post-CBT. After additional exclusion criteria, CB-MMc was evaluated at multiple timepoints in 36 patients (529 specimens). CB-MMc was present in 7 (19.4%) patients in bone marrow, peripheral blood, innate and adaptive immune cell subsets, and was detected up to 1-year post-CBT. Statistical trends to lower relapse, mortality, and treatment failure were observed for patients with vs. without CB-MMc post-CBT. Our study provides proof-of-concept that maternal cells of the CB graft can be tracked in recipients post-CBT, and underscore the importance of further investigating CB-MMc in sustained remission from leukemia following CBT.

Impact of T Cell Repertoire Diversity on Mortality Following Cord Blood Transplantation

Introduction

Cord blood transplantation (CBT) recipients are at increased risk of mortality due to delayed immune recovery (IR). Prior studies in CBT patients have shown that recovery of absolute lymphocyte count is predictive of survival after transplant. However, there are no data on the association of T-cell receptor (TCR) and clinical outcomes after CBT. Here we retrospectively performed TCR beta chain sequencing on peripheral blood (PB) samples of 34 CBT patients.

Methods

All patients received a total body irradiation based conditioning regimen and cyclosporine and MMF were used for graft versus host disease (GvHD) prophylaxis. PB was collected pretransplant on days 28, 56, 80, 180, and 1-year posttransplant for retrospective analysis of IR utilizing high-throughput sequencing of TCRβ rearrangements from genomic DNA extracted from PB mononuclear cells. To test the association between TCR repertoire diversity and patient outcomes, we conducted a permutation test on median TCR repertoire diversity for patients who died within the first year posttransplant versus those who survived.

Results

Median age was 27 (range 1–58 years) and most of the patients (n = 27) had acute leukemias. There were 15 deaths occurring between 34 to 335 days after transplant. Seven deaths were due to relapse. Rapid turnover of T cell clones was observed at each time point, with TCR repertoires stabilizing by 1-year posttransplant. TCR diversity values at day 100 for patients who died between 100 and 365 days posttransplant were significantly lower than those of the surviving patients (p = 0.01).

Conclusions

Using a fast high-throughput TCR sequencing assay we have demonstrated that high TCR diversity is associated with better patient outcomes following CBT. Importantly, this assay is easily performed on posttransplant PB samples, even as early as day 28 posttransplant, making it an excellent candidate for early identification of patients at high risk of death.

A Metaphor Analysis of Patients' With Chronic Conditions Experiences With Holistic Nurse Coaching

The purpose of this study was to examine metaphors used by patients with chronic conditions to describe their experience with holistic nurse coaching. A secondary analysis was conducted using Metaphor Identification Procedure to analyze the corpus of 112 pages of typed transcription. Five metaphors emerged: (1) taking personal power back like acquiring a new toolbox; (2) seeing health challenges from different angles like a duck pond race; (3) shifting perception of a chronic condition like a spider turned into a friend; (4) engaging in self-care like caring for a favorite plant; and (5) choosing to focus on the positive like a collage that changed from dark to light. Specific interventions can be developed to address each of these metaphors to help patients live well with chronic conditions.

Kinetics of Double-Stranded DNA Viremia After Allogeneic Hematopoietic Cell Transplantation

Background

Improved understanding of double-stranded DNA (dsDNA) virus kinetics after hematopoietic cell transplantation (HCT) would facilitate development of therapeutic strategies.

Methods

We tested weekly plasma samples from 404 patients through day 100 after allogeneic HCT for cytomegalovirus (CMV), human herpesvirus (HHV) 6A and 6B, BK polyomavirus (BKV), adenovirus (AdV), and Epstein-Barr virus (EBV) using quantitative polymerase chain reaction. Episodes lasting ≤1 week were defined as blips and >1 week as persistent. We described virus-specific kinetics, analyzed the association of virus area under the curve (AUC) with overall mortality, and identified risk factors for persistent episodes.

Results

We identified 428 episodes of CMV, 292 of BKV, 224 of HHV-6B, 46 of AdV, and 53 of EBV. CMV and BKV had the highest proportions of persistent episodes (68% and 80%, respectively). Detection and kinetics varied by virus. HHV-6B episodes reached maximum levels fastest and had the shortest intervals between detection and end-organ disease. End-organ disease occurred within 14 days of viremia in 68% of cases, generally during persistent episodes. For all viruses, higher viral load AUC increased risk for overall mortality through day 365, persistent episodes had higher viral load than blips, and higher first positive viral load significantly increased risk for persistent episodes. First viral load >2 log10 copies/mL (range, 2.04-3.06 per virus) had high specificity for persistent episodes.

Conclusions

Persistent high viral load dsDNA viremia episodes after allogeneic HCT predict mortality. Virus-specific kinetics can guide timing and thresholds for early intervention in studies of novel agents.

Pain Management in Patients with Heart Failure: A Survey of Nurses' Perception

BACKGROUND

Over 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses' perception.

AIMS

To investigate nurses' perception of pain management in HF patients.

METHODS

Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.

RESULTS

A total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.

CONCLUSIONS

The impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.

Stability of Differences in Weight-Related Characteristics of Mothers across Economic, Cultural, Social, and Environmental-Health Indicators of Socioeconomic Status

This study explored the differences in weight-related characteristics when socioeconomic status (SES) was assessed by economic, cultural, social, and environmental-health capital individually and as a composite with the goal of determining the stability of differences across types of capital and to ascertain whether single or a combination of capital indicators of SES should be used in nutrition and public health studies. Mothers (n = 557) of young children completed a survey assessing capital and weight-related characteristics. Mothers with higher economic, cultural, and social capital and composite SES had fewer sugar-sweetened beverage servings, fewer meals in front of the TV, more food security, and greater neighborhood space/supports for physical activity than comparators. Few differences occurred among environmental-health capital groups. Composite SES performed similarly to individual economic, cultural, and social capital measures. Findings suggest single SES indicators may be sufficiently stable to capture differences in weight-related characteristics. Each capital type captures a unique aspect of SES; thus, assessing an array of capital types could advance understanding of SES aspects on weight-related characteristics.

Candida auris exhibits resilient biofilm characteristics in vitro: implications for environmental persistence

Surfaces within healthcare play a key role in the transmission of drug-resistant pathogens. Candida auris is an emerging multidrug-resistant yeast which can survive for prolonged periods on environmental surfaces. Here we show that the ability to form cellular aggregates increases survival after 14 days, which coincides with the upregulation of biofilm-associated genes. Additionally, the aggregating strain demonstrated tolerance to clinical concentrations of sodium hypochlorite and remained viable 14 days post treatment. The ability of C. auris to adhere to and persist on environmental surfaces emphasizes our need to better understand the biology of this fungal pathogen.

Child Physical Activity Propensity and Parent Physical Activity Cognitions Behaviors and the Home Environment (P16-011-19)

Objectives

To examine the relationship between child physical activity (PA) propensity (i.e., tendency to be physically active) and parent PA cognitions and behaviors, as well PA-related aspects of the home environment.

Methods

Parents (N = 390) of young children (ages 2–9) completed an online survey assessing their PA cognitions, behaviors, home environment, and children's PA-propensity. Parents with child PA-propensity scores below the median (n = 141) were compared to those above with scores above the median (n = 249) compared using t-test.

Results

Parent PA cognitions differed significantly (P < 0.01) by child PA-propensity. Using 5-point scales, parents with high PA-propensity children tended to place more value on PA for themselves (3.01 ± 1.13 SD vs. 2.70 ± 1.09 SD) and their children (3.90 ± 0.88 vs. 3.41 ± 0.84 SD) than parents with low PA-propensity children. Parents with high PA-propensity children were significantly more likely to encourage and facilitate children's PA (4.15 ± 0.68 SD vs. 3.80 ± 0.60 SD), engaged in PA with their children more frequently (4.06 ± 1.88 SD vs. 3.11 ± 1.69 SD), and had more self-efficacy for promoting child PA (3.64 ± 1.01 SD vs. 3.25 ± 1.06 SD) than comparators. Parents with high PA-propensity children also placed greater importance on modeling healthy PA behaviors to their children (3.97 ± 0.84 SD vs. 3.74 ± 0.82 SD) and modeled these behaviors more often (2.72 ± 1.74 SD vs. 2.07 ± 1.67 SD) than the comparison group. PA level, measured using 42-point scales indicated parents with high PA-propensity children had higher PA levels (14.94 ± 10.31 SD vs. 11.57 ± 9.00 SD) as did their children (28.35 ± 11.41 SD vs. 21.62 ± 11.40 SD) than parents with low PA-propensity children. Home environments assessments (5-point scales) revealed parents with high PA-propensity children reported more indoor/home (3.44 ± 0.83 SD vs. 3.20 ± 0.86 SD) and outdoor/yard (4.39 ± 0.64 SD vs. 4.13 ± 0.78 SD) space and supports for PA than the comparison group.

Conclusions

Parents with higher child PA-propensity had more positive PA cognitions and behaviors, and had home environments more supportive of PA. Future research aiming to increase family PA levels should consider the potential effect parent perceptions of child PA-propensity and consider tailoring interventions based on these perceptions.

Funding Sources

2011-68001-30170 and 2017-680001-26351.

How Parents Can Help Kids Make Healthy Choices: Advice from Children (P04-006-19)

Objectives

To explore the advice school-age children would give parents to help their kids make good health-related behavioral choices (e.g., reducing sugary beverages, increasing fruits/vegetables, eating age-appropriate portions, having frequent family meals) and determine the congruence of children's advice with best-practice parenting guidelines.

Methods

Children (6 to 11 years) from three states (FL, NJ and WV) participated in 1 of 65 semi-structured focus group discussions. Trained focus group moderators used a semi-structured script to ask children what advice they would give parents to help kids make healthy choices.

Results

School-age children (n = 195, 47% female) felt that parents played an important role in helping kids make healthy choices. Standard content analysis procedures indicated that some of the advice children would give parents was in line with best-practice parenting guidelines, such as telling kids about the benefits of healthy choices, encouraging kids to make healthy choices, planning ahead to make healthy choices possible, and establishing a routine and expectations for healthy choices. Children also advised parents to involve kids in planning and preparing meals, politely ask kids to help them, and teach kids how to cook. However, other advice children gave contradicted best-practice parenting guidelines. Children often advised parents to use rewards (e.g., money and highly palatable foods) as bribes to get kids to make healthy choices. They also frequently advised parents to punish kids for making unhealthy choices by taking away dessert or electronic devices or grounding them. Children commonly advised parents to “trick” kids into making healthy choices by mixing vegetables into other dishes to hide them or coloring water so kids think it is juice.

Conclusions

Although some of the advice kids would give parents was in line with best-practice parenting guidelines, not all was. Kids’ advice may suggest that their parents have utilized non-recommended strategies, which can negatively influence children's own eating behaviors now as well as the parenting practices these kids may use in the future. Thus, to protect future generations, nutrition interventions targeting children should consider incorporating best-practice parenting strategies related to healthy choices.

Funding Sources

2011–68,001-30,170 and 2017–680,001-26,351.

Development and Evaluation of a Dynamic Response Cognitive Interview Methodology for Nutrition Education Material Design (P13-010-19)

Objectives

Cognitive testing (CT), an underutilized methodology in nutrition education, is applied during the development of educational materials to gauge the target audience's comprehension and interest in the education material's content as well as to assess whether the presentation (e.g., wording, design) of the content is responsive to the audience's sensibilities. CT data elucidate areas needing refinement to increase the effectiveness and acceptability of educational materials. Typically, CT interviews are conducted with ∼12 individuals from the target audience before data are content analyzed and used to refine materials. Waiting to revise materials until all CT interviews are completed often necessitates additional interviews to determine if the revisions sufficiently addressed areas needing refinement. To overcome the methodological inefficiency of typical CT, our lab developed and tested the feasibility of using a dynamic response CT (DRCT) methodology that iteratively refined materials after every CT interview.

Methods

The materials tested using DRCT interviews were designed to enable parents of school-age children to develop knowledge, skills, and self-efficacy for shaping home environments and lifestyle practices to prevent childhood obesity. Eight sets of materials were tested in 3 states (NJ, WV, FL). DRCT interviews were conducted by two trained nutrition researchers: one conducted the interview using a semi-structured script and the other took detailed notes. Within 24 hours of each DRCT interview, the notes were submitted for content analysis by two researchers who collaboratively used the analysis to revise the materials within 48 hours of interview completion and before the materials were tested again. The revised materials underwent DRCT again, and the revision process was repeated until data saturation was reached.

Results

DRCT interviews were conducted with 71 parents (90% female). Data saturation was reached with an average of 10 interviews.

Conclusions

The DRCT methodology requires constant availability of researchers to content analyze data and refine materials to ensure readiness for subsequent interviews. However, it compresses the timeline for data collection thereby saving research costs and getting tested educational materials to the target audience faster.

Funding Sources

2011–68,001-30,170 and 2017–680,001-26,351.

Parent Cognitions of Factors Influencing Snack Intake of Their School-aged Children at Away-from-home Events (P11-109-19)

Objectives

To qualitatively investigate the cognitions and decisions of parents of school-aged children vis-à-vis children's snacking at way-from-home events.

Methods

Parents (n = 37) of 6- to 11-year-old children from NJ, WV, and FL participated in 1 of 13 focus groups conducted by trained moderators. Data were content analyzed by trained researchers according to standard procedures.

Results

Parents (97% mothers) identified fruits, vegetables, pretzels, granola bars, muffins, and fish crackers as examples of healthy snacks. Although children frequently snacked at away-from-home events, many parents felt that it was not always realistic or important for children to consume healthy snacks at these events, particularly if children consumed an otherwise nutritious diet. Controlling the quality of snacks eaten away-from-home, particularly at school events, was a challenge for parents. When faced with the responsibility of supplying healthy snacks for a group of kids at an away-from-home event, barriers parents encountered were children's preferences for unhealthy snacks, cost, and food allergies. Some parents identified school policies as a barrier to providing healthy snacks, noting that schools required parents to supply snacks that were packaged, store-bought, and did not require refrigeration. Parents also reported that providing healthy snacks was time consuming, citing the time required to peel and cut fruits and vegetables or prepare a healthy muffin recipe. Parents reported that some school policies, such as the “no party rule” and guidelines for healthy snacks at celebrations facilitated provision of healthy snacks by parents. Parents also indicated that serving fruits/vegetable in interesting ways (e.g., with dip, cut into shapes) increased the likelihood kids would accept these healthy snacks. Parents thought schools could help parents by providing a list of healthy, affordable, low allergen and easy-to-prepare and store snacks that are well accepted by kids.

Conclusions

Parents identified numerous barriers to ensuring kids have healthy snacks at away-from-home events. Future nutrition interventions should help parents develop strategies to overcome these barriers and develop school policies supportive of healthy snacking.

Funding Sources

2011-68001-30170 and 2017-680001-26351.

The Experience of Holistic Nurse Coaching for Patients With Chronic Conditions

Purpose: The purpose of this study was to explore and describe the lived experience of adults with chronic conditions receiving holistic nurse coaching. Method: A qualitative phenomenological research design was used for this study. A purposive sample of 15 patients with varied chronic conditions participated. Institutional review board approval was obtained from the participating university prior to data collection. The patients’ stories of their experiences with holistic nurse coaching were analyzed using Colaizzi’s method of phenomenological analysis. Findings: Eight theme clusters emerged when the formulated meanings were organized into the following categories: (1) Seeking Guidance to Navigate Life’s Challenges, (2) Entering a Safe Sacred Place, (3) Feeling Empowered and Accountable, (4) Developing Strategies to Access Different Ways of Knowing, (5) Finding the Answers Within, (6) Making Healthy Behavioral Changes, (7) Forming a New Caring Relationship with Self, and (8) Transforming to a Brand-New Approach to Life. Conclusions: Findings from this study provide insight into experiences of holistic nurse coaching for patients with chronic conditions. Further research is needed to examine the influence of holistic nurse coaching on health outcomes related to chronic conditions such as quality of life, patient empowerment, and targeted metrics related to specific chronic conditions.

Prognosis of relapse after hematopoietic cell transplant (HCT) for treatment of leukemia or myelodysplastic syndrome (MDS) in children

We studied 232 consecutive children transplanted between 1990 and 2011 with relapse after first hematopoietic cell transplant (HCT). Kaplan-Meier survival and hazard ratios for mortality were calculated for factors known at time of relapse using Cox proportional hazards models. The median (range) age at time of first HCT was 10.9 (0.5-20.9) years, time to relapse was 6.1 (0.2-89.5) months after HCT, and age at relapse was 11.7 (0.7-23.6) years. The 3-year overall survival (OS) after relapse was 13% (95% confidence interval (CI): 9%, 18%).The median (range) follow-up for the 18 surviving patients was 7.2 (3.0-24.4) years after relapse. The remaining 214 died after a median of 3 months (0.02-190.4). OS was not significantly different for patients with ALL as compared to AML. Fifty-one patients proceeded to second transplant of whom nine survive. Factors associated with improved survival included late relapse (>12 months), ALL in first CR at the time of first transplant and chemotherapy-based first conditioning regimens. These results can be used to counsel patients at the time of relapse after first transplant and as a baseline for comparison as to the effectiveness of newer therapies which are greatly needed for treatment of post-transplant relapse.

Prognostic Performance of the Augmented Hematopoietic Cell Transplantation-Specific Comorbidity/Age Index in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation from Alternative Graft Sources

The Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) was developed and validated to weigh the burden of pretransplantation comorbidities and estimate their impact on post-transplantation risks of nonrelapse mortality (NRM). Recently, the HCT-CI was augmented by the addition of both age and the values of 3 markers: ferritin, albumin, and platelet count. So far, research involving The HCT-CI has been limited almost exclusively to recipients of allogeneic hematopoietic cell transplantation (HCT) from HLA-matched grafts. To this end, we sought to investigate the discriminative capacity of an augmented comorbidity/age index among 724 recipients of allogeneic HCT from HLA-mismatched (n = 345), haploidentical (n = 117), and umbilical cord blood (UCB; n = 262) grafts between 2000 and 2013. In the overall cohort, the augmented comorbidity/age index had a higher c-statistic estimate for prediction of NRM compared with the original HCT-CI (.63 versus .59). Findings were similar for recipients of HLA-mismatched (.62 versus .59), haploidentical (.60 versus .54), or UCB grafts (.65 versus .61). Compared with patients with an HCT-CI score ≥4, those with a score <4 had a higher survival rate among recipients of HLA-mismatched (55% versus 39%; P < .0008), HLA-haploidentical (58% versus 38%; P = .01), or UCB (67% versus 48%; P = .004) grafts. Our results demonstrate the utility of the augmented comorbidity/age index as a valid prognostic tool among recipients of allogeneic HCT from alternative graft sources.

Disability related to chronic graft -versus-host disease after alternative donor hematopoietic cell transplantation

We determined the incidence of disability related to chronic graft-versus-host disease (bronchiolitis obliterans, grade ≥2 keratoconjunctivitis sicca, sclerotic features or esophageal stricture) for three categories of alternative donor: cord blood, haplorelated marrow or peripheral blood with post-transplant cyclophosphamide, and unrelated single HLA-allele mismatched peripheral blood. Among 396 consecutive hematopoietic cell transplant recipients, 129 developed chronic graft-versus-host disease with 3-year cumulative incidences of 8% for cord blood, 24% for haplorelated grafts, and 55% for unrelated single HLA-allele mismatched peripheral blood. Disability rates were significantly lower for cord blood [hazard ratio (HR) 0.13; 95% confidence interval (CI): 0.1-0.4] and for the haplorelated group (HR 0.31; 95% CI: 0.1-0.7) compared to the rate in the group transplanted with unrelated single HLA-allele mismatched peripheral blood. Cord blood recipients were also >2-fold more likely to return to work/school within 3 years from the onset of chronic graft-versus-host disease (HR 2.54; 95% CI: 1.1-5.7, P=0.02), and the haplorelated group trended similarly (HR 2.38; 95% CI: 1.0-5.9, P=0.06). Cord blood recipients were more likely to discontinue immunosuppression than were recipients of unrelated single HLA-allele mismatched peripheral blood (HR 3.96; 95% CI: 1.9-8.4, P=0.0003), similarly to the haplorelated group (HR 4.93; 95% CI: 2.2-11.1, P=0.0001). Progression-free survival and non-relapse mortality did not differ between groups grafted from different types of donors. Our observations that, compared to recipients of unrelated single HLA-allele mismatched peripheral blood, recipients of cord blood and haplorelated grafts less often developed disability related to chronic graft-versus-host disease, and were more likely to resume work/school, should help better counseling of pre-hematopoietic cell transplant candidates.

Treosulfan, Fludarabine, and Low-Dose Total Body Irradiation for Children and Young Adults with Acute Myeloid Leukemia or Myelodysplastic Syndrome Undergoing Allogeneic Hematopoietic Cell Transplantation: Prospective Phase II Trial of the Pediatric Blood and Marrow Transplant Consortium

This multicenter study evaluated a treosulfan-based regimen in children and young adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing allogeneic hematopoietic cell transplant (HCT). Forty patients with median age 11 years (range, 1 to 19) underwent allogeneic HCT for AML in first (n = 18), second (n = 11), and third or greater remission (n = 3) or MDS (n = 8) using bone marrow (n = 25), peripheral blood stem cells (n = 5), or cord blood (n = 9). The regimen consisted of body surface area (BSA)-based treosulfan 10 g/m²/day (BSA ≤ .5 m²), 12 g/m²/day (BSA > .5 to 1.0 m²), or 14 g/m²/day (BSA > 1.0 m²) on days -6 to -4; fludarabine 30 mg/m²/day on days -6 to -2; and a single fraction of 200 cGy total body irradiation on day -1. Graft-versus-host disease (GVHD) prophylaxis included tacrolimus and methotrexate for marrow and peripheral blood stem cell and cyclosporine/mycophenolate mofetil for cord blood. One-year overall survival, disease-free survival, and nonrelapse mortality were 80%, 73%, and 3%, respectively. One-year relapse was 38% for AML and 13% for MDS. No serious organ toxicities were observed. All 37 assessable patients engrafted. Cumulative incidences of grades II to IV acute GVHD and chronic GVHD were 22% and 40%, respectively. BSA-based treosulfan dosing resulted in predictable area under the curve and maximum concentration, which is required for dosing without measuring individual pharmacokinetic parameters. Observed differences in pharmacokinetics did not impact disease control or regimen toxicity. This BSA-based treosulfan regimen resulted in excellent engraftment and disease-free survival and minimal toxicity and transplant-related mortality (3%) in children and young adults with AML and MDS.

Trends in Contemporary Holistic Nursing Research: 2010-2015

PURPOSE

The purpose of this study was to describe and summarize the characteristics of contemporary holistic nursing research (HNR) published nationally.

DESIGN

A descriptive research design was used for this study.

METHOD

Data for this study came from a consecutive sample of 579 studies published in six journals determined as most consistent with the scope of holistic nursing from 2010 to 2015. The Johns Hopkins level of evidence was used to identify evidence generated, and two criteria-power analysis for quantitative research and trustworthiness for qualitative research-were used to describe overall quality of HNR.

FINDINGS

Of the studies, 275 were considered HNR and included in the analysis. Caring, energy therapies, knowledge and attitudes, and spirituality were the most common foci, and caring/healing, symptom management, quality of life, and depression were the outcomes most often examined. Of the studies, 56% were quantitative, 39% qualitative, and 5% mixed-methods designs. Only 32% of studies were funded. Level III evidence (nonexperimental, qualitative) was the most common level of evidence generated.

CONCLUSIONS

Findings from this study suggest ways in which holistic nurse researchers can strengthen study designs and thus improve the quality of scientific evidence available for application into practice and improve health outcomes.

The marketing plan and outcome indicators for recruiting and retaining parents in the HomeStyles randomized controlled trial

Background

Despite the critical importance of successful recruitment and retention to study integrity, reporting of recruitment and retention strategies along with factors associated with successful recruitment and retention of participants in health-related interventions remain rare, especially for health and obesity prevention programs. Thus, the purpose of this article is to retrospectively examine the recruitment and retention marketing plan used in the online HomeStyles randomized controlled trial (RCT) and discuss outcomes associated with completion of the intervention.

Methods

The HomeStyles RCT is an online intervention developed to motivate parents of young children to gain the skills and self-confidence needed to shape home environments and lifestyles to be protective against childhood obesity. Using the seven Ps of services marketing (i.e., people, place, product, physical evidence, price, promotion, and process), a comprehensive and systematic plan for recruitment and retention was implemented and outcomes assessed.

Results

A total of 489 parents with a young child aged 2 to < 6 years were eligible to participate, a final capture rate of 33%. Only 23% of Hispanic participants chose to use the Spanish-language version of HomeStyles intervention materials, below the demand anticipated. However, Hispanic enrollment overall was substantially higher than the U.S. population proportion (i.e., 17%). The number of participants prematurely leaving the study was similar in both treatment groups, indicating attrition was not differential. Completers reported high satisfaction of HomeStyles, using a 1–5 scale (strongly disagree to strongly agree) on guide attractiveness, interestingness, and usefulness. Despite all the retention efforts, the average monthly recruitment accrual rate of ~ 33 eligible enrolled participants at baseline (i.e., 489 participants/15-month recruitment period), declined to ~ 18, 11, 9, and 8 remaining recruited participants/month at midpoint, post, follow-up, and long-term follow-up surveys, respectively. In general, survey completers were significantly more likely to be female and perceived their child’s health status to be better, and they were significantly less likely to be restrictive of their child’s food intake.

Conclusions

The findings of the present study highlight the need for far-reaching, concentrated, and varied recruitment strategies; sufficient time in the research plan for recruitment and retention activities; and creative, tireless, flexible, persistent project staff for health-related interventions.