Patient factors associated with cancer worry post-breast reconstruction: A cross-sectional study

PURPOSE

The BREAST-Q Breast Cancer module is a patient-reported outcome measure for women with breast cancer diagnosis. Our research team developed and validated a novel BREAST-Q scale for this module that measures quality of life outcomes specific to cancer worry. The aim of this study was to investigate patient related breast reconstruction factors that are associated with worse scores on the new BREAST-Q Cancer Worry Scale.

METHODS

Women with a history of breast cancer treated with mastectomy and reconstruction, aged ≥18 years, and English-speaking were recruited through the Love Research Army between October and November 2019. Participants completed demographic and clinical questions alongside the BREAST-Q Cancer Worry Scale. Univariable and multivariable regression analyses were used to identify participant characteristics associated with cancer worry scores.

RESULTS

Among the 554 potential respondents, 538 (97.1%) completed the Cancer Worry Scale. The average patient age was 58.4 (+9.8) years. Cancer Worry scores were normally distributed with a mean of 46.4 (+17.2). Cancer Worry scores were significantly associated (p < 0.01) with younger age, history of radiation therapy, complications associated with breast surgery since diagnosis, use of textured breast implants, and shorter duration since surgery.

CONCLUSIONS

This exploratory analysis provides evidence of patient characteristics that may be associated with cancer worry following postmastectomy breast reconstruction.

Potentially Modifiable Risk Factors for Dementia and Mild Cognitive Impairment: An Umbrella Review and Meta-Analysis

INTRODUCTION

The prevalence of mild and major neurocognitive disorders (NCDs), also referred to as mild cognitive impairment and dementia, is rising globally. The prevention of NCDs is a major global public health interest. We sought to synthesize the literature on potentially modifiable risk factors for NCDs.

METHODS

We conducted an umbrella review using a systematic search across multiple databases to identify relevant systematic reviews and meta-analyses. Eligible reviews examined potentially modifiable risk factors for mild or major NCDs. We used a random-effects multi-level meta-analytic approach to synthesize risk ratios for each risk factor while accounting for overlap in the reviews. We further examined risk factors for major NCD due to two common etiologies: Alzheimer's disease and vascular dementia.

RESULTS

A total of 45 reviews with 212 meta-analyses were synthesized. We identified fourteen broadly defined modifiable risk factors that were significantly associated with these disorders: alcohol consumption, body weight, depression, diabetes mellitus, diet, hypertension, less education, physical inactivity, sensory loss, sleep disturbance, smoking, social isolation, traumatic brain injury, and vitamin D deficiency. All 14 factors were associated with the risk of major NCD, and five were associated with mild NCD. We found considerably less research for vascular dementia and mild NCD.

CONCLUSION

Our review quantifies the risk associated with 14 potentially modifiable risk factors for mild and major NCDs, including several factors infrequently included in dementia action plans. Prevention strategies should consider approaches that reduce the incidence and severity of these risk factors through health promotion, identification, and early management.

Drug and Natural Health Product Data Collection and Curation in the Canadian Longitudinal Study on Aging

This study aimed to develop an efficient data collection and curation process for all drugs and natural health products (NHPs) used by participants to the Canadian Longitudinal Study on Aging (CLSA). The three-step sequential process consisted of (a) mapping drug inputs collected through the CLSA to the Health Canada Drug Product Database (DPD), (b) algorithm recoding of unmapped drug and NHP inputs, and (c) manual recoding of unmapped drug and NHP inputs. Among the 30,097 CLSA comprehensive cohort participants, 26,000 (86.4%) were using a drug or an NHP with a mean of 5.3 (SD 3.8) inputs per participant user for a total of 137,366 inputs. Of those inputs, 70,177 (51.1%) were mapped to the Health Canada DPD, 20,729 (15.1%) were recoded by algorithms, and 44,108 (32.1%) were manually recoded. The Direct algorithm correctly classified 99.4 per cent of drug inputs and 99.5 per cent of NHP inputs. We developed an efficient three-step process for drug and NHP data collection and curation for use in a longitudinal cohort.

Protocol for a living evidence synthesis on variants of concern and COVID-19 vaccine effectiveness

BACKGROUND

It is evident that COVID-19 will remain a public health concern in the coming years, largely driven by variants of concern (VOC). It is critical to continuously monitor vaccine effectiveness as new variants emerge and new vaccines and/or boosters are developed. Systematic surveillance of the scientific evidence base is necessary to inform public health action and identify key uncertainties. Evidence syntheses may also be used to populate models to fill in research gaps and help to prepare for future public health crises. This protocol outlines the rationale and methods for a living evidence synthesis of the effectiveness of COVID-19 vaccines in reducing the morbidity and mortality associated with, and transmission of, VOC of SARS-CoV-2.

METHODS

Living evidence syntheses of vaccine effectiveness will be carried out over one year for (1) a range of potential outcomes in the index individual associated with VOC (pathogenesis); and (2) transmission of VOC. The literature search will be conducted up to May 2023. Observational and database-linkage primary studies will be included, as well as RCTs. Information sources include electronic databases (MEDLINE; Embase; Cochrane, L*OVE; the CNKI and Wangfang platforms), pre-print servers (medRxiv, BiorXiv), and online repositories of grey literature. Title and abstract and full-text screening will be performed by two reviewers using a liberal accelerated method. Data extraction and risk of bias assessment will be completed by one reviewer with verification of the assessment by a second reviewer. Results from included studies will be pooled via random effects meta-analysis when appropriate, or otherwise summarized narratively.

DISCUSSION

Evidence generated from our living evidence synthesis will be used to inform policy making, modelling, and prioritization of future research on the effectiveness of COVID-19 vaccines against VOC.

Measuring physical performance in later life: reliability of protocol variations for common performance-based mobility tests

BACKGROUND AND AIMS

Performance-based tests of mobility or physical function such as the Timed Up and Go (TUG), gait speed, chair-rise, and single-leg stance (SLS) are often administered using different protocols in aging populations, however, the reliability of their assessment protocols is not often considered. The purpose of this study was to examine the reliabilities of frequently used assessment protocols for the TUG, gait speed, chair-rise, and SLS in different age groups.

METHODS

We administered the following assessment protocols in an age-stratified (50-64, 65-74, 75+ years) sample of participants (N = 147) from the Canadian Longitudinal Study on Aging (CLSA): TUG fast pace and TUG normal pace: TUG-cognitive counting backwards by ones and counting back by threes, gait speed with 3-m and 4-m course, chair-rise with arms crossed and allowing the use of arms, and SLS using preferred leg or both legs-on two occasions within 1 week. We assessed the relative (intra-class correlation) and absolute reliability (standard error of measurement, SEM and minimal detectable change, MDC) for each protocol variation and provided recommendations based on relative reliability.

RESULTS

For participants aged 50-64 years, our results suggest better reliability for TUG fast-pace compared with normal-pace (ICC and 95% CI 0.70; 0.41-0.85 versus 0.38; 0.12-0.59). The reliability values for 3-m gait speed were potentially higher than for 4-m gait speed (ICC 0.75; 0.67-0.82 versus 0.64; 0.54-0.73) and values for chair-rise suggested better reliability allowing participants to use their arms than with arms crossed (ICC 0.79; 0.66-0.86 versus 0.64; 0.45-0.77) for participants overall. For participants aged 75+ years, ICCs for SLS with the preferred leg showed better reliability than for both legs (ICC = 0.62-0.79 versus 0.30-0.39).

CONCLUSIONS AND DISCUSSION

These reliability data and the recommendations can help guide the selection of the most appropriate performance-based test protocols for measuring mobility in middle-aged and older community-dwelling adults.

Patient Factors Associated With Increased Cancer Worry, Fatigue, and Impact on Work Following a Breast Cancer Diagnosis: A Cross-Sectional Analysis

Introduction: A breast cancer diagnosis may result in disabling effects which may persist after treatment. The aim of this study was to identify patient factors that are associated with increased cancer worry, fatigue, and impact on work. Methods: Women with a history of breast cancer, aged ≥18 years, and English-speaking were recruited through the Love Research Army between October and November 2019. Participants completed demographic and clinical questions alongside the BREAST-Q Cancer Worry, Fatigue, and Impact on Work scales. Univariable and multivariable regression analyses were used to identify participant characteristics associated with each scale. Results: Cancer Worry, Fatigue, and Impact on Work scales were completed by n = 1680, n = 1037, and n = 873 participants, respectively. Most participants were older than 50 ( n = 1,470, 87.5%), married ( n = 1229, 73.2%), white ( n = 1557, 92.7%), and had undergone surgery for cancer treatment ( n = 1,472, 87.6%). Increased Cancer Worry was significantly associated ( P < .04) with younger age, less time since diagnosis, pain related to cancer/treatment, recurrence, prior chemotherapy, and ongoing breast edema. Increased Fatigue was significantly associated ( P < .01) with elevated BMI, less time since diagnosis, ethnicity, employment status, recurrence, prior chemotherapy, ongoing pain, and difficulty sleeping secondary to treatment. Decreased Impact on Work scores was significantly associated ( P < .04) with chemotherapy administration, shorter time since diagnosis, employment, fatigue related to treatment, breast edema, and ongoing pain. Conclusion: This study reveals patient characteristics associated with increased cancer worry, fatigue, and a negative impact on work following a breast cancer diagnosis. These findings can inform clinical and research initiatives to better support patients through treatment and survivorship.

Abstract B010: The effects of tumor cell-secreted factors on endothelial cell junction phenotype

Triple negative breast cancer (TNBC) is subtype of breast cancer that has no expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). TNBC metastasizes to specific tissues such as brain and bone in a process termed organotropism. In this process, TNBC cells cross the vascular endothelium; transport across endothelial cells is, in part, regulated by cell-cell junctions. The TNBC cell secretome has been shown to contain factors such as vascular growth factor (VEGF) and matrix metalloproteinases (MMPs) that could play a role in altering endothelium permeability. Prior work by us has shown that VEGF in tumor conditioned media can alter endothelial cell junction phenotype in human brain microvascular endothelial cells. Given the various factors present in tumor conditioned media (TCM), we hypothesized that both VEGF and MMPs are present at distinct levels in conditioned media derived from brain- or bone-seeking TNBC cells and that these factors alter junction phenotype in human umbilical vein endothelial cells. We quantified levels of VEGF and MMPs 1 and 9 in tumor conditioned media from parental, brain-seeking, and bone-seeking MDA-MB-231 cells. Our results show that brain-seeking tumor cell conditioned media reduces VE-cadherin continuous junction coverage compared to conditioned media from parental or bone-seeking cells. VE-Cadherin junctions also have decreased junction widths in response to tumor conditioned treatment from brain-seeking MDAs. These results show that secreted factors from TNBC cells have a modest impact on endothelium junction integrity, and future work will quantify changes in endothelium permeability to test barrier function. This work will contribute to a further understanding of TNBC organotropic metastasis and more effective targeted therapeutics to prevent disease progression.

Citation Format: Ariana Joy L. DeCastro, Lauren Griffith, Kimberly Stroka. The effects of tumor cell-secreted factors on endothelial cell junction phenotype [abstract]. In: Proceedings of the AACR Special Conference: Cancer Metastasis; 2022 Nov 14-17; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;83(2 Suppl_2):Abstract nr B010.

Interferon Control of Human Coronavirus Infection and Viral Evasion: Mechanistic Insights and Implications for Antiviral Drug and Vaccine Development

Recognition of viral infections by various pattern recognition receptors (PRRs) activates an inflammatory cytokine response that inhibits viral replication and orchestrates the activation of adaptive immune responses to control the viral infection. The broadly active innate immune response puts a strong selective pressure on viruses and drives the selection of variants with increased capabilities to subvert the induction and function of antiviral cytokines. This revolutionary process dynamically shapes the host ranges, cell tropism and pathogenesis of viruses. Recent studies on the innate immune responses to the infection of human coronaviruses (HCoV), particularly SARS-CoV-2, revealed that HCoV infections can be sensed by endosomal toll-like receptors and/or cytoplasmic RIG-I-like receptors in various cell types. However, the profiles of inflammatory cytokines and transcriptome response induced by a specific HCoV are usually cell type specific and determined by the virus-specific mechanisms of subverting the induction and function of interferons and inflammatory cytokines as well as the genetic trait of the host genes of innate immune pathways. We review herein the recent literatures on the innate immune responses and their roles in the pathogenesis of HCoV infections with emphasis on the pathobiological roles and therapeutic effects of type I interferons in HCoV infections and their antiviral mechanisms. The knowledge on the mechanism of innate immune control of HCoV infections and viral evasions should facilitate the development of therapeutics for induction of immune resolution of HCoV infections and vaccines for efficient control of COVID-19 pandemics and other HCoV infections.

Effects of Relationship Type on Quality of Life in Older Adults with Cognitive Impairment and the Informal Caregivers

Purpose: The purpose of this study was to assess whether there was an association between care-recipient relationship type and the QoL of older adults and their informal caregivers, and whether this association pertained to older adults’ cognitive function. Methods: This was a secondary data analysis. Older adults (n=1230) and their informal caregivers (n=1871) were identified from participants in the National Health and Aging Trends Study (NHATS) Round 5 and the National Study of Caregiving (NSOC) II. A series of bivariate and multivariable regression models examined the associations among the care-recipient relationship type and QoL in older adults and their informal caregivers, adjusted for socio-demographic variables as well as cognitive functioning. Results: Both older adults and caregivers’ QoL outcomes varied by the type of relationship. Recipients cared for by adult-child caregivers or multiple caregivers experienced higher functional limitation than those cared by spousal caregivers (β=.79, CI [.39, 1.19]; β=.50, CI [.17, .82], respectively). “Other” caregivers, such as siblings, friends, etc., had lower odds of experiencing negative emotional burden than spousal caregivers (OR=.26, CI [.13, .52]; OR=.53, CI [.35, .81], respectively). "Other" caregivers were also 51% less likely to experience social strain than spousal caregivers. Lower odds of experiencing negative emotional burdens were also found with multiple caregivers. The association between adult-child caregivers and social strain was explained by the recipients’ cognitive function. Conclusions: Care-recipient relationship type impacts the QoL in both recipients and their informal caregivers. This association appears to be affected by care recipients' cognitive function level.

A longitudinal analysis of the impact of the COVID-19 pandemic on the mental health of middle-aged and older adults from the Canadian Longitudinal Study on Aging

The coronavirus disease 2019 (COVID-19) pandemic presents an unprecedented challenge to public health, with over 233 million confirmed cases and over 4.6 million deaths globally as of September 2021¹. Although many studies have reported worse mental health outcomes during the early weeks of the pandemic, some sources suggest a gradual decrease in anxiety and depressive symptoms during the lockdown². It remains to be explained whether mental health continued to deteriorate during the initial lockdown or whether there were signs of stabilization or improvement in the mental health of community-dwelling middle-aged and older adults. Our results showed that adults had twice the odds of depressive symptoms during the pandemic compared with the prepandemic period, with subgroups characterized by lower socioeconomic status and poor health-related factors experiencing a greater impact. Over 43% of adults showed a pattern of moderate or clinically high levels of depressive symptoms at baseline that increased over time. Loneliness and COVID-19 stressors were predictors of worsening depressive symptom trajectories. The disparities and patterns in the depressive symptom trajectories suggest that the negative mental health impacts of the pandemic persist and may worsen over time. Interventions that address the pandemic stressors and alleviate their impact on the mental health of adults are needed.

The trajectories of depressive symptoms among working adults during the COVID-19 pandemic: a longitudinal analysis of the InHamilton COVID-19 study

Background

Longitudinal studies examining the impact of changes in COVID-19 pandemic-related stressors and experiences, and coping styles on the mental health trajectory of employed individuals during the lockdown are limited. The study examined the mental health trajectories of a sample of employed adults in Hamilton, Ontario during the initial lockdown and after the re-opening following the first wave in Canada. Further, this study also identified the pandemic-related stressors and coping strategies associated with changes in depressive symptoms in employed adults during the COVID-19 pandemic.

Methods

The InHamilton COVID-19 longitudinal study involved 579 employees aged 22–88 years from a large public university in an urban area of Hamilton, Ontario at baseline (April 2020). Participants were followed monthly with 6 waves of data collected between April and November 2020. A growth mixture modeling approach was used to identify distinct groups of adults who followed a similar pattern of depressive symptoms over time and to describe the longitudinal change in the outcome within and among the identified sub-groups.

Results

Our results showed two distinct trajectories of change with 66.2% of participants displaying low-consistent patterns of depressive symptoms, and 33.8% of participants displaying high-increasing depressive symptom patterns. COVID-19 pandemic-related experiences including health concerns, caregiving burden, and lack of access to resources were associated with worsening of the depressive symptom trajectories. Frequent use of dysfunctional coping strategies and less frequent use of emotion-focused coping strategies were associated with the high and increasing depressive symptom pattern.

Conclusions

The negative mental health impacts of the COVID-19 pandemic are specific to subgroups within the population and stressors may persist and worsen over time. Providing access to evidence-informed approaches that foster adaptive coping, alleviate the depressive symptoms, and promote the mental health of working adults is critical.

Reliability and minimal detectable change values for performance-based measures of physical functioning in the Canadian Longitudinal Study on Aging (CLSA)

BACKGROUND

The aim of this study was to determine the relative and absolute reliabilities of five key performance-based measures of physical function in the Canadian Longitudinal Study on Aging (CLSA).

METHODS

An age-stratified sub-sample of 147 participants from the CLSA who were undergoing their 3-year data collection visit participated in two repeat visits (within one week). Participants underwent tests of grip strength, 4-metre gait speed, Timed Up and Go (TUG), chair-rise and single-leg stance (left, right, mean, maximum). Intra-class correlation coefficients (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) values were calculated.

RESULTS

The relative reliability for grip strength was excellent (ICC = 0.95); the TUG and single-leg stance tests had good reliability (ICC = 0.80 or 0.78-0.82, respectively); gait speed and the chair-rise test had moderate reliability (ICC=0.64 for both) for participants overall. For participants between 50 and 64 years, TUG and gait speed had poor reliabilities (ICC = 0.38 or 0.33, respectively). For participants aged 75+ years, the single-leg stance had poor reliability (ICC=0.30-0.39). The MDC90 was about 6 kg for grip strength, 2.3 seconds for TUG, 0.2 metres/second for gait speed, 5.2 seconds for chair-rise, and ranged from 22.8 to 26.2 seconds for the single-leg stance.

CONCLUSIONS

Among community-dwelling Canadians >50 years old, the reliabilities of the CLSA measures were moderate to excellent. The TUG and gait speed in the youngest age group, and the single-leg stance in oldest age group, showed poor reliability. MDC values can be used to interpret changes over time.

Multimorbidity in Canadians living in the community: Results from the Canadian Longitudinal Study of Aging

OBJECTIVE

To determine the mean number of chronic diseases in Canadians aged 45 to 85 years who are living in the community, and to characterize the association of multimorbidity with age, sex, and social position.

DESIGN

An analysis of data from the Canadian Longitudinal Study on Aging. The number of self-reported chronic diseases was summed, and then the mean number of chronic health problems was standardized to the 2011 Canadian population. Analyses were conducted stratified on sex, age, individual income, household income, and education level.

SETTING

Canada.

PARTICIPANTS

A total of 21 241 community-living Canadians aged 45 to 85 years.

MAIN OUTCOME MEASURES

Overall, 31 chronic diseases (self-reported from a list) were considered, as were risk factors that were not mental health conditions or acute in nature. Age, sex, education, and household and individual incomes were also self-reported.

RESULTS

Multimorbidity was common, and the mean number of chronic illnesses was 3.1. Women had a higher number of chronic illnesses than men. Those with lower income and less education had more chronic conditions. The number of chronic conditions was strongly associated with age. The mean number of conditions was 2.1 in those aged 45 to 54; 2.9 in those 55 to 64; 3.8 in those aged 65 to 74, and 4.8 in those aged 75 and older (P < .05, ANOVA [analysis of variance]).

CONCLUSION

Multimorbidity is common in the Canadian population and is strongly related to age.

Mobility Screening for Fall Risk Assessment in a Population-Based Sample of Older Adults: An Analysis From the CLSA

Existing guidelines for fall prevention in older adults recommend mobility screening for fall risk assessment; however, there is no consensus on which test to use and at what cut-off. This study aimed to determine the accuracy and optimal cut-off values of commonly used mobility tests for predicting falls in the Canadian Longitudinal Study on Aging (CLSA). Mobility tests at baseline included the Timed Up and Go (TUG), Single Leg Stance (SLS), chair-rise, and gait speed test. Inclusion criteria were: age ≥ 65 years and history of a fall or mobility problem at baseline. Accuracy of fall prediction at 18-months for each mobility test was measured by the area under the receiver operating curve (AUC). Of 1,121 participants that met inclusion criteria (mean age 75.2 ± 5.9 years; 66.6% women), 218 (19.4%) participants reported ≥1 fall at 18-months. None of the mobility tests achieved acceptable accuracy for identifying individuals with ≥1 fall at follow-up. Among women 65-74 and 75-85 years, the TUG identified recurrent fallers (≥2 falls) with optimal cut-off scores of 14.1 and 12.9 seconds (both AUCs 0.70), respectively. Among men 65-74 years, only the SLS showed acceptable accuracy (AUC 0.85) for identifying recurrent fallers with an optimal cut-off of 3.6 seconds. Our findings indicate that for a population-based sample of community-dwelling older adults, commonly used mobility tests do not have sufficient accuracy for identifying fallers. The TUG and SLS can identify older adults at risk for recurrent falls, however their accuracy and cut-off values vary by age and sex.

Improving the Driving of Community-Dwelling Older Canadians: A Randomized Controlled Trial

Older Canadians, similar to aging drivers in many other countries, want to drive, need to drive, and live in communities where driving is both valued and necessary for out-of-home participation. Many community-dwelling seniors are medically fit-to-drive, yet their collision risk remains higher than most other age groups, which some have attributed to their propensity to drive shorter distances in high-traffic areas (Antin et al., 2017). In this randomized controlled trial, the effect of a customized video-based older driver training program on behind-the-wheel performance was captured using the latest technology for an on-road evaluation. Results indicated the mean reduction in number of driving errors [mean (95% CI)=-12.0(-16.5, -7.6),p<0.001] favoured the intervention group where their change between baseline and 4-week follow-up was statistically significant [mean(95% CI)=-10.3(-13.8, -6.8),p<0.001], but not for the control group [mean (95% CI)=1.7(-0.08, 4.2), p>0.05]. Our novel, video-based approach that provided individualized feedback improved driving performance for older drivers. Part of a symposium sponsored by Transportation and Aging Interest Group.

Test-retest reliability, internal consistency, construct validity and factor structure of a falls risk perception questionnaire in older adults with type 2 diabetes mellitus: a prospective cohort study

BACKGROUND

Older adults with type 2 diabetes (DM2) are at increased risk of falling due to complications including: diabetic peripheral neuropathy, diabetic retinopathy, autonomic neuropathy and diabetic foot ulcers. The purpose of this study was to determine the test-retest reliability, internal consistency, construct validity and to perform factor analysis of a new falls Risk Perception Questionnaire (RPQ) in older community-dwelling adults with DM2.

METHODS

A prospective cohort of 30 community-dwelling older adults, ≥ 55 years, with DM2 was assembled. At baseline, perceived risk of falling, fear of falling and physical activity were measured. At time 2 (T2), at least 2 days later, perceived risk of falling was assessed again to determine the test-retest reliability of the RPQ. At time 3 (T3), approximately six weeks later, and time 4 (T4), at least 2 days after T3, perceived risk of falling was assessed by phone to determine the test-retest reliability of the RPQ when administered by phone.

RESULTS

The RPQ demonstrated excellent test-retest reliability when delivered in person (ICC = 0.78, 95% Confidence Interval, CI: 0.59-0.89) and by phone (ICC = 0.82, 95% CI: 0.65-0.91), good internal consistency (α = 0.78) and adequate construct validity (r = 0.52, 95% CI: 0.20-0.74, p = 0.003) in older adults with DM2.

CONCLUSION

Given the good psychometric properties in this sample of persons with Diabetes, the RPQ has the potential to be used in clinical practice as a risk assessment and fall prevention tool. However, further testing needs to be done using a larger sample.

Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department

BACKGROUND

Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department.

METHODS

We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT).

RESULTS

For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2).

INTERPRETATION

The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457.

Family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health: Multi-program survey

OBJECTIVE

To assess family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health (EH).

DESIGN

Two-part study with questionnaire construction using a modified Delphi method, and a Web-based questionnaire administered to family medicine residents between November 2015 and January 2016.

SETTING

All Canadian family medicine programs (for questionnaire construction) and 4 Ontario family medicine training programs (for questionnaire administration).

PARTICIPANTS

First- to third-year family medicine residents (for questionnaire administration).

MAIN OUTCOME MEASURES

Responses to 93 survey items that measured family medicine residents' knowledge of, attitudes toward, and clinical practices related to EH.

RESULTS

For the final administered questionnaire, 203 of 887 (22.9%) family medicine residents responded. Although 92.0% of respondents somewhat or strongly believed that taking an environmental exposure history was important, only 18.1% of them had specific training in taking environmental exposure history, and 48.4% believed that taking an exposure history takes up too much time in office practice. While 82.9% of residents correctly identified recreational water use as a cause of gastroenteritis, only 60.2% correctly identified radon as a cause of lung cancer and 37.6% knew that elevated ground-level ozone is associated with asthma. Only 10.8% believed their supervisors had a good understanding of environmental exposures. Residents who believed their supervisors understood environmental exposures were more likely to take exposure histories for patients with uncontrolled asthma (P < .05), and those who discussed EH exposure with supervisors frequently, or thought environmental exposure histories were very important, were more likely to provide patients with EH education materials (P < .01).

CONCLUSION

Although family medicine residents are aware of the importance of assessing patients' environmental exposures, they lack training and mentorship in EH. As a health determinant of critical importance, EH should be a high priority for inclusion in postgraduate family medicine education.

Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial

BACKGROUND

The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes.

METHODS

We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit.

RESULTS

There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]).

INTERPRETATION

Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.

Multimorbidity predicts functional decline in community-dwelling older adults: Prospective cohort study

OBJECTIVE

To determine if multimorbidity is associated with functional status, and to assess if multimorbidity predicts declining functional status over a 5-year time frame, after accounting for baseline functional status and other potential confounding factors.

DESIGN

Analysis of an existing population-based cohort study.

SETTING

Manitoba.

PARTICIPANTS

Community-dwelling adults aged 65 and older.

MAIN OUTCOME MEASURES

Age, sex, education, and the Mini-Mental State Examination (MMSE) and Center for Epidemiological Studies Depression Scale (CES-D) scores were recorded for each patient. Multimorbidity was measured using a simple tally of self-reported diseases. Function was measured using the Older Americans Resources and Services scale in 1991 to 1992 and again 5 years later. Good or excellent level of function was compared with level of disability (mild or moderate or higher). Cross-sectional and prospective analyses were conducted.

RESULTS

In a cross-sectional analysis, multimorbidity predicted disability. The unadjusted odds ratio (OR) (95% CI) for disability was 1.45 (1.39 to 1.52) for each additional chronic illness. In models adjusting for age, sex, education, and MMSE and CES-D scores, the adjusted OR (95% CI) was 1.35 (1.29 to 1.42) for each additional chronic illness. Multimorbidity also predicted disability 5 years later. The unadjusted OR (95% CI) was 1.31 (1.24 to 1.38). In models adjusting for age, sex, education, and MMSE and CES-D scores in addition to baseline functional status, the adjusted OR (95% CI) was 1.15 (1.09 to 1.24).

CONCLUSION

Multimorbidity predicts disability in cross-sectional and prospective analyses.

Workplace incivility, psychological distress, and the protective effect of co-worker support

Purpose

Previous in-depth focus groups found that postal workers employed by a crown corporation in Canada identified a lack of respect in the workplace. A lack of respect or discourteous behavior might be better understood as a phenomenon of workplace incivility. The purpose of this paper is to report a larger cross-sectional survey to determine: the magnitude of workplace incivility among Canadian postal workers; any association between incivility and indicators of worker well-being; and, the potential buffering benefits of social support from co-workers.

Design/methodology/approach

Questionnaire packages were mailed to nearly 2,000 employees of Canada Post Corporation, asking for anonymous responses to questions about their job, demographics, satisfaction and commitment, treatment in the workplace, and well-being.

Findings

More than 82 percent of 950 respondents reported at least some workplace incivility. After controlling for demographic and work factors, incivility explained significant variation in worker burnout, anxiety, depression, and hostility (i.e. adjusted R2 values ranged from 5 to 46). In addition, the association between incivility and worker anxiety, depression, and hostility was reduced when workers reported greater social support from co-workers.

Research limitations/implications

Incivility is more than just a minor or infrequent source of psychological distress for people working in service. However, a positive outcome is that co-worker support helps reduce the adverse effects of rude and discourteous behavior.

Originality/value

To our knowledge, this was the first large-scale survey exploring workplace incivility in the public postal service. The data from a large sample of postal workers across Canada suggest that the treatment of employees is an ongoing problem at this organization. This research is relevant for understanding workplace interactions and health in the service sector in Canada, though the authors expect it is germane also to other occupations worldwide.

High-sensitivity cardiac troponin concentrations at emergency department presentation in females and males with an acute cardiac outcome

Background There is interest in utilizing different cut-offs per sex for high-sensitivity cardiac troponin I (hs-cTnI) but less so for high-sensitivity cardiac troponin T (hs-cTnT) for patient management in the acute setting. Our objective was to assess if differences in hs-cTn concentrations exist between males and females for an acute cardiac outcome following the presentation measurement in the emergency department. Methods An observational emergency department population with hs-cTn measurements (Roche Diagnostics and Abbott Diagnostics) at presentation with seven-day outcomes for a composite acute cardiac outcome (i.e. myocardial infarction, unstable angina, ventricular arrhythmia, heart failure or cardiovascular death) (ClinicalTrials.gov: NCT01994577). Receiver operating characteristic curve analyses were performed for each sex with both hs-cTn assays. Results In those patients who had a composite acute cardiac outcome ( n = 128 females; n = 145 males), there was no difference in hs-cTn concentrations between the sexes (median [IQR] female hs-cTnT = 35 ng/L [21-69] vs. male hs-cTnT = 38 ng/L [19-77], P = 0.95; and median [IQR] female hs-cTnI = 27 ng/L [12-75] vs. male hs-cTnI = 26 ng/L [12-85], P = 0.97]. There was also no difference in the area under the curve between the hs-cTn assays and between the sexes ( P > 0.10). Comparing hs-cTn concentrations in those patients with the composite outcome between the sexes <60 years and ≥60 years of age also did not yield significant differences ( P > 0.70). Conclusions The concentrations and area under the curves of hs-cTnT and hs-cTnI at patient presentation in the emergency department for an acute composite cardiac outcome were similar between the sexes in this exploratory study.

Systematic review: Can non-mydriatic cameras accurately detect diabetic retinopathy?

AIMS

Diabetes puts many individuals at risk for developing diabetic retinopathy (DR). Non-mydriatic (NM) retinal photography without pharmacological pupil dilation can be used to detect DR, however, its value in a general clinical setting has not been established. The objective of this review is to evaluate the validity of NM retinal photos, as compared to the reference standard of seven standard stereoscopic 30 degree field photographs (7SF), for their use of detecting DR in community-dwelling adults.

METHODS

English articles were identified through MEDLINE (1992-2016), EMBASE (1992-2016), Center for Disease Control and Prevention, Food and Drug Administration, Health Canada, and Google Scholar (1992-2016). Only studies that examined the validity of NM retinal photos, without pharmacological pupil dilation, as compared to 7SF, used in a community-dwelling adult population were included. Risk of bias was assessed using the QUADAS-2.

RESULTS

Of the 368 articles identified in the search, 6 articles met eligibility requirements. Sensitivities ranged from 64 to 97.9% and specificities ranged from 65.6 to 98%. Studies that used multiple field images to detect DR in a younger population generally produced higher quality photos and more valid results.

CONCLUSIONS

The strongest validity indicators were reported in studies capturing multiple field images.

Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†

Background

there is no standardised test for assessing mobility in the Emergency Department (ED).

Objective

we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma.

Methods

this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated.

Results

TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5).

Conclusion

in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

A liver microphysiological system of tumor cell dormancy and inflammatory responsiveness is affected by scaffold properties

Distant metastasis is the major cause of breast cancer-related mortality, commonly emerging clinically after 5 or more years of seeming 'cure' of the primary tumor, indicating a quiescent dormancy. The lack of relevant accessible model systems for metastasis that recreate this latent stage has hindered our understanding of the molecular basis and the development of therapies against these lethal outgrowths. We previously reported on the development of an all-human 3D ex vivo hepatic microphysiological system that reproduces several features of liver physiology and enables spontaneous dormancy in a subpopulation of breast cancer cells. However, we observed that the dormant cells were localized primarily within the 3D tissue, while the proliferative cells were in contact with the polystyrene scaffold. As matrix stiffness is known to drive inflammatory and malignant behaviors, we explored the occurrence of spontaneous tumor dormancy and inflammatory phenotype. The microphysiological system was retrofitted with PEGDa-SynKRGD hydrogel scaffolding, which is softer and differs in the interface with the tissue. The microphysiological system incorporated donor-matched primary human hepatocytes and non-parenchymal cells (NPCs), with MDA-MB-231 breast cancer cells. Hepatic tissue in hydrogel scaffolds secreted lower levels of pro-inflammatory analytes, and was more responsive to inflammatory stimuli. The proportion of tumor cells entering dormancy was markedly increased in the hydrogel-supported tissue compared to polystyrene. Interestingly, an unexpected differential response of dormant cells to varying chemotherapeutic doses was identified, which if reflective of patient pathophysiology, has important implications for patient dosing regimens. These findings highlight the metastatic microphysiological system fitted with hydrogel scaffolds as a critical tool in the assessment and development of therapeutic strategies to target dormant metastatic breast cancer.

Comorbidity and its relationship with health service use and cost in community-living older adults with diabetes: A population-based study in Ontario, Canada

AIMS

This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs.

METHODS

This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services.

RESULTS

There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities.

CONCLUSIONS

Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning.

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults

BACKGROUND

Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person's life that centers on meeting a person's health goals and needs will result in optimal aging.

METHODS/DESIGN

This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person's life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months.

DISCUSSION

Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system's transformation of person-focused, primary care for older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02283723.

Factors influencing discrepancies in self-reported memory and performance on memory recall in the Canadian Community Health Survey-Healthy Aging, 2008-09

OBJECTIVE

the objectives of this study were: (i) to estimate the rate of discrepancy between participant single-item self-reports of good memory and poor performance on a list-learning task and (ii) to identify the factors including age, gender and health status that influence these discrepant classifications.

STUDY DESIGN AND SETTINGS

in total, 14,172 individuals, aged 45-85, were selected from the 2008-09 Canadian Community Health Survey on Healthy Aging. We examined the individual characteristics of participants with and without discrepancies between memory self-reports and performance with a generalised linear model, adjusting for potential covariates.

RESULTS

the mean age of respondents was 62.9 years with 56.7% being female, 53.8% having post-secondary graduation and 83% being born in Canada. Higher discrepant classification rates we observed for younger people (6.77 versus 3.65 for lowest and highest group), female (5.90 versus 3.68) and with higher education (6.17 versus 3.52). Discrepant classification rates adjusted with all covariates were higher for those without chronic diseases (5.37 [95% Confidence Interval (CI): 4.16, 6.90] versus 4.05 95% CI: 3.38, 4.86; P = 0.0127), those who did not drink alcohol (5.87 95% CI: 4.69, 7.32 versus 3.70 95% CI: 3.00, 4.55; P < 0.0001), lonely participants (5.45 95% CI: 4.20, 7.04 versus 3.99 95% CI: 3.36, 4.77; P = 0.0081) and bilingual participants (5.67 95% CI: 4.18, 7.64 versus 3.83 95% CI: 3.27, 4.50; P = 0.0102).

CONCLUSION

the findings of this study suggest that the self-reported memory and memory performance differ in a substantial proportion of the population. Therefore, relying on a self-reported memory status may not accurately capture those experiencing memory difficulties.

Measuring Frailty Can Help Emergency Departments Identify Independent Seniors at Risk of Functional Decline After Minor Injuries

BACKGROUND

This study aims to (i) describe frailty in the subgroup of independent community-dwelling seniors consulting emergency departments (EDs) for minor injuries, (ii) examine the association between frailty and functional decline 3 months postinjury, (iii) ascertain the predictive accuracy of frailty measures and emergency physicians' for functional decline.

METHOD

Prospective cohort in 2011-2013 among 1,072 seniors aged 65 years or older, independent in basic daily activities, evaluated in Canadian EDs for minor injuries.Frailty was assessed at EDs using the Canadian Study of Health and Aging-Clinical Frailty scale (CSHA-CFS) and the Study of Osteoporotic Fracture frailty index (SOF). Functional decline was defined as a loss ≥2/28 on the Older American Resources Services scale 3 months postinjury. Generalized mixed models were used to explore differences in functional decline across frailty levels. Areas under the receiver operating characteristic curve were used to ascertain the predictive accuracy of frailty measures and emergency physicians' clinical judgment.

RESULTS

The SOF and CSHA-CFS were available in 342 and 1,058 participants, respectively. The SOF identified 55.6%, 32.7%, 11.7% patients as robust, prefrail, and frail. These CSHA-CFS (n = 1,058) proportions were 51.9%, 38.3%, and 9.9%. The 3-month incidence of functional decline was 12.1% (10.0%-14.6%). The Areas under the receiver operating characteristic curves of the CSHA-CFS and the emergency physicians' were similar (0.548-0.777), while the SOF was somewhat higher (0.704-0.859).

CONCLUSION

Measuring frailty in community-dwelling seniors with minor injuries in EDs may enhance current risk screening for functional decline. However, before implementation in usual care, feasibility issues such as inter-rater reliability and acceptability of frailty tools in the EDs have to be addressed.

Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: predictors among independent seniors within 6 months

BACKGROUND

minor traumatic injuries among independent older people have received little attention to date, but increasingly the impact of such injuries is being recognised.

OBJECTIVES

we assessed the frequency and predictors of acute health care use, defined as return to the emergency department (ED) or hospitalisation.

STUDY DESIGN

national multicentre prospective observational study.

SETTING

eight Canadian teaching EDs between April 2009 and April 2013.

PARTICIPANTS

a total of 1,568 patients aged 65-100 years, independent in basic activities of daily living, discharged from ED following a minor traumatic injury.

METHODS

trained assessors measured baseline data including demographics, functional status, cognition, comorbidities, frailty and injury severity. We then conducted follow-up telephone interviews at 6 months to assess subsequent acute health care use. We used log-binomial regression analyses to identify predictors of acute health care use, and reported relative risks and 95% CIs.

RESULTS

participants' mean age was 77.0, 66.4% female, and their injuries included contusions (43.5%), lacerations (25.1%) and fractures (25.4%). The cumulative rate of acute health care use by 6 months post-injury was 21.5% (95% CI: 19.0-24.3%). The strongest predictors of acute health care use within 6 months were cognitive impairment, RR = 1.6 (95% IC: 1.2-2.1) and the mechanism of injury including pedestrian struck or recreational injuries, RR = 1.6 (95% CI 1.2-2.2).

CONCLUSIONS

among independent community living older persons with a minor injury, cognitive impairment and mechanism of injury were independent risk factors for acute healthcare use. Future studies should look at whether tailored discharge planning can reduce the need for acute health care use.

Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome?

Objective:

To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome.

Methods:

This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes.

Results:

Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3–0.9) for TnI values &lt;0.5 µg/L, 1.6 (0.4–6.5) for TnI values from 0.5 to 2.0 µg/L, 5.8 (1.7–19.5) for TnI values from &gt;2.0 to 10.0 µg/L and 14.4 (4.8–42.9) for TnI values &gt;10.0 µg/L.

Conclusions:

TnI values &gt;2.0 µg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 µg/L are weakly positive predictors. TnI values &lt;0.5 µg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.

Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis

BACKGROUND

It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses.

METHODS

By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes.

RESULTS

We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12).

INTERPRETATION

We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.

Spontaneous dormancy of metastatic breast cancer cells in an all human liver microphysiologic system

Background:

Metastatic outgrowth in breast cancer can occur years after a seeming cure. Existing model systems of dormancy are limited as they do not recapitulate human metastatic dormancy without exogenous manipulations and are unable to query early events of micrometastases.

Methods:

Here, we describe a human ex vivo hepatic microphysiologic system. The system is established with fresh human hepatocytes and non-parenchymal cells (NPCs) creating a microenvironment into which breast cancer cells (MCF7 and MDA-MB-231) are added.

Results:

The hepatic tissue maintains function through 15 days as verified by liver-specific protein production and drug metabolism assays. The NPCs form an integral part of the hepatic niche, demonstrated within the system through their participation in differential signalling cascades and cancer cell outcomes. Breast cancer cells intercalate into the hepatic niche without interfering with hepatocyte function. Examination of cancer cells demonstrated that a significant subset enter a quiescent state of dormancy as shown by lack of cell cycling (EdU⁻ or Ki67⁻). The presence of NPCs altered the cancer cell fraction entering quiescence, and lead to differential cytokine profiles in the microenvironment effluent.

Conclusions:

These findings establish the liver microphysiologic system as a relevant model for the study of breast cancer metastases and entry into dormancy.

Abstract P5-04-08: Modeling breast cancer dormancy

Most cancer mortality results from distant metastases. The metastatic microenvironment protects ectopic tumors, these nodules are often resistant to agents that eradicate the primary mass. Although significant interventional progress has been made on primary tumors, the lack of relevant accessible model in vitro systems in which to study metastases has plagued metastatic therapeutic development – particularly among micrometastases. One third of women diagnosed with breast cancer (BC) will have metastatic disease which often presents years after a seeming cure from the primary malignancy. An in silico model of micrometastases strongly suggests that these disseminated cells are quiescent, or ‘dormant’, for long periods of time. Current models fail to recapitulate metastatic dormancy, in vivo due to issues of spontaneous metastases and rodent lifespan and in vitro due to the nascent state of organotypic organs or microphysiological systems (MPS). We hypothesize that even the most developed MPS do not allow tumors to attain dormancy due to continued stress signaling from stiff matrices and an artificial microenvironment. We use an innovative all human three dimensional liver MPS to faithfully reproduce human physiology and pathology. In the initial iteration, the liver cells are isolated from therapeutic partial hepatectomies, but as this source may be limiting, we are examining induced pluripotent stem cells (iPSC). Currently these iPSC-derived hepatocyte-like cells demonstrate cyp p450 activity and production of fibrinogen and urea through 15 days in our MPS, albeit at levels below fresh human hepatocytes; optimization protocols are underway.

In the first phase of this work we optimized the flow rate and seeding of hepatocytes with non-parenchymal cells (NPCs) from fresh human liver resections. We found that higher flow rates produced poorer tissue formation and increased stress fibers/actin filaments. We maintained functioning hepatocytes in the MPS through 15 days. Hepatocyte function and injury was measured by urea, lactate, AST, ALT, A1AT, fibrinogen and cyp p450 assays. NPCs survived through the 15 day endpoint with immunofluorescent microscopy visualizing leukocytes, endothelial cells and macrophages. The proliferative MDA MB 231 BC cell line showed preliminary evidence of growth attenuation after 12 days of culture in a subpopulation of cells in our MPS. Luminex cancer panel studies are underway with systems biology modeling to describe a communication network in the early microenvironment of micrometastases.

In parallel we are piloting hydrogel scaffolds that support tissue formation but provide a more physiologic rheology; stiff supporting materials yield an inflammatory phenotype in the NPC which forces even well-differentiated BC cells towards a mesenchymal phenotype. We found that hydrogels support hepatocytes through 15 days and incorporate cancer cells. Micropumps are also being developed by Draper Laboratories to allow for physiologic diurnal variations of hormones and nutrients to liver tissues to accurately assess dormancy and chemotherapy response. The completion of these studies will provide insights into the tumor biology of dormant micrometastases and an accessible tool for testing of therapeutics against metastatic BC in a metabolically competent system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-04-08.

Red blood cell transfusion and increased length of storage are not associated with deep vein thrombosis in medical and surgical critically ill patients: a prospective observational cohort study

Introduction

With prolonged storage times, cell membranes of red blood cells (RBCs) undergo morphologic and biochemical changes, termed 'RBC storage lesions'. Storage lesions may promote inflammation and thrombophilia when transfused. In trauma patients, RBC transfusion was an independent risk factor for deep vein thrombosis (DVT), specifically when RBC units were stored > 21 days or when 5 or more units were transfused. The objective of this study was to determine if RBC transfusions or RBC storage age predicts incident DVT in medical or surgical intensive care unit (ICU) patients.

Methods

Using a database which prospectively enrolled 261 patients over the course of 1 year with an ICU stay of at least 3 days, we analyzed DVT and RBC transfusions using Cox proportional hazards regression. Transfusions were analyzed with 4 thresholds, and storage age using 3 thresholds. DVTs were identified by twice-weekly proximal leg ultrasounds. Multivariable analyses were adjusted for 4 significant DVT predictors in this population (venous thrombosis history, chronic dialysis, platelet transfusion and inotropes).

Results

Of 261 patients, 126 (48.3%) had at least 1 RBC transfusion; 46.8% of those transfused had ≥ 5 units in ICU. Patients receiving RBCs were older (68.8 vs 64.1 years), more likely to be female (47.0 vs 30.7), sicker (APACHEII 26.8 vs 24.4), and more likely to be surgical (21.4 vs 8.9) (P < 0.05). The total number of RBCs per patient was 1-64, mean was 6.3 (SD 7.5), median was 4 (IQR 2,8). In univariate analyses, there was no association between DVT and RBC exposure (1 day earlier, 3 days earlier, 7 days earlier, or ever) or RBC storage (≤ 7 or > 7 days, ≤ 14 or > 14 days, ≤ 21 or > 21 days). Among patients transfused, no multivariable analyses showed that RBC transfusion or storage age predicted DVT. Trends were counter to the hypothesis (e.g., RBC storage for ≤ 7 days suggested a higher DVT risk compared to > 7 days (HR 5.3; 95% CI 1.3-22.1).

Conclusions

We were unable to detect any association between RBC transfusions or prolonged red cell storage and increased risk of DVT in medical or surgical ICU patients. Alternate explanations include a lack of sufficient events or patients' interaction, between patient groups, a mixing of red cell storage times creating differential effects on DVT risk, and unmeasured confounders.