Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) in Appalachia: protocol for a group randomized, delayed intervention trial

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

Factors related to retention in a longitudinal study of infants at familial risk for autism

Background

Reporting retention data is critical to determining the soundness of a study's conclusions (internal validity) and broader generalizability (external validity). Although selective attrition can lead to overestimates of effects, biased conclusions, or overly expansive generalizations, retention rates are not reported in many longitudinal studies.

Methods

We examined multiple child- and family-level factors potentially associated with retention in a longitudinal study of younger siblings of children with autism spectrum disorder (ASD; n = 304) or typical development (n = 163). The sample was followed from the first year of life to 36 months of age, for up to 7 visits.

Results

Of the 467 infant siblings who were consented and participated in at least one research visit, 397 (85.0%) were retained to study completion at 36 months. Retention rates did not differ by familial risk group (ASD-risk vs. Low-risk), sex, race, ethnicity, age at enrollment, number of children in the family, maternal employment, marital status, or parent concerns about the child at enrollment. A stepwise regression model identified 4 variables that, together, provided the most parsimonious predictive model of study retention: maternal education, maternal age at child's birth, travel distance to the study site, and diagnostic outcome classification at the final study visit.

Conclusions

The retained and not-retained groups did not differ on most demographic and clinical variables, suggesting few threats to internal and external validity. The significantly higher rate of retention of children diagnosed with ASD (95%) than typically developing children (83%) may, however, present biases when studying recurrence risk. We conclude by describing engagement and tracking methods that can be used to maximize retention in longitudinal studies of children at risk of ASD.

Factors associated with the accurate self-report of cancer screening behaviors among women living in the rural Midwest region of the United States

This study examines the accuracy of the self-report of up-to-date cancer screening behaviors (Mammography, Papanicolaou (Pap)/Human Papillomavirus (HPV) tests, Fecal Occult Blood Test (FOBT)/Fecal Immunochemical Test (FIT), Colonoscopy) compared to medical record documentation prior to eligibility determination and enrollment in a randomized controlled trial of an intervention to increase cancer screening among women living in rural counties of Indiana and Ohio. Women (n = 1,641) completed surveys and returned a medical record release form from November 2016-June 2019. We compared self-report to medical records for up-to-date cancer screening behaviors to determine the validity of self-report. Logistic regression models identified variables associated with accurate reporting. Women were up-to-date for mammography (75 %), Pap/HPV test (54 %), colonoscopy (53 %), and FOBT/FIT (6 %) by medical record. Although 39.6 % of women reported being up-to-date for all three anatomic sites (breast, cervix, and colon), only 31.8 % were up to date by medical records. Correlates of accurate reporting of up-to-date cancer screening varied by screening test. Approximately-one-third of women in rural counties in the Midwest are up-to-date for all three anatomic sites and correlates of the accurate reporting of screening varied by test. Although most investigators use medical records to verify completion of cancer screening behaviors as the primary outcome of intervention trials, they do not usually use medical records for the routine verification of study eligibility. Study results suggest that future research should use medical record documentation of cancer screening behaviors to determine eligibility for trials evaluating interventions to increase cancer screening.

Early predictors of language skills at 3 years of age vary based on diagnostic outcome: A baby siblings research consortium study

While previous work has identified the early predictors of language skills in infants at elevated familial risk (ER) and low familial risk (LR) for autism spectrum disorder (ASD), no studies to date have explored whether these predictors vary based on diagnostic outcome of ASD or no ASD. The present study used a large, multisite dataset to examine associations between a set of commonly studied predictor variables (infant gesture abilities, fine motor skills, nonverbal cognition, and maternal education level), measured at 12 months, and language skills, measured at 3 years, across three diagnostic outcome groups-infants with ASD ("ASD"), ER infants without ASD ("ER-no ASD"), and LR infants without ASD ("LR-no ASD"). Findings revealed that the predictors of language skills differed across groups, as gesture abilities were positively associated with language skills in the ER-no ASD group but negatively associated with language skills in the ASD group. Furthermore, maternal education level was positively associated with language skills in the ASD and LR-no ASD groups only. Variability in these early predictors may help explain why language skills are heterogeneous across the autism spectrum, and, with further study, may help clinicians identify those in need of additional and/or specialized intervention services that support language development. LAY SUMMARY: The present study identified predictors of language skills in infants with and without autism spectrum disorder (ASD). Maternal education level and 12-month gesture abilities predicted 3-year language skills in infants with ASD. Measuring these predictors early in life may help identify infants and families in need of additional and/or specialized intervention services that support language development.

Social orienting and initiated joint attention behaviors in 9 to 12 month old children with autism spectrum disorder: A family home movies study

According to the Social Motivation model children with autism show deficits in social orienting (looking at faces and responding to name) at the end of their first year of life. In this model, those deficits are both the earliest behavioral consequences of an alteration in the dopamine reward system balance and the foundation of the social impairments that characterize this neurodevelopmental disorder. The current study tests two of the main predictions of this model: that social orienting deficits are the first behavioral manifestation of autism, and that they are developmentally related to joint attention deficits. We retrospectively analyzed family home movies of 9- to 12-month-old infants, 29 of whom were later diagnosed with autism and 16 of whom were typically developing. After confirming that the videotapes of both groups were similar in content of the scenes recorded (contexts, type of social activity, etc.), we compared their social orienting (social gaze and responding to name) and joint attention behaviors (gaze alternation and gestures). No significant differences between groups were found in looking at faces, but the group with autism showed deficits in responding to name and initiations of joint attention (IJA). Looking at people was not significantly correlated with IJA behaviors, but response to name was. The lack of group differences in looking at faces between 9 and 12 months, and the existence of IJA difficulties in the ASD group without concurrent impairment in looking at faces, do not support predictions of the Social Motivation model. LAY SUMMARY: Various theories have been proposed to explain the emergence of autism symptoms early in life. This study tested two key predictions of the Social Motivation model. Comparing family movies of children 9- to 12-months-old later diagnosed with autism or with typical development, we did not observe difficulties in looking at other people's faces but children with autism responded to name and used gaze and gestures to direct the adult's attention to events of interest less frequently. This absence of difficulties in looking at faces does not fit with what the Social Motivation model of autism predicts and therefore we must develop alternative explanations.

Can Familial Risk for ADHD Be Detected in the First Two Years of Life?

Objective: We evaluated trajectories of attention-deficit/hyperactivity (ADHD)-relevant behaviors in a sample of infants at high and low familial risk for ADHD who were prospectively evaluated at 12, 18, and 24 months of age.Method: Participants included 43 infants at risk for ADHD based on family history (i.e., diagnosed first-degree relative) and 40 low-risk infants (i.e., no family history of ADHD). Instances of inattention, out-of-seat, and grabbing behavior were coded from video; analogous constructs were rated by examiners unaware of familial risk status after completing structured standardized assessments with the infants/toddlers. At the end of each study visit, examiners solicited parents' concerns about their child's behavior. Differences in ADHD-related behaviors and parent concerns were examined between 12 and 24 months of age.Results: Infants with an older sibling or parent diagnosed with ADHD were distinguishable from infants with no family history of ADHD as early as 12 months of age based on directly observed and examiner reports of behavior, particularly with respect to hyperactive-impulsive behavior. Parents of infants at familial risk for ADHD also reported significantly more behavior/temperament concerns as early as 12 months of age compared to parents of infants at low risk for ADHD.Conclusions: These findings highlight the ability to detect genetic liability for ADHD by the end of the first year of life, suggesting that well-designed family risk studies of ADHD are feasible and may be clinically valuable. They also suggest the potential for earlier detection of risk for ADHD than has previously been possible.

Repetitive behavior with objects in infants developing autism predicts diagnosis and later social behavior as early as 9 months

We evaluated repetitive behavior with objects in infants at risk for autism spectrum disorder (ASD) from 9 to 36 months of age, and associations between early repetitive behavior and social engagement. Infant siblings of children with ASD (high-risk) or typical development (low-risk) were administered a task eliciting repetitive object use at 9, 12, 15, 18, 24, and 36 months of age. Infants (n = 147) were classified into 1 of 3 outcome groups at 36 months: Low-Risk Non-ASD (n = 58), High-Risk Non-ASD (n = 72), and ASD (n = 17). Behavior was coded from video for frequencies of unusual visual inspection, spinning, and rotating behaviors. Differences in unusual visual inspection were most prominent, consistent, and present earliest: At 9 months, the ASD group engaged in this behavior more frequently than both other groups, persisting through 36 months. Differences in frequencies of spinning and rotating were later-appearing, more time-limited, and/or related to familial ASD risk rather than ultimate diagnosis. Sensitivity and specificity estimates for the presence of unusual visual inspection at 9 months of age were in the moderate range (.60 and .68, respectively) for ASD versus Low-Risk Non-ASD comparisons, generally increasing over time. Unusual visual inspection at 9 months predicted 12-month social behavior controlling for 9-month social behavior, but not vice versa, with no evidence of moderation by ASD diagnosis. In summary, unusual visual inspection of objects is present and stable by 9 months of age in infants developing ASD and predicts reduced social engagement three-months later. Close monitoring of this behavior may aid early detection. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Altered Gray-White Matter Boundary Contrast in Toddlers at Risk for Autism Relates to Later Diagnosis of Autism Spectrum Disorder

BACKGROUND

Recent neuroimaging studies have highlighted differences in cerebral maturation in individuals with autism spectrum disorder (ASD) in comparison to typical development. For instance, the contrast of the gray-white matter boundary is decreased in adults with ASD. To determine how gray-white matter boundary integrity relates to early ASD phenotypes, we used a regional structural MRI index of gray-white matter contrast (GWC) on a sample of toddlers with a hereditary high risk for ASD.

MATERIALS AND METHODS

We used a surface-based approach to compute vertex-wise GWC in a longitudinal cohort of toddlers at high-risk for ASD imaged twice between 12 and 24 months (n = 20). A full clinical assessment of ASD-related symptoms was performed in conjunction with imaging and again at 3 years of age for diagnostic outcome. Three outcome groups were defined (ASD, n = 9; typical development, n = 8; non-typical development, n = 3).

RESULTS

ASD diagnostic outcome at age 3 was associated with widespread increases in GWC between age 12 and 24 months. Many cortical regions were affected, including regions implicated in social processing and language acquisition. In parallel, we found that early onset of ASD symptoms (i.e., prior to 18-months) was specifically associated with slower GWC rates of change during the second year of life. These alterations were found in areas mainly belonging to the central executive network.

LIMITATIONS

Our study is the first to measure maturational changes in GWC in toddlers who developed autism, but given the limited size of our sample results should be considered exploratory and warrant further replication in independent and larger samples.

CONCLUSION

These preliminary results suggest that ASD is linked to early alterations of the gray-white matter boundary in widespread brain regions. Early onset of ASD diagnosis constitutes an independent clinical parameter associated with a specific corresponding neurobiological developmental trajectory. Altered neural migration and/or altered myelination processes potentially explain these findings.

Measuring social-communication difficulties in school-age siblings of children with autism spectrum disorder: Standardized versus naturalistic assessment

Younger siblings of children with autism spectrum disorder (ASD; high-risk siblings) are at elevated risk for developing the broader autism phenotype (BAP), which consists of subclinical features of ASD. We examined conversational skills in a naturalistic context and standardized assessments of pragmatic language and communication skills in high-risk and low-risk school-age children with BAP (n = 22) and ASD (n = 18) outcomes, as well as comparison children without ASD or BAP (n = 135). Children with BAP characteristics exhibited lower conversational skills than comparison children, but did not differ on any of three standardized measures. Only the conversational ratings significantly predicted membership in the BAP versus Comparison group. This suggests that naturalistic tasks are crucial when assessing social-communication difficulties in children with a family history of ASD. LAY SUMMARY: The broader autism phenotype (BAP) consists of subclinical features of autism spectrum disorder (ASD) and is more common among family members of those with ASD. School-age children with BAP characteristics exhibited lower conversational skills than comparison children, but did not differ on standardized language measures tapping similar abilities. This suggests that naturalistic tasks may be more sensitive to the social-communication difficulties seen in some children with a family history of ASD than the standardized language tests used in most evaluations.

Development of a multilevel intervention to increase colorectal cancer screening in Appalachia

BACKGROUND

Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of "Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia," a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics.

METHODS

Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs.

RESULTS

Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components.

CONCLUSIONS

Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years.

TRIAL REGISTRATION

Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

Immediate effects of treadmill walking in individuals with Lewy body dementia and Huntington's disease

BACKGROUND

Treadmill training may improve gait disorders associated with neurodegenerative diseases. In Parkinson's disease (PD), treadmill training alters gait patterns after one session, and long-term training improves gait parameters, fall risk, and quality of life.

RESEARCH QUESTION

What is the feasibility and safety of using this intervention for people with Lewy body dementia (LBD) or Huntington's disease (HD)?

METHODS

In this observational study, 10 individuals with HD, 8 individuals with LBD, and 10 control individuals walked for 20 min on a treadmill using a speed dependent protocol starting at a slow comfortable speed and increasing incrementally toward their normal overground speed. Feasibility was determined by compliance to protocol and safety by no incidents of abnormal vital signs or expressions of distress. Changes in gait measures, Timed Up and Go (TUG) scores and quantitative motor function measures (Q-Motor; precision grasp force variability, finger and foot tapping frequency) before and after treadmill walking were analyzed using linear models.

RESULTS

Treadmill training is feasible and safe in LBD and HD; although, participants could not initiate treadmill walking at their comfortable overground speeds, and only 3 participants with HD were able to achieve their overground walking speed within the 20-minute session. No changes in gait measures, TUG times, and Q-Motor measures were found among LBD and HD participants after treadmill walking, although control participants demonstrated significant increases in several gait measures, and foot tap frequency (estimated difference = 0.290; p = 0.026).

SIGNIFICANCE

Longer and more frequent treadmill sessions may be needed to see gait and motor function effects in LBD and HD. Motor and cognitive impairments associated with these diseases may make them less amenable to the effects of treadmill training.

Declining Gaze to Faces in Infants Developing Autism Spectrum Disorder: Evidence From Two Independent Cohorts

Two independent cohorts (N = 155, N = 126) of infants at high and low risk for autism spectrum disorder (ASD) were followed prospectively between 6 and 36 months of age, when n = 46 were diagnosed with ASD. Gaze to adult faces was coded-during a developmental assessment (Cohort 1) or a play interaction (Cohort 2). Across both cohorts, most children developing ASD showed sharp declines in gaze to faces over time, relative to children without ASD. These findings suggest that declining developmental trajectories may be more common than previously recognized by retrospective methods. Trajectory-based screening methods could potentially identify children in the early stages of symptom onset and allow for early intervention before the full disorder has developed.

Trajectories of Autism Symptom Severity Change During Early Childhood

Autism symptom severity change was evaluated during early childhood in 125 children diagnosed with autism spectrum disorder (ASD). Children were assessed at approximately 3 and 6 years of age for autism symptom severity, IQ and adaptive functioning. Each child was assigned a change score, representing the difference between ADOS Calibrated Severity Scores (CSS) at the two ages. A Decreased Severity Group (28.8%) decreased by 2 or more points; a Stable Severity Group (54.4%) changed by 1 point or less; and an Increased Severity Group (16.8%) increased by 2 or more points. Girls tended to decrease in severity more than boys and increase in severity less than boys. There was no clear relationship between intervention history and membership in the groups.

High Psychopathology Subgroup in Young Children With Autism: Associations With Biological Sex and Amygdala Volume

OBJECTIVE

The aims of this study were to identify a subset of children with autism spectrum disorder (ASD) and co-occurring symptoms of psychopathology, and to evaluate associations between this subgroup and biological sex and amygdala volume.

METHOD

Participants included 420 children (ASD: 91 girls, 209 boys; typically developing controls: 57 girls, 63 boys). Latent profile analysis was used to identify ASD subgroups based on symptoms of psychopathology, adaptive functioning, cognitive development, and autism severity. Differences in the proportions of girls and boys across subgroups were evaluated. Magnetic resonance imaging scans were acquired (346 children); amygdala volumes were evaluated in relation to subgroups and problem behavior scores.

RESULTS

Three ASD subgroups were identified. One group was characterized by high levels of psychopathology and moderate impairment on other measures (High Psychopathology Moderate Impairments [HPMI], comprising 27% of the sample). The other two subgroups had lower symptoms of psychopathology but were differentiated by high and low levels of impairment on other measures. A higher proportion of girls were classified into the HPMI subgroup (40% of girls versus 22% of boys). Relative to controls, amygdala volumes were enlarged only in the HPMI subgroup. There was a positive association between right amygdala volume and internalizing behaviors in girls but not in boys with ASD.

CONCLUSION

A higher proportion of girls with ASD faced greater challenges with psychopathology, suggesting a need for closer evaluation and potentially earlier intervention to help improve outcomes. Amygdala enlargement was associated with co-occurring symptoms of psychopathology, and sex-specific correlations with symptoms were observed.

Dyadic Synchrony and Responsiveness in the First Year: Associations with Autism Risk

In the first year of life, the ability to engage in sustained synchronous interactions develops as infants learn to match social partner behaviors and sequentially regulate their behaviors in response to others. Difficulties developing competence in these early social building blocks can impact later language skills, joint attention, and emotion regulation. For children at elevated risk for autism spectrum disorder (ASD), early dyadic synchrony and responsiveness difficulties may be indicative of emerging ASD and/or developmental concerns. As part of a prospective developmental monitoring study, infant siblings of children with ASD (high-risk group n = 104) or typical development (low-risk group n = 71), and their mothers completed a standardized play task when infants were 6, 9, and/or 12 months of age. These interactions were coded for the frequency and duration of infant and mother gaze, positive affect, and vocalizations, respectively. Using these codes, theory-driven composites were created to index dyadic synchrony and infant/maternal responsiveness. Multilevel models revealed significant risk group differences in dyadic synchrony and infant responsiveness by 12 months of age. In addition, high-risk infants with higher dyadic synchrony and infant responsiveness at 12 months received significantly higher receptive and expressive language scores at 36 months. The findings of the present study highlight that promoting dyadic synchrony and responsiveness may aid in advancing optimal development in children at elevated risk for autism. LAY SUMMARY: In families raising children with an autism spectrum disorder (ASD), younger siblings are at elevated risks for social communication difficulties. The present study explored whether social-communication differences were evident during a parent-child play task at 6, 9, and 12 months of age. For infant siblings of children with ASD, social differences during play were observed by 12 months of age and may inform ongoing monitoring and intervention efforts.

Abstract PO-253: Increasing colorectal cancer screening in rural underserved communities with multilevel interventions: Formative evaluation of accelerating colorectal cancer screening and follow-up through implementation science in Appalachia

Background: Colorectal cancer (CRC) screening is lower in Appalachian regions of Kentucky and Ohio than in their non-Appalachian counterparts, with lower screening contributing to increased CRC incidence and mortality. To address CRC disparities in these underserved regions, researchers from the University of Kentucky and The Ohio State University partnered with two federally qualified health centers (FQHCs) to develop and implement multilevel interventions (MLIs) during year one of a 5-year National Cancer Institute funded Cancer Moonshot project to increase CRC screening and follow-up in Appalachian Kentucky and Ohio. Methods: Drawing from the Model for the Analysis of Population Health and Health Disparities and using a social determinants of health framework, researchers selected and partnered with Community Advisory Boards (CAB) to guide project formation in two Appalachian counties, one in Kentucky and one in Ohio. These formative activities included creating community profiles, conducting key informant interviews with clinic and community champions, and completing data inventories to assess clinic capacity, ultimately resulting in two primary care clinics being selected for pilot year implementation activities. Results: Key informant interviews revealed barriers to CRC screening at multiple levels: patient (e.g., fear of screening results), provider (e.g., competing priorities), clinic (e.g., lack of reminder or tracking systems), and community (e.g., cultural norms). Clinic champions were provided with menus of evidence-based interventions (EBIs) to address barriers at each level and were encouraged to select locally relevant, implementable EBIs. Clinics chose to implement the following EBIs: improved patient education materials (patient-level), additional provider education (provider-level), improvement of electronic health record (EHR) reporting and creation of clinic-wide screening protocols (clinic-level), and provision of interactive screening education at community events (community- level). Conclusion: Results from pilot year activities were used to refine the project approach for years two through five. Project activities will be expanded to 10 more Appalachian counties in Kentucky and Ohio using a design wherein counties will be paired by participating clinic patient volume. As in pilot year activities, clinic/community champions will be encouraged to select EBIs appropriate to their patients, providers, clinics, and communities. To measure clinical outcomes, self- reported screening will be monitored using data from county-wide telephone surveys with additional data from clinic EHRs. Using an MLI approach may be well- received in underserved rural Appalachian communities and may ultimately be successful at reducing CRC screening disparities.

Citation Format: Aaron J. Kruse-Diehr, Jill M. Oliveri, Mira L. Katz, Mark Cromo, Robin C. Vanderpool, Michael L. Pennell, Darrell M. Gray II, Paul L. Reiter, Bin Huang, Gregory S. Young, Darla Fickle, Melinda Rogers, David Gross, Sue Russell, Electra D. Paskett, Mark Dignan. Increasing colorectal cancer screening in rural underserved communities with multilevel interventions: Formative evaluation of accelerating colorectal cancer screening and follow-up through implementation science in Appalachia [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-253.

Abstract B001: Rural interventions to improve breast, cervical and colorectal screening rates: Recruitment strategies for women in rural areas

Rural areas of the United States have less access to quality healthcare, higher rates of cancer incidence and mortality, and lower screening rates compared to urban areas. The Rural Interventions for Screening Effectiveness (RISE) Study conducted by Indiana University and The Ohio State University focuses on improving breast, cervical and colorectal cancer screening rates in rural Indiana and Ohio by encouraging female residents ages 50-74 years to receive necessary screenings. Two interventions are tested: an interactive DVD, and the DVD combined with patient navigation. Recruitment occurred October 2017 - June 2019. This paper evaluates recruitment strategies used by RISE in order to better understand which method was most effective and to determine if participants differed demographically by recruitment method. An array of recruitment strategies were used, including purchasing contact lists to call women in the recruitment area, internet advertising, and physical advertisements placed within the communities. Outbound mailing and calling, the sole method initially planned, was performed for the first 6 months of recruitment, using purchased phone and address lists of female residents of rural counties of northeast Indiana and northwest Ohio. Internet advertising was primarily conducted using Facebook to target female users 50 years or older in rural areas of both states. Community advertising was performed by mailing flyers to be displayed in rural libraries, senior and community centers, and other locations where residents congregate. Recruitment strategies differed in effort, cost, and yield. Mailing and calling using purchased lists was used to attempt to reach 5240 women, successfully reaching and reviewing medical records for 275 women, yielding 154 eligible women. Median household income of these women was $50,000-$59,999 and median age was 63 years. This strategy was costly, high effort, and did not yield enough participants to warrant continuing. Community advertising involved identifying suitable locations and requesting permission to post promotional materials. Although this strategy’s reach cannot be determined, 163 women contacted staff to request more information, 67 progressed to medical record review, and 38 were enrolled. Median household income of these participants was $70,000-$79,999 and median age was 62 years. Through Internet advertising, 3116 spoke to interviewers about the study, with 1297 progressing to medical record review, yielding 793 eligible participants. Median household income was $70,000-$79,999; median age was 58 years. Although Internet recruitment was the most successful strategy, it may have unintentionally targeted younger or more affluent women who own and use smartphones or home computers with internet access. With technology becoming increasingly pervasive and as people become more hesitant to answer phone calls from foreign numbers, recruitment strategies must be evaluated to ensure the study population is truly being reached.

Citation Format: Ryan D Baltic, Gregory S Young, Mira L Katz, Susan Rawl, Victoria Champion, Electra D Paskett. Rural interventions to improve breast, cervical and colorectal screening rates: Recruitment strategies for women in rural areas [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B001.

Abstract B017: Rural interventions for screening effectiveness: Baseline cancer screening behaviors of rural women of Indiana and Ohio

Rural areas of the United States experience increased cancer incidence and mortality rates and lower cancer screening rates compared to urban areas. According to the National Center for Health Statistics, Ohio and Indiana are ranked 8th and 10th highest, respectively, for cancer mortality rates nationally. The Rural Interventions for Screening Effectiveness (RISE) Study conducted by The Ohio State University and Indiana University focuses on improving breast, cervical and colorectal cancer screening rates in rural areas of both states to reduce this cancer burden. RISE is testing two interventions to educate and encourage women in rural counties of Ohio and Indiana ages 50-74 years to complete any needed screenings. Participants complete baseline and 12-month surveys and receive usual care brochures, an interactive DVD, or the DVD along with phone-based assistance from a patient navigator. In order to be eligible to participate, women must be residents of a rural county of either state, outside of guidelines for breast, cervical, and/or colorectal cancer screening per medical record review, and have no personal history of inflammatory bowel disease, cancer (except non-melanoma skin cancer), or genetic conditions that increase cancer risk. Baseline demographic and cancer screening history data were collected from 1634 women (1041 Ohio, 593 Indiana), and 985 were ultimately eligible and enrolled in the study (599 Ohio, 386 Indiana). Women who were within guidelines for all three screening tests were excluded from the study; 442 (42.5%) in Ohio and 207 (34.9%) in Indiana. A larger proportion of Indiana women were outside of guidelines for all three screening tests (80 of 593 (13.5%)) compared to Ohio women (107 of 1041 (10.3%)). Across both states, more women were adherent to breast cancer screening guidelines (75.3%) than cervical (66%) or colorectal cancer screening guidelines (58.8%). A comparison of screening behaviors of Indiana and Ohio participants will be conducted to determine if differences between the two exist. Analyses will focus on being inside or outside of guidelines by individual test (breast, cervical, and colorectal) and all three tests combined. Although rural women of Midwest states are often considered to be very similar, differences in screening behaviors exist, even between women of neighboring states, and future efforts to improve the cancer burden in rural women could benefit from considering factors that contribute to these differences, such as access to quality care.

Citation Format: Electra D Paskett, Ryan D Baltic, Mira L Katz, Gregory S Young, Susan Rawl, Victoria Champion. Rural interventions for screening effectiveness: Baseline cancer screening behaviors of rural women of Indiana and Ohio [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B017.

Increasing Adherence to Adjuvant Hormone Therapy Among Patients With Breast Cancer: A Smart Phone App-Based Pilot Study

PURPOSE

This study tested the feasibility and efficacy of using a text-based intervention to increase initiation, decrease discontinuation, and improve adherence as prescribed to adjuvant hormone therapy (AHT) among hyphenate post-menopausal breast cancer survivors.

METHODS

The 3-month intervention consisted of daily text message reminders to take medication, coupled with a dynamic (eg, feedback on progress) tailored intervention using weekly interactive surveys delivered by a smartphone app. Five clinic sites within the Alliance for Clinical Trials in Oncology participated. Hormone levels were measured prior to AHT initiation and at study exit.

RESULTS

Of the 39 patients recruited to the pilot study, 27 (69.2%) completed all study requirements (completed both the baseline and the exit surveys, both blood draws, and did not miss more than 2 weekly surveys). Significant improvements were observed pre- to postintervention for self-reported medication adherence (P = .015), mental health functioning (P = .007), and perceived stress (P = .04). Significant decreases in estradiol, estrogen, and estrone hormone levels were observed from baseline to study exit (P < .001), indicating the accuracy of self-reported AHT adherence. Participants (91.9%) and physicians (100%) agreed that participant participation in the intervention was beneficial.

CONCLUSIONS

The results of this pilot study established the general feasibility and efficacy of an app-based intervention to support patient AHT adherence. Larger controlled, randomized trials are needed to examine the effectiveness of the app-based intervention in improving AHT and quality of life among breast cancer survivors.

Onset, Trajectory, and Pattern of Feeding Difficulties in Toddlers Later Diagnosed with Autism

OBJECTIVE

To examine the emergence and trajectory of feeding difficulties in young children who are later diagnosed with autism spectrum disorder (ASD).

METHODS

The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was administered to a sample of 93 toddlers with an older sibling with ASD-the high-risk group-and 62 toddlers with no known familial ASD-the low-risk group-as part of a larger infant sibling study. The BPFAS was completed by parents at 15, 18, 24, and 36 months of age. At 36 months, participants underwent a diagnostic assessment and were classified into 1 of the following 4 outcome groups: ASD, nontypical development, high-risk typically developing, and low-risk typically developing. The BPFAS was scored for total frequency of feeding difficulties and autism-specific factor scores previously described in the literature.

RESULTS

The frequency of feeding difficulties increased significantly more rapidly in the ASD group between 15 and 36 months of age, and by 36 months, they exhibited a significantly higher total frequency score than all other groups. Analysis of the factor scores revealed a similar pattern for the food acceptance and mealtime behavior domains but no significant differences in the medical/oral motor domain.

CONCLUSION

Feeding difficulties develop significantly more rapidly in children with ASD, with longitudinal monitoring revealing the steeper trajectory earlier than can be detected with cross-sectional analysis. Children with ASD are at risk of health and social consequences of poor feeding behavior that may potentially be minimized if addressed early and appropriately.

A video-based measure to identify autism risk in infancy

BACKGROUND

Signs of autism are present in the first 2 years of life, but the average age of diagnosis lags far behind. Instruments that improve detection of autism risk in infancy are needed. This study developed and tested the psychometric properties of a novel video-based approach to detecting ASD in infancy.

METHODS

A prospective longitudinal study of children at elevated or lower risk for autism spectrum disorder was conducted. Participants were 76 infants with an older sibling with ASD and 37 infants with no known family history of autism. The Video-referenced Infant Rating System for Autism (VIRSA) is a web-based application that presents pairs of videos of parents and infants playing together and requires forced-choice judgments of which video is most similar to the child being rated. Parents rated participants on the VIRSA at 6, 9, 12, and 18 months of age. We examined split-half and test-retest reliability; convergent and discriminant validity; and sensitivity, specificity, and negative and positive predictive value for concurrent and 36-month ASD diagnoses.

RESULTS

The VIRSA demonstrated satisfactory reliability and convergent and discriminant validity. VIRSA ratings were significantly lower for children ultimately diagnosed with ASD than children with typical development by 12 months of age. VIRSA scores at 18 months identified all children diagnosed with ASD at that age, as well as 78% of children diagnosed at 36 months.

CONCLUSIONS

This study represents an initial step in the development of a novel video-based approach to detection of ASD in infancy. The VIRSA's psychometric properties were promising when used by parents with an older affected child, but still must be tested in community samples with no family history of ASD. If results are replicated, then the VIRSA's low-burden, web-based format has the potential to reduce disparities in communities with limited access to screening.

Comparative Effectiveness of Two Interventions to Increase Colorectal Cancer Screening for Those at Increased Risk Based on Family History: Results of a Randomized Trial

BACKGROUND

First-degree relatives (FDR) of patients with colorectal cancer are at risk for colorectal cancer, but may not be up to date with colorectal cancer screening. We sought to determine whether a one-time recommendation about needing colorectal cancer screening using patient navigation (PN) was better than just receiving the recommendation only.

METHODS

Participants were FDRs of patients with Lynch syndrome-negative colorectal cancer from participating Ohio hospitals. FDRs from 259 families were randomized to a website intervention (528 individuals), which included a survey and personal colorectal cancer screening recommendation, while those from 254 families were randomized to the website plus telephonic PN intervention (515 individuals). Primary outcome was adherence to the personal screening recommendation (to get screened or not to get screened) received from the website. Secondary outcomes examined who benefited from adding PN.

RESULTS

At the end of the 14-month follow-up, 78.6% of participants were adherent to their recommendation for colorectal cancer screening with adherence similar between arms (P = 0.14). Among those who received a recommendation to have a colonoscopy immediately, the website plus PN intervention significantly increased the odds of receiving screening, compared with the website intervention (OR: 2.98; 95% confidence interval, 1.68-5.28).

CONCLUSIONS

Addition of PN to a website intervention did not improve adherence to a colorectal cancer screening recommendation overall; however, the addition of PN was more effective in increasing adherence among FDRs who needed screening immediately.

IMPACT

These findings provide important information as to when the additional costs of PN are needed to assure colorectal cancer screening among those at high risk for colorectal cancer.

Follow up after sample size re-estimation in a breast cancer randomized trial for disease-free survival

BACKGROUND

While the clinical trials and statistical methodology literature on sample size re-estimation (SSRE) is robust, evaluation of SSRE procedures following the completion of a clinical trial has been sparsely reported. In blinded sample size re-estimation, only nuisance parameters are re-estimated, and the blinding of the current trial treatment effect is preserved. Blinded re-estimation procedures are well-accepted by regulatory agencies and funders. We review our experience of sample size re-estimation in a large international, National Institutes of Health funded clinical trial for adjuvant breast cancer treatment, and evaluate our blinded sample size re-estimation procedure for this time-to-event trial. We evaluated the SSRE procedure by examining assumptions made during the re-estimation process, estimates resulting from re-estimation, and the impact on final trial results with and without the addition of participants, following sample size re-estimation.

METHODS

We compared the control group failure probabilities estimated at the time of SSRE to estimates used in the original planning, to the final un-blinded control group failure probability estimates for those included in the SSRE procedure (SSRE cohort), and to the final total control group failure probability estimates. The impact of re-estimation on the final comparison between randomized treatment groups is evaluated for those in the originally planned cohort (n = 340) and for the combination of those recruited in the originally planned cohort and those added after re-estimation (n = 509).

RESULTS

Very little difference is observed between the originally planned cohort and all randomized patients in the control group failure probabilities over time or in the overall hazard ratio estimating treatment effect (originally planned cohort HR 1.25 (0.86, 1.79); all randomized cohort HR 1.24 95% CI (0.91, 1.68)). At the time of blinded SSRE, the estimated control group failure probabilities at 3 years (0.24) and 5 years (0.40) were similar to those for the SSRE cohort once un-blinded (3 years, 0.22 (0.16, 0.30); 5 years, 0.33 (0.26, 0.41)).

CONCLUSIONS

We found that our re-estimation procedure performed reasonably well in estimating the control group failure probabilities at the time of re-estimation. Particularly for time-to-event outcomes, pre-planned blinded SSRE procedures may be the best option to aid in maintaining power.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00201851 . Registered on 9 September 2005. Retrospectively registered.

Mothers of children with autism spectrum disorders: Play behaviors with infant siblings and social responsiveness

Mother-infant interactions are a proximal process in early development and may be especially salient for children who are at risk for social difficulties (i.e. infant siblings of children with autism spectrum disorder). To inform how indices of maternal behaviors may improve parent-mediated interventions designed to mitigate autism spectrum disorder risk, the present study explored maternal social responsiveness ratings and social behaviors during dyadic play interactions. Dyads were recruited from families with at least one older child with autism spectrum disorder (high-risk group, n = 90) or families with no history of autism spectrum disorder (low-risk group, n = 62). As part of a prospective study, interactions were coded when infant siblings were 6, 9, and 12 months of age, for gaze, affect, vocalizations, and multimodal bids or responses (i.e. social smiles). Maternal social responsiveness was indexed via the Social Responsiveness Scale. Mothers in both risk groups had comparable Social Responsiveness Scale scores and social behaviors during play. Two maternal behaviors emerged as positive correlates of infant social behaviors and are thus of high relevance to parent-mediated interventions. Specifically, more maternal positive affect and the use of multimodal bids or responses were associated with more infant positive affect, vocalizations, gaze to face, and multimodal bids or responses.

The dysregulation profile in preschoolers with and without a family history of autism spectrum disorder

BACKGROUND

The 'dysregulation profile' (DP) is a measure of emotional and behavioral dysregulation that may cut across diagnostic boundaries. Siblings of children with autism spectrum disorder (ASD) who do not develop ASD themselves are at risk for atypical outcomes including behavioral challenges and therefore may be a useful population in which to investigate the structure of the DP in preschoolers.

METHODS

We sought to examine the factor structure and predictors of the DP in a sample enriched for a wide range of phenotypic variation-36-month-olds with and without family histories of ASD-and to determine whether children with genetic liability for ASD are at risk for a phenotype characterized by elevated dysregulation. Data were collected from 415 children with (n = 253) and without (n = 162) an older sibling with ASD, all without ASD themselves, at 18, 24, and 36 months of age.

RESULTS

Our findings replicate prior reports, conducted in predominantly clinically referred and older samples, supporting the superiority of a bifactor model of the DP in the preschool period compared to the second-order and one-factor models. Examiner ratings were longitudinally and concurrently associated with the DP at 36 months of age. Family history of ASD was associated with higher dysregulation in the Anxious/Depressed dimension.

CONCLUSIONS

These findings support the relevance of examining the structure of psychopathology in preschoolers and suggest that examiner observations as early as 18 months of age, particularly of overactivity, may help identify risk for later DP-related concerns. Non-ASD preschoolers with family histories of ASD may be at risk for a phenotype characterized by elevated dysregulation particularly in the Anxious/Depressed dimension by age 3.

Insurance Stability and Cancer Screening Behaviors

Background: Disparities in rates of cancer screening are observed in underserved populations. Lack of stable health insurance may contribute to these disparities. The goal of this study was to examine the association between insurance stability and up-to-date cancer screening in underserved populations.

Methods and Findings: We enrolled 333 community participants aged 40–74 years across four different sites in three states: Chinese Americans in Boston, Massachusetts; Hispanics in Columbus, Ohio; Appalachian populations from Ohio's Appalachian counties; and Blacks and African Americans in Philadelphia, Pennsylvania. Self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer (CRC). Screening rates fell short of Health People 2020 targets for breast, colorectal, and cervical cancer screenings. Being currently insured was associated with current CRC screenings (69.7% among insured vs. 30.7% among uninsured, p=0.0055), but not with breast or cervical cancer screenings. Stable 12-month insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Having current insurance was associated with CRC screening; stability of insurance was not associated with cancer screening. Insurance coverage alone is not the main driver of cancer screening.

Predictors of Willingness to Participate in Biospecimen Donation and Biobanking among Appalachian Adults

BACKGROUND

Rural residents in the U.S., particularly residents of Appalachia, are underrepresented in biomedical research, limiting the generalizability of research findings.

OBJECTIVE

To examine factors associated with Appalachian adults' willingness to participate in biospecimen donation and banking.

METHODS

A survey assessing willingness to donate blood, saliva, and buccal specimens and to have these biospecimens stored for future use in genetic studies was conducted among 493 Appalachian adults.

RESULTS

Most participants 73% (358/493) were willing to donate one or more biospecimen type; among them, 75% (268/358) were willing to donate blood, saliva, and buccal specimens. Approximately 61% (300/493) were willing to have their biospecimens banked and 97% (290/300) of these were willing to have their samples used for genetic studies. Appalachian self-identity predicted willingness to donate biospecimens, to have them stored, and used in genetic studies (OR1.52, 95% CI 1.03-2.24).

CONCLUSIONS

Appalachian adults were generally willing to participate in biobanking research.

Correlates of Rural, Appalachian, and Community Identity in the CITIES Cohort

PURPOSE

To determine correlates of rural, Appalachian, and community identity among a cohort of participants in the Community Initiative Towards Improving Equity and Health Status (CITIES) project.

METHODS

Mixed linear and logistic regression effects models were utilized to determine correlates of 3 outcomes: 1) community identity, 2) rural identity, and 3) Appalachian identity among participants in the Ohio CITIES project.

FINDINGS

Distinct demographic characteristics were found to be associated with each of the outcomes. For community identity, while no differences were found for rural or urban participants, those who were single or never married (P < .0001) as well as those who graduated from college (P = .0005) reported significantly lower community identity scores than married individuals with less than a college education. Those who resided in an Appalachian county reported higher community identity scores (P = .0009) than non-Appalachian residents. For rural identity, those who did not identify as Christian (P = .018) as well as those who identified as Democrat (P = .027) reported significantly lower rural identity scores than others. Lastly, for Appalachian identity, county-level percentage of families in poverty (P = .06), as well as gender (P = .05), were associated with self-reported Appalachian identity, but these effects were only marginally significant.

CONCLUSIONS

Although community, rural, and Appalachian identity may be viewed as similar due to their measure of attachment to a place, results from this study suggest that there are distinct individual and area-level correlates associated with community, rural, and Appalachian identity.

Cancer-Related Beliefs and Perceptions in Appalachia: Findings from 3 States

BACKGROUND

Appalachians experience increased rates of cancer incidence and mortality compared to non-Appalachians. Many factors may contribute to the elevated cancer burden, including lack of knowledge and negative beliefs about the disease.

METHODS

Three National Cancer Institute (NCI)-designated cancer centers with Appalachian counties in their respective population-based geographic service areas-Kentucky, Ohio, and Pennsylvania-surveyed their communities to better understand their health profiles, including 5 items assessing cancer beliefs. Weighted univariate and bivariate statistics were calculated for each of the 3 state's Appalachian population and for a combined Appalachian sample. Weighted multiple linear regression was used to identify factors associated with a cancer beliefs composite score. Data from the combined Appalachian sample were compared to NCI's Health Information National Trends Survey (HINTS).

RESULTS

Data from 1,891 Appalachian respondents were included in the analysis (Kentucky = 798, Ohio = 112, Pennsylvania = 981). Significant differences were observed across the 3 Appalachian populations related to income, education, marital status, rurality, perceptions of present income, and body mass index (BMI). Four of 5 cancer beliefs were significantly different across the 3 states. Education, BMI, perceptions of financial security, and Kentucky residence were significantly associated with a lower composite score of cancer beliefs. When comparing the combined Appalachian population to HINTS, 3 of 5 cancer belief measures were significantly different.

CONCLUSIONS

Variations in cancer beliefs were observed across the 3 states' Appalachian populations. Interventions should be tailored to specific communities to improve cancer knowledge and beliefs and, ultimately, prevention and screening behaviors.

Early motor abilities in infants at heightened versus low risk for ASD: A Baby Siblings Research Consortium (BSRC) study

Research has identified early appearing differences in gross and fine motor abilities in infants at heightened risk (HR) for autism spectrum disorder (ASD) because they are the younger siblings of children with ASD, and it suggests that such differences may be especially apparent among those HR infants themselves eventually diagnosed with ASD. The present study examined overall and item-level performance on the gross (GM) and fine motor (FM) subscales of the Mullen Scales of Early Learning (MSEL) administered at 6 months to a large, geographically diverse sample of HR infants with varying developmental outcomes (ASD, elevated ADOS without ASD, low ADOS without ASD) and to infants with low ASD risk (low risk [LR]). We also explored whether motor abilities assessed at 6 months predicted ASD symptom severity at 36 months. FM (but not GM) performance distinguished all 3 HR groups from LR infants with the weakest performance observed in the HR-Elevated ADOS children, who exhibited multiple differences from both LR and other HR infants in both gross and fine motor skills. Finally, 6-month FM (but not GM) scores significant predicted 36-month ADOS severity scores in the HR group; but no evidence was found of specific early appearing motor signs associated with a later ASD diagnosis. Vulnerabilities in infants' fine and gross motor skills may have significant consequences for later development not only in the motor domain but in other domains. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Sibling Recurrence Risk and Cross-aggregation of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder

Importance

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are believed to partially share genetic factors and biological influences. As the number of children with these diagnoses rises, so does the number of younger siblings at presumed risk for ADHD and ASD; reliable recurrence risk estimates within and across diagnoses may aid screening and early detection efforts and enhance understanding of potential shared causes.

Objective

To examine within-diagnosis sibling recurrence risk and sibling cross-aggregation of ADHD and ASD among later-born siblings of children with either disorder.

Design, Setting, and Participants

Using data extracted from medical records of 2 large health care systems in the United States, estimates of recurrence risk and cross-aggregation in later-born siblings of children with ADHD or ASD were compared with later-born siblings of children without these diagnoses. One data set included children seen between January 1, 1995, and December 31, 2013; the other included children born between January 1, 1998, and May 17, 2010. Participants included 15 175 later-born siblings of children with ADHD, ASD, and no known diagnosis. The study was conducted from October 2, 2017, to August 14, 2018.

Main Outcomes and Measures

Diagnoses of ASD or ADHD in the later-born sibling, ascertained from medical records, were the primary outcomes of interest; moderators included sex, gestational age, and maternal age.

Results

A total of 15 175 later-born siblings were classified by familial risk status based on the older child's diagnostic status: ADHD risk (n = 730; male [51.92%]), ASD risk (n = 158; male [48.10%]), and no known risk (n = 14 287; male [50.73%]). Compared with later-born siblings of children without ADHD or ASD, later-born siblings of children with ASD were more likely to be diagnosed with ASD (odds ratio [OR], 30.38; 95% CI, 17.73-52.06) or ADHD in the absence of ASD (OR, 3.70; 95% CI, 1.67-8.21). Compared with later-born siblings of children without a diagnosis, later-born siblings of children with ADHD were more likely to be diagnosed with ADHD (OR, 13.05; 95% CI, 9.86-17.27) or ASD in the absence of ADHD (OR, 4.35; 95% CI, 2.43-7.79).

Conclusions and Relevance

Later-born siblings of children with ASD or ADHD appear to be at elevated risk for the same disorder, but also of being diagnosed with the other disorder. These findings provide further support for shared familial mechanisms underlying ASD and ADHD, which may be useful for genetic and prospective developmental studies. Later-born siblings of children with ADHD or ASD should be monitored for both conditions.

A Novel Tomato-Soy Juice Induces a Dose-Response Increase in Urinary and Plasma Phytochemical Biomarkers in Men with Prostate Cancer

Background

Tomato and soy intake is associated with reduced prostate cancer risk or severity in epidemiologic and experimental studies.

Objective

On the basis of the principle that multiple bioactives in tomato and soy may act on diverse anticancer pathways, we developed and characterized a tomato-soy juice for clinical trials. In this phase 2 dose-escalating study, we examined plasma, prostate, and urine biomarkers of carotenoid and isoflavone exposure.

Methods

Men scheduled for prostatectomy were recruited to consume 0, 1, or 2 cans of tomato-soy juice/d before surgery (mean ± SD duration: 24 ± 4.6 d). The juice provided 20.6 mg lycopene and 66 mg isoflavone aglycone equivalents/177-mL can. Plasma carotenoids and urinary isoflavone metabolites were quantified by HPLC-photometric diode array and prostate carotenoids and isoflavones by HPLC-tandem mass spectrometry.

Results

We documented significant dose-response increases (P < 0.05) in plasma concentrations of tomato carotenoids. Plasma concentrations were 1.86-, 1.69-, 1.73-, and 1.69-fold higher for lycopene, β-carotene, phytoene, and phytofluene, respectively, for the 1-can/d group and 2.34-, 3.43-, 2.54-, and 2.29-fold higher, respectively, for the 2-cans/d group compared with 0 cans/d. Urinary isoflavones daidzein, genistein, and glycitein increased in a dose-dependent manner. Prostate carotenoid and isoflavone concentrations were not dose-dependent in this short intervention; yet, correlations between plasma carotenoid and urinary isoflavones with respective prostate concentrations were documented (R2 = 0.78 for lycopene, P < 0.001; R2 = 0.59 for dihydrodaidzein, P < 0.001). Secondary clustering analyses showed urinary isoflavone metabolite phenotypes. To our knowledge, this is the first demonstration of the phytoene and phytofluene in prostate tissue after a dietary intervention. Secondary analysis showed that the 2-cans/d group experienced a nonsignificant decrease in prostate-specific antigen slope compared with 0 cans/d (P = 0.078).

Conclusion

These findings provide the foundation for evaluating a well-characterized tomato-soy juice in human clinical trials to define the impact on human prostate carcinogenesis. This trial is registered at clinicaltrials.gov as NCT01009736.

The Developmental Sequence and Relations Between Gesture and Spoken Language in Toddlers With Autism Spectrum Disorder

In typical development, gestures precede and predict language development. This study examines the developmental sequence of expressive communication and relations between specific gestural and language milestones in toddlers with autism spectrum disorder (ASD), who demonstrate marked difficulty with gesture production and language. Communication skills across five stages (gestures, word approximations, first words, gesture-word combinations, and two-word combinations) were assessed monthly by blind raters for toddlers with ASD participating in an randomized control trial of parent-mediated treatment (N = 42, 12-30 months). Findings revealed that toddlers acquired skills following a reliable (vs. idiosyncratic) sequence and the majority of toddlers combined gestures with words before combining words in speech, but in contrast to the pattern observed in typical development, a significant subset acquired pointing after first words.

Diagnosis of Autism Spectrum Disorder After Age 5 in Children Evaluated Longitudinally Since Infancy

OBJECTIVE

The diagnosis of autism spectrum disorder (ASD) has been found to be remarkably stable but few studies have followed children not initially diagnosed with ASD beyond 3 years of age to examine late or delayed diagnoses. The present study used a prospective familial-risk design to identify children who had undergone multiple comprehensive assessments in preschool and were determined to be negative for ASD only to meet criteria for ASD when tested in middle childhood.

METHOD

Data were pooled across 3 research teams studying later-born siblings of children with ASD. Fourteen children met inclusion criteria for the late-diagnosed group and were compared with a large sample of high- and low-risk siblings from the same sites who had ASD or typical development (TD) outcomes at 3 years of age.

RESULTS

As a group, the late-diagnosed children scored between the TD and ASD groups on most measures administered at 3 years and differed significantly from the ASD group on most measures. However, there was significant heterogeneity among the late-diagnosed cases. Seven showed very little evidence of ASD in preschool, whereas 7 demonstrated subtle, subthreshold symptomatology.

CONCLUSION

Some children with ASD might present with a subtle phenotype early in life or show a prolonged time course of symptom development. This emphasizes the need for screening and surveillance schedules that extend past 36 months and continued evaluation of any child who presents with atypical early development and/or high-risk status. The findings also shed light on reasons why the mean age of ASD diagnosis remains older than 4 years.

The CITIES Project: Understanding the Health of Underrepresented Populations in Ohio

BACKGROUND

Ohio, the catchment area of The Ohio State University Comprehensive Cancer Center (OSUCCC), includes diverse populations with different cancer profiles. As part of the National Cancer Institute (NCI)-funded initiative to conduct population health assessments in cancer center catchment areas, the OSUCCC surveyed residents, focusing on factors contributing to cancer disparities in Ohio populations.

METHODS

Two sampling strategies were used: (i) probability sampling of mailing lists and (ii) convenience sampling at community events, coupled with phone/in-person/web surveys. Survey items were chosen along multilevel framework constructs, used in concert with other funded NCI-Designated Cancer Centers. Multivariable logistic regression models investigated predictors associated with health behaviors, cancer beliefs, knowledge, and screening.

RESULTS

The sample of 1,005 respondents were white (46.6%), African American (24.7%), Hispanic (13.7%), Somali (7.6%), and Asian (7.5%). A total of 216 respondents were Appalachian. Variations in cancer attitudes, knowledge, and behaviors were noted by racial/ethnic and geographic group. Multivariable models identified individuals with less financial security as less likely to exercise or be within guidelines for screening, but more likely to smoke and have a poor diet. At the community-level, measures of poverty were highest in Appalachia, whereas children in female-headed households were greater in urban minority areas.

CONCLUSIONS

This population health assessment reinforced the diversity of the OSUCCC catchment area. These populations are ripe for implementation science strategies, focusing in communities and clinics that serve vulnerable populations.

IMPACT

Understanding attitudes, knowledge, and behaviors of this population can assist tailoring outreach and research strategies to lessen the cancer burden.

A Group Randomized Trial to Reduce Obesity among Appalachian Church Members: The Walk by Faith Study

Background: Appalachia is a rural, socioeconomically disadvantaged region with high rates of cancer and obesity. Using community-based participatory research principles, the Appalachia Community Cancer Network tested an initiative to reduce weight among overweight and obese participants by partnering with churches, an important community-based institution in Appalachia.Methods: A group randomized trial was conducted with counties or groups of counties in five Appalachian states. These groups were randomly assigned to receive either monthly diet and exercise education sessions ("Walk by Faith"; WbF) or an educational program focused on cancer screening and education ("Ribbons of Faith"; RoF) to examine effects on weight change. Participants completed questionnaires and biometric measurements at baseline and 12 months. The primary outcome of the study was weight change from baseline to 12 months.Results: The relative difference in weight loss from baseline to 12 months for WbF compared with RoF was 1.4% but was not statistically significant (P = 0.13). However, results varied by sex and marital status. WbF men experienced a significant 2.8% decrease in body weight, married WbF women a 1.5% decrease, and unmarried WbF women a 1.5% increase compared with their respective RoF subgroups (interaction P = 0.016). Among WbF participants, greater participation in monthly educational sessions was associated with greater weight loss (P = 0.002).Conclusions: WbF facilitated weight loss mainly in male participants. Level of participation in WbF activities correlated with weight loss.Impact: Findings suggest that additional research is needed to better understand factors associated with participation in health promotion programs for underserved rural communities. Cancer Epidemiol Biomarkers Prev; 27(11); 1289-97. ©2018 AACR.

Early Detection of ADHD: Insights From Infant Siblings of Children With Autism

Converging evidence suggests shared genetic underpinnings of attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Studies of infants at risk for ASD have proliferated over the past decade; the few studies that have followed these infants beyond age 3 report a range of difficulties facing a subset of these infants as they reach school age, including elevated levels of attention problems and externalizing behavior. Given this, we aimed to identify early predictors of school-age ADHD outcomes in a sample of infant siblings at risk for ASD. This study reports on a sample of 59 infants at high and low risk for ASD who had been followed for more than a decade, collecting data at regular intervals from 3 to 36 months and then determining diagnostic outcome at 8-10 years of age. Seventeen participants were diagnosed with Diagnostic and Statistical Manual of Mental Disorders (5th ed.) ADHD at school age (n = 14 high risk, 3 low risk). As infants, the ADHD outcome group demonstrated atypical longitudinal patterns of sustained visual attention. A significantly larger proportion of their parents reported behavior/temperament problems at 36 months of age, and examiners noted the presence of inattentive, hyperactive, and/or impulsive behaviors in this group by 18 months of age. These data suggest that behavioral indicators of risk for later ADHD may be present early in development, which may improve earlier detection and treatment of the disorder.

Gaze to faces across interactive contexts in infants at heightened risk for autism

Infant social-communicative behavior, such as gaze to the face of an interactive partner, is an important early developmental skill. Children with autism spectrum disorder exhibit atypicalities in social-communicative behavior, including gaze and eye contact. Behavioral differences in infancy may serve as early markers of autism spectrum disorder and help identify individuals at highest risk for developing the disorder. Researchers often assess social-communicative behavior in a single interactive context, such as during assessment with an unfamiliar examiner or play with a parent. Understanding whether infant behavior is consistent across such contexts is important for evaluating the validity of experimental paradigms and the generalizability of findings from one interactive context/partner to another. We examined infant gaze to the face of a social partner at 6, 9, and 12 months of age in infants who were later diagnosed with autism spectrum disorder, as well as low- and high-risk infants without autism spectrum disorder outcomes, across two interactive contexts: structured testing with an unfamiliar examiner and semi-structured play with a parent. By 9 months, infant gaze behavior was significantly associated between the two contexts. By 12 months, infants without autism spectrum disorder outcomes exhibited higher mean rates of gaze to faces during parent-child play than Mullen testing, while the gaze behavior of the autism spectrum disorder group did not differ by context-suggesting that infants developing autism spectrum disorder may be less sensitive to context or interactive partner. Findings support the validity of assessing infant social-communicative behavior during structured laboratory settings and suggest that infant behavior exhibits consistency across settings and interactive partners.

Cognitive Dysfunction Contributes to Mobility Impairments in Huntington's Disease

Background:

Huntington’s disease (HD) is a progressive neurodegenerative disorder that results in a gradual decline in mobility and balance. Increasing evidence has documented an important role of executive function in the safe ambulation of the elderly and people with a variety of neurological disorders. Little is known about the contribution of cognitive deficits to decline in mobility over time in HD.

Objective:

This study examined the relationships of mobility, motor and cognitive function measures at baseline, and of mobility and cognitive measures over four years.

Methods:

A retrospective chart review was performed on 70 patients with genetically confirmed HD (age 20–75 years old) across 121 HD clinic visits. Correlations between Unified Huntington’s Disease Rating Scale – Total Motor, Tinetti Mobility Test (TMT), and cognitive measures (Letter Verbal Fluency, Symbol Digit Modalities Test (SDMT), and Stroop Test) were analyzed. Longitudinal relationships between TMT and cognitive measures were examined using mixed effect regression models.

Results:

Gait and balance measures representing domains of mobility (TMT scores) were significantly correlated with each of the cognitive measures with the exception of the Verbal Fluency score. Mixed effects regression modeling showed that the Stroop Interference sub-test and SDMT were significant predictors (p-values <0.01) of TMT total scores.

Conclusions:

Impairments in executive function measures correlate highly with measures of gait, balance and mobility in individuals with HD. Interventions designed to improve mobility and decrease fall risk should also address issues of cognitive impairments with particular consideration given to interventions that may focus on motor-cognitive dual task training.

Financial burden among older, long-term cancer survivors: Results from the LILAC study

Background

Increasing attention is being paid to financial burdens of cancer survivorship, but little is known about the prevalence and predictors of these burdens in older, long‐term survivors.

Methods

We used data from 6012 participants diagnosed with cancer since enrolling in the Women's Health Initiative, and who participated in the Life and Longevity After Cancer (LILAC) ancillary study to estimate prevalence and identify predictors of financial burden. We used logistic regression to identify sociodemographic, socioeconomic, health‐ and cancer‐related factors associated with financial burden and backward selection to build a final multivariable model.

Results

Average age at LILAC participation was 79 and 9.2 years had elapsed since cancer diagnosis. Overall, 6% experienced some form of financial burden, including having an insurance company refuse a claim (2.6%), being denied loans or insurance due to cancer history (2.2%), or experiencing significant indebtedness (1.8%, including facing large debts or bills or declaring bankruptcy). Eight predictors remained associated (P < 0.05) with financial burden in the fully‐adjusted model: younger age, shorter time since diagnosis, African‐American race, household income <$20 000/year, modified Charlson comorbidity score ≥2, receipt of chemotherapy, regional stage at diagnosis, and no private health insurance. Education, cancer site, social support, receipt of radiation, and receipt of hormone therapy were not associated with financial burden. Predictors differed between types of financial burden experienced and age at diagnosis (<65 vs 65+).

Conclusion

Cancer‐related financial burden was rare in this population of older, female long‐term cancer survivors. The identification of several socioeconomic, health‐related and demographic predictors of financial burden may suggest targets of intervention to reduce financial burdens.

Precis

Financial burden was uncommon in older, female, long‐term survivors. Predictors of financial burden included age, race, income, comorbidities, time since diagnosis, stage, insurance, and receipt of chemotherapy.

Abstract C77: Impact of insurance and primary care stability on cancer screening behaviors

Background: Disparities in rates of cancer screening are observed in racial and ethnic minority, immigrant, low-income, and low-education populations. One of the means by which these vulnerable populations may not receive screening is due to lack of stable health insurance. The goal of the present study is to examine the association between current insurance status, insurance stability, and up-to-date cancer screening in underserved populations.

Methods: As part of the Cancer Disparities Research Network pilot cohort, the study recruited participants across four sites: Boston Chinatown, African American communities in Philadelphia, Hispanic communities in Columbus, and rural white communities in Appalachia, Ohio. Enrolled participants were eligible if they were 40-74 years old, did not live in a nursing home or other facility, and had no prior invasive cancer diagnosis. Additionally, each participant met at least one of the following criteria indicating being medically underserved: living in a medically underserved area, having low literacy, low income (defined as 100% of the 2015 Federal Poverty Level) or being uninsured, having gaps in insurance, or receiving subsidized health insurance coverage.

Participants completed a baseline survey of demographic data, health insurance status, primary care physician (PCP) status, and most recent breast, cervical, and colorectal cancer screenings. Using the USPSTF guidelines, breast cancer screening was considered up to date if women ages 40–74 had a mammogram within the past 2 years. Cervical cancer screenings were up to date if women had a Pap test within the last 3 years or both a Pap test and an HPV test within the last 5 years. Colorectal cancer screening was current if participants had either a colonoscopy within the last 10 years, a flexible sigmoidoscopy within the last 5 years, or a fecal occult blood test (FOBT) within the last year. To assess participants' consistency of coverage, we defined stable insurance coverage as continuous coverage over the prior 12 months, and unstable insurance coverage as being uninsured, losing insurance, or having switches across major insurance categories at any point in the prior 12 months.

Results: Of the 333 participants enrolled in the study, 65.5% were women, 14.1% were 40-50 years of age, 59.8% were 51-64 years, and 26.1% were 65-74. The cohort was racially and ethnically diverse: 8.4% participants identified as Hispanic, 30.3% as non-Hispanic White, 31.2% as non-Hispanic Black, 29.4% as non-Hispanic Asian, and 0.6% as Other. 62.2% spoke English, 8.1% Spanish, and 29.7% Chinese as their primary language. Low incomes were common: 33.6% reported incomes $15,000 or less, and 25.8% reported incomes between $15,000 and $24,999.

Overall self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer. 90.7% of participants reported being currently insured at the time of the interview, and 70% reported stable insurance coverage. Being currently insured was associated with colorectal cancer screenings [69.5% among insured vs. 30.8% among uninsured (p= 0.0059)] but not with breast or cervical cancer screenings. Stable insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Overall screening rates meet Healthy People 2020 targets for breast cancer, but fall short for cervical and colorectal cancer screening. Rates of insurance are high at 90%, reflecting adoption of Medicaid expansion in all three states. In spite of low income, this population reported being up to date on colorectal cancer screenings if they had current health insurance. The low overall rates of colorectal cancer screening might be related to the lower prevalence of free or low-cost colon cancer screening programs.

Citation Format: Karen M. Freund, Sarah A. Reisinger, Amy LeClair, Sarah Al-Najar, Gregory S. Young, Jill Oliveri, Evelyn Gonzalez, Electra Paskett. Impact of insurance and primary care stability on cancer screening behaviors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C77.

Assessing Colorectal Cancer Screening Barriers by Two Methods

Colorectal cancer (CRC) is commonly diagnosed in the USA despite screening tests that have decreased CRC incidence and mortality. Finding the best method to identify patient-level screening barriers is important to improve CRC screening rates. A group-randomized trial was conducted among ten primary-care clinics. Clinics were randomized to a multi-level (clinic, provider, patient) CRC screening intervention or usual care (2007-2013). Subsequent to clinic- and provider-level interventions, a three-step, patient-level intervention was conducted. One step of the patient-level intervention was a CRC screening barriers counseling call conducted by a lay health advisor (LHA). During the call, two methods were used to identify CRC screening barriers. An open-ended question was used first to determine why participants had not completed screening (without probes). Subsequently, the LHA read a list of additional potential screening barriers and asked participants whether each barrier was applicable (with probes). A generalized estimating equation approach was used to compare the two methods. Participants (n = 109) were female (59%), had a mean age of 57.2 years, and were white (67%) or black (31%). Most participants had some college education or a college degree (79%), annual household income $30,000+ (60%), and health insurance (80%). The number of CRC screening barriers increased with probing compared to the open-ended question format (OR 2.10, 95% CI 1.92-2.31; p < 0.01). The ranking of reported CRC screening barriers did not vary by assessment method. However, the methodology used to document CRC screening barriers may influence the content of patient-directed interventions.

Fear of recurrence among older breast, ovarian, endometrial, and colorectal cancer survivors: Findings from the WHI LILAC study

OBJECTIVE

To examine the prevalence of and factors associated with fear of recurrence (FCR) following treatment for breast, ovarian, endometrial, and colorectal cancer among older women.

METHODS

Participants were enrolled in the Women's Health Initiative Life and Longevity After Cancer study. Descriptive statistics and multivariate logistic regression models were used to assess the association of demographic, clinical, and quality of life variables with survivors' FCR, dichotomized as <14 (low) or ≥14 (high) using the Cancer Worry Scale.

RESULTS

Out of the 4259 participants, 3124 (73.3%) were diagnosed with breast cancer, 559 (13.1%) with colorectal cancer, 493 (11.6%) with endometrial cancer, and 83 (2%) with ovarian cancer. There were no significant differences in FCR by cancer type (P = .75), with a mean scale score of 10.8 ± 2.87 for all participants combined. Approximately 16% (n = 679) were in the high FCR group. Multivariable analyses indicated that being younger at diagnosis, reporting a symptom score of ≥8, receipt of chemotherapy, and lower self-rated health were significantly associated with high FCR. Women who were widowed or never married were less likely to report high FCR.

CONCLUSIONS

Fear of recurrence was experienced by a small but important proportion of older, long-term cancer survivors and is associated with multiple demographic and clinical variables. These results will better inform researchers and clinicians regarding the individuals who are at risk of FCR.

The Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) Study: Description and Baseline Characteristics of Participants

Background: The Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study offers an important opportunity to advance cancer research by extending the original WHI studies to examine survivorship in women diagnosed with cancer during their participation in WHI.Methods: The goals of LILAC are to (i) obtain cancer treatment information and long-term cancer outcomes for women diagnosed with one of eight selected cancers (breast, endometrial, ovarian, lung, and colorectal cancers, and melanoma, lymphoma, and leukemia); (ii) augment the existing WHI biorepository with fixed tumor tissue from the solid tumor sites for cancers diagnosed since 2002; and (iii) develop, refine, and validate methods to use administrative data to capture treatment and recurrence data. Methods for accomplishing these goals are described, as are results from the initial LILAC participant survey.Results: A total of 9,934 WHI participants living with cancer were eligible for LILAC participation, of which 78% (N = 7,760) agreed to participate. Among the three most prevalent cancer types, 54% are breast cancer survivors, 11% are melanoma survivors, and 10% are survivors of colorectal cancer.Conclusions: In addition to describing this resource, we present pertinent lessons that may assist other investigators interested in embedding survivorship research into existing large epidemiologic cohorts.Impact: The LILAC resource offers a valuable opportunity for researchers to study cancer survivorship and issues pertinent to cancer survivors in future studies. Cancer Epidemiol Biomarkers Prev; 27(2); 125-37. ©2017 AACR.

Tele-Motivational Interviewing for Cancer Survivors: Feasibility, Preliminary Efficacy, and Lessons Learned

OBJECTIVE

Determine the feasibility, acceptability, and efficacy of tele-Motivational Interviewing (MI) for overweight cancer survivors.

DESIGN

Six-month nonrandomized phase 2 clinical trial.

SETTING

Urban garden and remote platforms.

PARTICIPANTS

Overweight and obese cancer survivors post active treatment.

INTERVENTION

Remote tele-MI from a trained registered dietitian nutritionist (RDN).

MAIN OUTCOME MEASURES

Feasibility, acceptability, and preliminary efficacy.

ANALYSIS

Groups were stratified as users and nonusers based on tele-MI use. Qualitative survey data and remote MI interaction logs were analyzed for trends. Two-sample t tests were performed to assess pre-post intervention changes in physical activity and dietary behaviors, quality of life, self-efficacy, and clinical biomarkers.

RESULTS

A total of 29 participants completed the intervention. There were 17 tele-MI users (59%) and 12 nonusers (41%). Users were primarily female (88%), breast cancer survivors (59%), college educated (82%), with a mean age of 58 years. Users set 50% more goals, lost more weight (4.8 vs 2.6 kg), significantly improved quality of life (P = .03), and trended more positively in clinical biomarkers (eg, cholesterol, blood pressure) than did nonusers.

CONCLUSIONS AND IMPLICATIONS

Findings from this study indicate that tele-MI is a feasible and acceptable intervention for overweight cancer survivors after active therapy. Larger randomized trials are needed to establish efficacy and generalizability to a variety of demographic populations.

Characterizing Time to Diagnostic Resolution After an Abnormal Cancer Screening Exam in Older Adult Participants in the Ohio Patient Navigation Research Program

OBJECTIVE

This study aims to test the effectiveness of a patient navigation (PN) intervention to reduce time to diagnostic resolution among older adults age ≥65 years versus those <65 years with abnormal breast, cervical, or colorectal cancer screening exams participating in the Ohio Patient Navigation Research Program (OPNRP).

METHOD

The OPNRP utilized a nested cohort group-randomized trial design to randomize 862 participants ( n = 67 for ≥65 years; n = 795 for <65 years) to PN or usual care conditions. A shared frailty Cox model tested the effect of PN on time to resolution.

RESULTS

Older adult participants randomized to PN achieved a 6-month resolution rate that was 127% higher than those randomized to usual care ( p = .001). This effect was not significantly different from participants <65 years.

DISCUSSION

PN significantly reduced time to diagnostic resolution among older adults beginning 6 months after an abnormal cancer screening exam. Health care systems should include this population in PN programs to reduce cancer disparities.

Fibroblast Growth Factor-23 Concentration in Dogs with Chronic Kidney Disease

Background

Chronic kidney disease (CKD) is associated with hyperphosphatemia, decreased vitamin D metabolite concentrations, and hyperparathyroidism. This syndrome is known as CKD‐mineral bone disorder (CKD‐MBD). Recently, it has been shown that an increase in fibroblast growth factor‐23 (FGF‐23) concentration is an early biomarker of CKD in people. It is an independent risk factor for both progression of renal disease and survival time in humans and cats with CKD. Information about FGF‐23 in healthy dogs and those with CKD is lacking.

Objectives

To measure FGF‐23 concentration in dogs with different stages of CKD and determine its association with factors involved in CKD‐MBD, including serum phosphorus and parathyroid hormone (PTH) concentrations. A secondary aim was to validate an ELISA for measurement of plasma FGF‐23 concentration in dogs.

Animals

Thirty‐two client‐owned dogs with naturally occurring CKD and 10 healthy control dogs.

Methods

Prospective cross‐sectional study. An FGF‐23 ELISA was used to measure plasma FGF‐23 concentration in dogs and their association with serum creatinine, phosphorus, calcium, and PTH concentrations.

Results

Plasma FGF‐23 concentrations increased with severity of CKD and were significantly different between IRIS stages 1 and 2 versus stages 3 and 4 (P < .0001). Increases in FGF‐23 concentrations were more frequent than hyperparathyroidism or hyperphosphatemia in this cohort. Serum creatinine and phosphorus concentrations were the strongest independent predictors of FGF‐23 concentration.

Conclusions and clinical importance

Plasma FGF‐23 concentrations increase in dogs with CKD as disease progresses. Plasma FGF‐23 concentrations appear to be useful for further study of the pathophysiology of CKD‐MBD in dogs.

Measured Head CT/CTA Skin Dose and Intensive Care Unit Patient Cumulative Exposure

BACKGROUND AND PURPOSE

Estimates of cumulative CT/CTA radiation dose based on volumetric CT dose index have raised concern that neurological intensive care unit patient exposures may reach thresholds for deterministic skin injury. Because the accuracy of volumetric CT dose index for this purpose in unknown, we set out to directly measure head CT and CTA peak skin dose, assess the relationship of volumetric CT dose index to measured peak skin dose, and determine whether multiple CT/CTA exposures in typical patients in the neurological intensive care unit produce cumulative doses approaching or exceeding single-dose deterministic thresholds for skin injury.

MATERIALS AND METHODS

In a prospective study from 2011-2013, nanoDot optical stimulated luminescence dosimeters were used to measure head CT/CTA peak skin dose in 52 patients (28 female, 24 male; mean age, 63 years) divided equally between 2 CT scanners. Volumetric CT dose index and dose-length product were recorded for each examination. Peak skin dose was also measured on an acrylic skull phantom in each scanner. A 2-tailed, unpaired t test was used to compare mean patient skin doses between the 2 scanners. The measured peak skin doses were then used to calculate cumulative peak skin dose in 4 typical patients in intensive care units who received multiple CT/CTA scans.

RESULTS

Head CT/CTA peak skin dose agreed between scanners in patients and phantoms: (scanner 1 CT/CTA: patients, 39.2 ± 3.7 mGy and 98.9 ± 5.3 mGy, respectively, versus phantom, 40.0 mGy and 105.4 mGy, respectively; scanner 2 CT/CTA: patients, 42.9 ± 9.4 mGy and 98.8 ± 7.4 mGy, respectively, versus phantom, 37.6 mGy and 95.2 mGy, respectively). Volumetric CT dose index overestimated peak skin dose by a factor of 1.4-1.9 depending on examination and CT scanner. Cumulative doses in 4 patients in the intensive care unit estimated from measured CT/CTA peak skin dose ranged from 1.9-4.5 Gy.

CONCLUSIONS

Directly measured radiation skin doses from head CT/CTA patient examinations are substantially lower than volumetric CT dose index. Measured peak skin dose confirms that multiple head CT/CTA examinations in representative patients in the neurological intensive care unit may produce cumulative doses exceeding the single-dose deterministic threshold for skin injury.