Loneliness, social isolation, and cardiovascular disease among nonveteran and veteran women

We examined the prospective associations of social isolation and loneliness with incident cardiovascular disease (CVD) among aging nonveteran and veteran women, and effect modification by veteran status. Participants with no history of myocardial infarction (MI), stroke, coronary heart disease (CHD), or coronary heart failure from the Women's Health Initiative Extension Study II self-reported social isolation, loneliness, health behaviors, health status, and veteran status. CVD and CVD subevents were physician adjudicated. Hazard ratios (HR) and 95% confidence intervals (CI) for the Interquartile Range (IQR) in social isolation (IQR = 1) and loneliness (IQR=.33) were calculated using Cox proportional hazard models adjusting for sociodemographic, health behavior, and health status characteristics. Veteran status was tested as an effect modifier. Among 52,442 women (Mean age = 79 ± 6.1; veterans n = 1023; 89.2% non-Hispanic White), 3579 major CVD events occurred over an average 5.8 follow-up years. Compared to nonveterans, veteran women reported higher levels of social isolation (p < .01) and loneliness (p < .01). The CVD HR was 1.07 (95% CI, 1.04-1.10) for the IQR in social isolation and 1.03 (95% CI, 1.10-1.06) for the IQR in loneliness. The HR for the IQR in both social isolation and loneliness was 1.10 (95% CI, 1.05-1.15). Social isolation was associated with CHD (HR = 1.12; 95% CI, 1.03-1.21). The CHD HR for the IQR in social isolation was 1.12 (95% CI, 1.03-1.21). Associations did not differ by veteran status (all p-interactions > 0.08). Findings suggest that the adverse associations of social isolation and loneliness with CVD are similar among veteran and nonveteran women.

Accelerometer-Measured Physical Activity, Sedentary Time, and Heart Failure Risk in Women Aged 63 to 99 Years

Importance

Heart failure (HF) prevention is paramount to public health in the 21st century.

Objective

To examine incident HF and its subtypes with preserved ejection fraction (HFpEF) and reduced EF (HFrEF) according to accelerometer-measured physical activity (PA) and sedentary time.

Design, Setting, and Participants

This was a prospective cohort study, the Objective Physical Activity and Cardiovascular Health (OPACH) in Older Women study, conducted from March 2012 to April 2014. Included in the analysis were women aged 63 to 99 years without known HF, who completed hip-worn triaxial accelerometry for 7 consecutive days. Follow-up for incident HF occurred through February 2022. Data were analyzed from March to December 2023.

Exposure

Daily PA (total, light, moderate to vigorous PA [MVPA], steps) and sedentary (total, mean bout duration) behavior.

Main Outcomes and Measures

Adjudicated incident HF, HFpEF, and HFrEF.

Results

A total of 5951 women (mean [SD] age, 78.6 [6.8] years) without known HF were included in this analysis. Women self-identified with the following race and ethnicity categories: 2004 non-Hispanic Black (33.7%), 1022 Hispanic (17.2%), and 2925 non-Hispanic White (49.2%). There were 407 HF cases (257 HFpEF; 110 HFrEF) identified through a mean (SD) of 7.5 (2.6) years (range, 0.01-9.9 years) of follow-up. Fully adjusted hazard ratios (HRs) for overall HF, HFpEF, and HFrEF associated with a 1-SD increment were 0.85 (95% CI, 0.75-0.95), 0.78 (95% CI, 0.67-0.91), and 1.02 (95% CI, 0.81-1.28) for minutes per day total PA; 0.74 (95% CI, 0.63-0.88), 0.71 (95% CI, 0.57-0.88), and 0.83 (95% CI, 0.62-1.12) for steps per day; and 1.17 (95% CI, 1.04-1.33), 1.29 (95% CI, 1.10-1.51), and 0.94 (95% CI, 0.75-1.18) for minutes per day total sedentary. Cubic spline curves for overall HF and HFpEF were significant inverse for total PA and steps per day and positive for total sedentary. Light PA and MVPA were inversely associated with overall HF (HR per 1 SD: 0.88; 95% CI, 0.78-0.98 and 0.84; 95% CI, 0.73-0.97) and HFpEF (0.80; 95% CI, 0.70-0.93 and 0.85; 95% CI, 0.72-1.01) but not HFrEF. Associations did not meaningfully differ when stratified by age, race and ethnicity, body mass index, physical function, or comorbidity score. Results for sedentary bout duration were inconsistent.

Conclusions and Relevance

Higher accelerometer-measured PA (MVPA, light PA, steps per day) was associated with lower risk (and greater total sedentary time with higher risk) of overall HF and HFpEF in a racially and ethnically diverse cohort of older women. Increasing PA and reducing sedentary time for primary HFpEF prevention may have relevant implications for cardiovascular resilience and healthy aging in later life.

Prospective Associations of Accelerometer-Measured Machine-Learned Sedentary Behavior With Death Among Older Women: The OPACH Study

BACKGROUND

Sedentary behavior is a recognized mortality risk factor. The novel and validated convolutional neural network hip accelerometer posture algorithm highly accurately classifies sitting and postural changes compared with accelerometer count cut points. We examined the prospective associations of convolutional neural network hip accelerometer posture-classified total sitting time and mean sitting bout duration with all-cause and cardiovascular disease (CVD) death.

METHODS AND RESULTS

Women (n=5856; mean±SD age, 79±7 years; 33% Black women, 17% Hispanic or Latina women, 50% White women) in the Women's Health Initiative Objective Physical Activity and Cardiovascular Health (OPACH) Study wore the ActiGraph GT3X+ for ~7 days from May 2012 to April 2014 and were followed through February 19, 2022 for all-cause and CVD death. The convolutional neural network hip accelerometer posture algorithm classified total sitting time and mean sitting bout duration from GT3X+ output. Over follow-up (median, 8.4 years; range, 0.1-9.9), there were 1733 deaths (632 from CVD). Adjusted Cox regression hazard ratios (HRs) comparing women in the highest total sitting time quartile (>696 min/d) to those in the lowest (<556.0 min/d) were 1.57 (95% CI; 1.35-1.83; P-trend<0.001) for all-cause death and 1.78 (95% CI; 1.36-2.31; P-trend<0.001) for CVD death. HRs comparing women in the longest mean sitting bout duration quartile (>15 minutes) to the shortest (<9.3 minutes) were 1.43 (95% CI; 1.23-1.66; P-trend<0.001) for all-cause death and 1.52 (95% CI; 1.18-1.96; P-trend<0.001) for CVD death. Apparent nonlinear associations for total sitting time suggested higher all-cause death (P nonlinear=0.009) and CVD death (P nonlinear=0.008) risk after ~660 to 700 min/d.

CONCLUSIONS

Higher total sitting time and longer mean sitting bout duration are associated with higher all-cause and CVD mortality risk among older women. These data support interventions aimed at reducing both total sitting time and interrupting prolonged sitting.

Evaluation of the relevance of the growth modulation index (GMI) from the FFCD 0307 randomized phase III trial comparing the sequence of two chemotherapeutic regimens

BACKGROUND

Precision medicine trials disrupted the paradigm of randomized controlled trials in large populations. Patient selection may be based on molecular alterations rather than on primary tumor location. In small patient populations, the growth modulation index (GMI) has been developed to evaluate treatment efficacy by using each patient as its own control. The FFCD 0307 randomized phase III trial compared two sequences of chemotherapy in advanced gastric cancer, which represents a unique opportunity to evaluate the relevance of the GMI.

PATIENTS AND METHODS

In the FFCD 0307 trial, patients with advanced gastric cancer were randomized between two chemotherapy sequences [ECX followed by FOLFIRI at disease progression (arm A) versus FOLFIRI followed by ECX (arm B)]. GMI was defined as the ratio of the progression-free survival on second treatment (PFS2) to the time to progression on first treatment (TTP1). Sequence benefit was defined as a GMI exceeding 1.3 (GMI-high). GMI was correlated with overall survival (OS). OS1 and OS2 were measured from first randomization and second-line failure to death.

RESULTS

Four hundred and sixteen patients were randomized (209 in arm A, 207 in arm B). One hundred and seventy-five patients (42%) received the two sequences and were assessable for GMI (97 in arm A, 79 in arm B). The median GMI was higher in arm A than in arm B (0.62 versus 0.47, P = 0.04). Patients with a high GMI had a longer OS1 (median 14.9 versus 11.5 months, NS). Median OS2 was doubled in the GMI-high group (3.4 versus 1.6 months, NS).

CONCLUSION

GMI analyses suggest that ECX followed by FOLFIRI might represent a better therapeutic strategy than FOLFIRI followed by ECX. High GMI was associated with prolonged survival.

Pediatric private practice in the Nord-Pas-de-Calais region: Demographics, organization, and challenges

While the needs for pediatric care are increasing and becoming more diverse, pediatric private practice in France is encountering difficulties linked to a growing medical demographic deficit. The objective of this study was to give an overview of pediatric private practice in the Nord-Pas-de-Calais region and to describe the main challenges encountered.

METHODS

For this descriptive observational survey, private practice pediatricians in the Nord-Pas-de-Calais region filled out an online questionnaire between April 2019 and October 2020.

RESULTS

The response rate was 64%. Most respondents practiced in an urban area (87%) and shared the practice with other physicians (59%). A majority (85%) had previously worked in hospital; 65% reported training in a subspecialty. Overall, 48% had other professional activities; 28% worked night shifts and 96% accepted urgent requests for consultations. A total of 33% reported having difficulties contacting specialists for consults, and 46% had difficulties in obtaining written reports of their patients' hospitalizations. All respondents participated in a form of ongoing medical education. The main difficulties were: lack of information about how to found a private practice (68%), lack of personal time (61%), balance between medical and administrative work (59%), and an excess of patients to care for (57%). The main satisfactions were: trusting relationships with patients (98%), freedom in their choice of practice (85%), and the diversity of problems and situations encountered (68%).

CONCLUSION

Our study underlines that private practice pediatricians are involved in healthcare provision, in particular regarding ongoing medical training, subspecialties, and continuity of care. It also highlights the problems encountered and the possible improvements: developing better communication between private practice and hospitals, reinforcing training during residency, and highlighting the importance and complementarity of private practice in children's healthcare.

Abstract 30: Associations of Accelerometer-Measured Machine-Learning Classified Sitting With All-Cause and Cardiovascular Disease Mortality Among Older Women: The Opach Study

Introduction: Sedentary behavior (SB) is a recognized mortality and CVD risk factor. Most studies with accelerometry classified SB using cut-points, which do not capture postural transitions as accurately as thigh-worn devices. The recently published convolutional neural network hip accelerometer posture (CHAP) algorithm more accurately classifies sitting than cut-point methods.

Hypothesis: Higher amounts of CHAP-classified sitting time (ST) and mean sitting bout duration (MSBD) are associated with higher all-cause (ACM) and CVD mortality risk.

Methods: Older women (n=6,056; mean age=79±7; 34% Black, 17% Hispanic) in the Objective Physical Activity and Cardiovascular Health (OPACH) study without prior MI or stroke wore accelerometers for 7 days in May 2012-April 2014 and were followed through February 19, 2022 for mortality. The CHAP algorithm has been shown to have higher sensitivity (97.1% vs 88.2%) and specificity (88.6% vs 59.7%) for classifying sitting compared to the 100 counts/minute cut-point. Cox models estimated hazard ratios (HR) and 95% confidence intervals (CI) for ACM and CVD mortality adjusting for age, race/ethnicity, education, alcohol, smoking, multimorbidity, self-rated health, physical functioning, HDL, triglycerides, SBP, and log hs-CRP.

Results: There were 1,808 deaths and 651 CVD deaths over a median follow-up of 8.4 years. The HR (95% CI; P-trend) comparing women in the highest ST quartile (>11.6 hr/day) to those in the lowest (<9.2 hr/day) was 1.43 (1.23-1.66; <0.001) for ACM and 1.64 (1.27-2.14; <0.001) for CVD mortality. The HR (95% CI; P-trend) comparing women in the highest MSBD quartile (>15 minutes) to those in the lowest (<9.3 minutes) was 1.33 (1.15-1.55; <0.001) for ACM and 1.50 (1.16-1.94; <0.001) for CVD mortality. The HR (95% CI) for women with the highest ST and MSBD was 1.63 (1.38-1.93) for ACM and 1.95 (1.47-2.60) for CVD mortality.

Conclusions: ST and MSBD were positively associated with ACM and CVD mortality risk, supporting interventions aimed at reducing both ST and MSBD.

Characteristics and outcomes of patients presenting with out of hospital cardiac arrest to a regional hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

Out of hospital cardiac arrest (OHCA) carries a high rate of mortality and can be due to cardiac or non-cardiac causes. We reviewed consecutive patients presenting with OHCA to the emergency department of a regional hospital in Australia, between January 2019 and March 2022. Medical records were reviewed to assess presenting rhythm, final diagnosis, risk factors known at time of presentation, results of cardiac investigations and survival to hospital discharge.

Results

Over the study period, 107 patients presented with cardiac arrest, with an average age of 67 years (range 29 to 95 years). Most patients were male (70, 67%), although in those with a non-cardiac cause identified only 53% were male. An underlying cardiac cause was identified in 50 (47%), a non-cardiac cause was identified in 18 (17%), and 39 (36%) had no identifiable cause. The most common cardiac causes were ST-elevation myocardial infarction (18, 36%), followed by non-ischaemic cardiomyopathy (9, 18%) and scar-related arrhythmia (7, 14%). Overall, ischaemic heart disease was responsible for 31 (62%) cases. Coronary angiography was performed in 36 (72%) of cardiac cases. Those who were diagnosed with ST-elevation myocardial infarction had an average time from presentation to coronary angiography of 61 minutes while the average was 38 hours for all patients presenting with OHCA. The most common presenting rhythm was ventricular fibrillation (39, 38%). The overall mortality rate was 61% for all OHCA. Among those with a cardiac cause, a non-cardiac cause or no cause identified for the OHCA, the mortality rates were 32%, 87% and 87% respectively. Data published by the regional Ambulance Service show that the survival to discharge from hospital of 39% in our regional hospital is comparable with state-wide outcomes.

Discussion

These data reflect the significant mortality and wide spectrum of disease underlying OHCA, and thus the challenge of managing patients presenting with OHCA. Cardiac disease accounts for almost half of all cases of OHCA, and also encompasses a wide spectrum of disease. However, the mortality in patients with OHCA due to an underlying cardiac cause, while still significant, is better than those patients in whom no cardiac cause is identified.

Accelerometer-measured physical activity and sitting with incident mild cognitive impairment or probable dementia among older women

INTRODUCTION

Physical activity (PA) is prospectively inversely associated with dementia risk, but few studies examined accelerometer measures of PA and sitting with rigorously-adjudicated mild cognitive impairment (MCI) and dementia risk.

METHODS

We examined the associations of accelerometer measures (PA and sitting) with incident MCI/probable dementia in the Women's Health Initiative (n = 1277; mean age = 82 ± 6 years) RESULTS: Over a median follow-up of 4.2 years, 267 MCI/probable dementia cases were identified. Adjusted Cox regression HRs (95% CI) across moderate-to-vigorous PA (MVPA) min/d quartiles were 1.00 (reference), 1.28 (0.90 to 1.81), 0.79 (0.53 to 1.17), and 0.69 (0.45 to 1.06); P-trend = 0.01. Adjusted HRs (95% CI) across steps/d quartiles were 1.00 (reference), 0.73 (0.51 to 1.03), 0.64 (0.43 to 0.94), and 0.38 (0.23 to 0.61); P-trend < 0.001. The HR (95% CI) for each 1-SD increment in MVPA (31 min/d) and steps/d (1865) were 0.79 (0.67 to 0.94) and 0.67 (0.54 to 0.82), respectively. Sitting was not associated with MCI/probable dementia.

DISCUSSION

Findings suggest ≥ moderate intensity PA, particularly stepping, associates with lower MCI and dementia risk.

HIGHLIGHTS

Few studies have examined accelerometer-measured physical activity, including steps, and sitting with incident ADRD. Moderate-to-vigorous physical activity and steps, but not light physical activity or sitting, were inversely associated with lower ADRD risk. Among older women, at least moderate intensity physical activity may be needed to reduce ADRD risk.

Characterizing and predicting the relationship between translaminar fracture toughness and pull-out length distributions under distinct temperatures

The translaminar fracture toughness reflects the damage tolerance of a fibre-reinforced composite under longitudinal tension, which often governs the final failure of structures. One of the main energy-dissipation mechanisms that contributes to the translaminar toughness of composites is the fibre pull-out process. The present study aims to quantify and model the statistical distribution of fibre pull-out lengths formed on the translaminar fracture surface of composites, for the first time in the literature; this is done under different temperatures, so that the relationship between pull-out length distributions, micromechanical properties and the translaminar fracture toughness can be established. The fracture surfaces of cross-ply compact tension specimens tested under three different temperatures have been scanned through X-ray computed tomography to quantify the extent of fibre pull-out on the fracture surfaces; the distribution of pull-out lengths showed alarger average and larger variability with an increase in temperature, which also lead to an increase in translaminar fracture toughness. A similar trend has been captured by the proposed analytical model, which predicts the pull-out length distribution based on the analysis of quasi-fractal idealizations of the fracture surface, yielding an overall accuracy of more than 85%. This article is part of the theme issue 'Ageing and durability of composite materials'.

Technology Usage and Impacts by COVID-19 among Patients in a Radiation Oncology Clinic

Purpose/Objective(s)

Mobile devices provide platforms for consistent and real time symptom tracking for cancer patients, allowing for better symptom reporting and more timely interventions. There is limited research investigating barriers to adoption within the oncology setting and COVID-19 impacts on patent willingness to use health technology. Understanding these issues is key to successful development and implementation. We designed a survey to assess patient willingness and barriers to using mobile devices to report/track symptoms (e-report).

Materials/Methods

Two cohorts of adult patients completed a 21-question anonymized survey. The survey was administered to clinic patients before (PRE) and 18mo after (POST) the start of the COVID pandemic. Three additional questions were added to POST survey to investigate impacts from COVID. Demographics, technology usage, willingness to report data, barriers to utilization, and changes due to COVID were evaluated using descriptive statistics. Predictors of willingness to e-report, barriers to use, and changes due to the COVID-19 pandemic were analyzed using univariate and multivariate logistic regression (MVA).

Results

318 patients completed the survey (PRE= 144 patients; POST= 174 patients) with mean age 65y, 75% Caucasian, 55% male. Altogether, 75% used a smart phone (PRE=66.7%; POST=81.3%; p 0.003), 90% reported home internet access (PRE=87.5%; POST=91.4%; p 0.259), 86% used a computer (PRE=79.2%; POST=90.8%; p 0.004), and 26% used a wearable health tracker (PRE 25.7%; POST 26.4%; p 0.881). On MVA, age>65 (OR 0.32; p 0.001), annual income>50K (OR 2.16; p 0.032), smart phone ownership (OR 4.07; p 0.000), and new/current patient status (OR 2.15; p 0.020) were all significant factors impacting willingness to e- report. Limited tech literacy (p 0.024) and time commitment (p 0.048) were the only significant barriers. Privacy as a barrier was greater in PRE vs POST cohort (OR 2.3 vs OR 1.1) trending toward significance. Nearly all modes of tech usage were greater in POST vs PRE cohort. POST cohort was significantly more willing to e- report (81.1% vs 69.1%; OR 1.91; p 0.016). This remained significant on MVA after adjusting for age, concern for privacy, tech literacy, and patient status (OR 1.88; p 0.026). Furthermore, 51% of POST cohort reported the pandemic directly influenced their willingness to e-report (40% more, 11% less).

Conclusion

Radiation oncology patients are willing to use mobile technology to report symptoms. Willingness increases with decreasing age, increasing annual income, smartphone ownership, and new/current patient status. Significant barriers include tech literacy and time commitment. Post-pandemic patients are more willing to e-report and list fewer barriers. The COVID-19 pandemic appears to have had a positive impact on technology usage by patients. Efforts to develop and test mobile applications for this population are justified.

SARS-CoV-2 Brain Regional Detection, Histopathology, Gene Expression, and Immunomodulatory Changes in Decedents with COVID-19

Brains of 42 COVID-19 decedents and 107 non-COVID-19 controls were studied. RT-PCR screening of 16 regions from 20 COVID-19 autopsies found SARS-CoV-2 E gene viral sequences in 7 regions (2.5% of 320 samples), concentrated in 4/20 subjects (20%). Additional screening of olfactory bulb (OB), amygdala (AMY) and entorhinal area for E, N1, N2, RNA-dependent RNA polymerase, and S gene sequences detected one or more of these in OB in 8/21 subjects (38%). It is uncertain whether these RNA sequences represent viable virus. Significant histopathology was limited to 2/42 cases (4.8%), one with a large acute cerebral infarct and one with hemorrhagic encephalitis. Case-control RNAseq in OB and AMY found more than 5000 and 700 differentially expressed genes, respectively, unrelated to RT-PCR results; these involved immune response, neuronal constituents, and olfactory/taste receptor genes. Olfactory marker protein-1 reduction indicated COVID-19-related loss of OB olfactory mucosa afferents. Iba-1-immunoreactive microglia had reduced area fractions in cerebellar cortex and AMY, and cytokine arrays showed generalized downregulation in AMY and upregulation in blood serum in COVID-19 cases. Although OB is a major brain portal for SARS-CoV-2, COVID-19 brain changes are more likely due to blood-borne immune mediators and trans-synaptic gene expression changes arising from OB deafferentation.

Integrative analysis of clinical and epigenetic biomarkers of mortality

DNA methylation (DNAm) has been reported to be associated with many diseases and with mortality. We hypothesized that the integration of DNAm with clinical risk factors would improve mortality prediction. We performed an epigenome-wide association study of whole blood DNAm in relation to mortality in 15 cohorts (n = 15,013). During a mean follow-up of 10 years, there were 4314 deaths from all causes including 1235 cardiovascular disease (CVD) deaths and 868 cancer deaths. Ancestry-stratified meta-analysis of all-cause mortality identified 163 CpGs in European ancestry (EA) and 17 in African ancestry (AA) participants at p < 1 × 10^-7 , of which 41 (EA) and 16 (AA) were also associated with CVD death, and 15 (EA) and 9 (AA) with cancer death. We built DNAm-based prediction models for all-cause mortality that predicted mortality risk after adjusting for clinical risk factors. The mortality prediction model trained by integrating DNAm with clinical risk factors showed an improvement in prediction of cancer death with 5% increase in the C-index in a replication cohort, compared with the model including clinical risk factors alone. Mendelian randomization identified 15 putatively causal CpGs in relation to longevity, CVD, or cancer risk. For example, cg06885782 (in KCNQ4) was positively associated with risk for prostate cancer (Beta = 1.2, P_MR  = 4.1 × 10^-4 ) and negatively associated with longevity (Beta = -1.9, P_MR  = 0.02). Pathway analysis revealed that genes associated with mortality-related CpGs are enriched for immune- and cancer-related pathways. We identified replicable DNAm signatures of mortality and demonstrated the potential utility of CpGs as informative biomarkers for prediction of mortality risk.

Accelerometer-Derived Daily Life Movement Classified by Machine Learning and Incidence of Cardiovascular Disease in Older Women: The OPACH Study

Background Current physical activity guidelines focus on volume and intensity for CVD prevention rather than common behaviors responsible for movement, including those for daily living activities. We examined the associations of a machine-learned, accelerometer-measured behavior termed daily life movement (DLM) with incident CVD. Methods and Results Older women (n=5416; mean age, 79±7 years; 33% Black, 17% Hispanic) in the Women's Health Initiative OPACH (Objective Physical Activity and Cardiovascular Health) study without prior CVD wore ActiGraph GT3X+ accelerometers for up to 7 days from May 2012 to April 2014 and were followed for physician-adjudicated incident CVD through February 28th, 2020 (n=616 events). DLM was defined as standing and moving in a confined space such as performing housework or gardening. Cox models estimated hazard ratios (HR) and 95% CI, adjusting for age, race and ethnicity, education, alcohol use, smoking, multimorbidity, self-rated health, and physical function. Restricted cubic splines examined the linearity of the DLM-CVD dose-response association. We examined effect modification by age, body mass index, Reynolds Risk Score, and race and ethnicity. Adjusted HR (95% CIs) across DLM quartiles were: 1.00 (reference), 0.68 (0.55-0.84), 0.70 (0.56-0.87), and 0.57 (0.45-0.74); p-trend<0.001. The HR (95% CI) for each 1-hour increment in DLM was 0.86 (0.80-0.92) with evidence of a linear dose-response association (p non-linear>0.09). There was no evidence of effect modification by age, body mass index, Reynolds Risk Score, or race and ethnicity. Conclusions Higher DLM was independently associated with a lower risk of CVD in older women. Describing the beneficial associations of physical activity in terms of common behaviors could help older adults accumulate physical activity.

Evaluation of Social Isolation, Loneliness, and Cardiovascular Disease Among Older Women in the US

IMPORTANCE

Social isolation and loneliness are increasing public health concerns and have been associated with increased risk of cardiovascular disease (CVD) among older adults.

OBJECTIVE

To examine the associations of social isolation and loneliness with incident CVD in a large cohort of postmenopausal women and whether social support moderated these associations.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study, conducted from March 2011 through March 2019, included community-living US women aged 65 to 99 years from the Women's Health Initiative Extension Study II who had no history of myocardial infarction, stroke, or coronary heart disease.

EXPOSURES

Social isolation and loneliness were ascertained using validated questionnaires.

MAIN OUTCOMES AND MEASURES

The main outcome was major CVD, which was physician adjudicated using medical records and included coronary heart disease, stroke, and death from CVD. Continuous scores of social isolation and loneliness were analyzed. Hazard ratios (HRs) and 95% CIs for CVD were calculated for women with high social isolation and loneliness scores (midpoint of the upper half of the distribution) vs those with low scores (midpoint of the lower half of the distribution) using multivariable Cox proportional hazards regression models adjusting for age, race and ethnicity, educational level, and depression and then adding relevant health behavior and health status variables. Questionnaire-assessed social support was tested as a potential effect modifier.

RESULTS

Among 57 825 women (mean [SD] age, 79.0 [6.1] years; 89.1% White), 1599 major CVD events occurred over 186 762 person-years. The HR for the association of high vs low social isolation scores with CVD was 1.18 (95% CI, 1.13-1.23), and the HR for the association of high vs low loneliness scores with CVD was 1.14 (95% CI, 1.10-1.18). The HRs after additional adjustment for health behaviors and health status were 1.08 (95% CI, 1.03-1.12; 8.0% higher risk) for social isolation and 1.05 (95% CI, 1.01-1.09; 5.0% higher risk) for loneliness. Women with both high social isolation and high loneliness scores had a 13.0% to 27.0% higher risk of incident CVD than did women with low social isolation and low loneliness scores. Social support was not a significant effect modifier of the associations (social isolation × social support: r, -0.18; P = .86; loneliness × social support: r, 0.78; P = .48).

CONCLUSIONS AND RELEVANCE

In this cohort study, social isolation and loneliness were independently associated with modestly higher risk of CVD among postmenopausal women in the US, and women with both social isolation and loneliness had greater CVD risk than did those with either exposure alone. The findings suggest that these prevalent psychosocial processes merit increased attention for prevention of CVD in older women, particularly in the era of COVID-19.

Body mass index prediction rule for mid-upper arm circumference: the atherosclerosis risk in communities study

OBJECTIVES

Electronic health records (EHR) are a convenient data source for clinical trial recruitment and allow for inexpensive participant screening. However, EHR may lack pertinent screening variables. One strategy is to identify surrogate EHR variables which can predict the screening variable of interest. In this article, we use BMI to develop a prediction rule for arm circumference using data from the Atherosclerosis Risk in Communities (ARIC) Study. This work applies to EHR patient screening for clinical trials of hypertension.

METHODS

We included 11 585 participants aged 52-75 years with BMI and arm circumference measured at ARIC follow-up visit 4 (1996-1998). We selected the following arm circumference cutpoints based on the American Heart Association recommendations for blood pressure (BP) cuffs: small adult (≤26 cm), adult (≤34 cm) and large adult (≤44 cm). We calculated the sensitivity and specificity of BMI values for predicting arm circumference using receiver operating characteristic curves. We report the BMI threshold that maximized Youden's Index for each arm circumference upper limit of a BP cuff.

RESULTS

Participants' mean BMI and arm circumference were 28.8 ± 5.6 kg/m2 and 33.4 ± 4.3 cm, respectively. The BMI-arm circumference Pearson's correlation coefficient was 0.86. The BMI threshold for arm circumference≤26 cm was 23.0 kg/m2, arm circumference≤34 cm was 29.2 kg/m2 and arm circumference≤44 cm was 37.4 kg/m2. Only the BMI threshold for arm circumference≤34 cm varied significantly by sex.

CONCLUSIONS

BMI predicts arm circumference with high sensitivity and specificity and can be an accurate surrogate variable for arm circumference. These findings are useful for participant screening for hypertension trials. Providers can use this information to counsel patients on appropriate cuff size for BP self-monitoring.

Associations between DNA methylation and BMI vary by metabolic health status: a potential link to disparate cardiovascular outcomes

Background

Body mass index (BMI), a well-known risk factor for poor cardiovascular outcomes, is associated with differential DNA methylation (DNAm). Similarly, metabolic health has also been associated with changes in DNAm. It is unclear how overall metabolic health outside of BMI may modify the relationship between BMI and methylation profiles, and what consequences this may have on downstream cardiovascular disease. The purpose of this study was to identify cytosine-phosphate-guanine (CpG) sites at which the association between BMI and DNAm could be modified by overall metabolic health.

Results

The discovery study population was derived from three Women’s Health Initiative (WHI) ancillary studies (n = 3977) and two Atherosclerosis Risk in Communities (ARIC) ancillary studies (n = 3520). Findings were validated in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort (n = 1200). Generalized linear models regressed methylation β values on the interaction between BMI and metabolic health Z score (BMI × MHZ) adjusted for BMI, MHZ, cell composition, chip number and location, study characteristics, top three ancestry principal components, smoking, age, ethnicity (WHI), and sex (ARIC). Among the 429,566 sites examined, differential associations between BMI × MHZ and DNAm were identified at 22 CpG sites (FDR q < 0.05), with one site replicated in MESA (cg18989722, in the TRAPPC9 gene). Three of the 22 sites were associated with incident coronary heart disease (CHD) in WHI. For each 0.01 unit increase in DNAm β value, the risk of incident CHD increased by 9% in one site and decreased by 6–10% in two sites over 25 years.

Conclusions

Differential associations between DNAm and BMI by MHZ were identified at 22 sites, one of which was validated (cg18989722) and three of which were predictive of incident CHD. These sites are located in several genes related to NF-kappa-B signaling, suggesting a potential role for inflammation between DNA methylation and BMI-associated metabolic health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01194-3.

Objectively Measured Physical Activity, Sedentary Behavior, and Incident Fracture in Older Women: The OPACH Study

Women aged 65 and older experience nearly three-fourths of the 2 million osteoporotic fractures annually in the US, yet whether accelerometer-measured volumes and intensities of physical activity and sedentary behavior (SB) are associated with reduced fracture risk is understudied. We investigated associations of accelerometer-measured light physical activity (LPA), moderate-to-vigorous physical activity (MVPA), sedentary time (ST), and mean sedentary bout duration (MBD) with incident clinical fractures (hip, vertebral, pelvis, lower leg, upper arm, forearm, and wrist) in the WHI OPACH cohort. Participants (N=6248; mean±SD age=78.6±6.7; 34% Black, 17% Hispanic) without prior hip fracture wore the ActiGraph GT3X+ for 7 days between May 2012-April 2014 and were followed through March 2020 for incident clinical fracture (N=711). Cox models estimated hazard ratios (HR) and 95% confidence intervals (CI), adjusting for age, race-ethnicity, education, alcohol, smoking, height, weight, falls history, RAND-36 physical function, diabetes, thiazide use, prescription osteoporotic therapy, and age at menopause. The HR(95% CI) across MVPA quartiles was 1.00(reference), 1.15(0.93-1.41), 0.90(0.72-1.13), and 0.79(0.61-1.02); p-trend=0.01. The HR(95% CI) for a one-interquartile range increment in MVPA (42 minutes/day) was 0.86(0.76-0.97). Associations were modified by prescription osteoporotic therapy [no: HR=0.77(0.66-0.89), yes: HR=1.03(0.85-1.25); p-interaction=0.01] and varied in magnitude by age[<80: HR=0.78(0.64-0.96), ≥80: HR=0.92(0.79-1.07); p-interaction=0.09], BMI [<30 kg/m2: HR=0.85(0.75-0.97), ≥30 kg/m2: HR=0.90(0.67-1.19); p-interaction=0.08], and race-ethnicity [Black: HR =0.63(0.44-0.89), Hispanic: HR =0.78(0.56-1.09), White: HR =0.92(0.80-1.06); p-interaction=0.16]. LPA, ST, or MBD were not associated with incident fractures. These data suggest that MVPA may reduce and not increase fracture risk and that LPA and SB do not increase fracture risk.

Differences in antimicrobial susceptibility testing complicating management of IMP carbapenemase-producing Enterobacterales infection

OBJECTIVES

IMP-type carbapenemases are rarely detected in Europe and limited information is available to guide the treatment of infections caused by carbapenemase-producing Enterobacterales (CPE) producing these carbapenemases. Accurate antimicrobial susceptibility testing (AST) results are essential for optimal antibiotic management. Here we report discrepancies in AST of IMP-producing Enterobacterales (IMP-CPE) complicating the management of severe sepsis.

METHODS

Antimicrobial susceptibilities were analysed by in-house VITEK® 2, Etest and broth microdilution (BMD). Carbapenemase-encoding genes were detected by PCR. Whole-genome sequencing (WGS) was performed using an Illumina MiSeq platform.

RESULTS

Minimum inhibitory concentrations (MICs) determined by VITEK® 2 for Enterobacter hormaechei and Klebsiella oxytoca blood culture isolates were ≥16 mg/L for meropenem and ≤0.5 mg/L for ertapenem. In contrast, Etest analysis and BMD returned MICs of 2 mg/L and 1 mg/L, respectively. Both isolates tested positive for IMP carbapenemase-encoding genes by PCR. WGS revealed that both isolates carried the same bla_IMP-4 gene. Based on VITEK® 2 susceptibilities, initial treatment was with tigecycline and amikacin. After subsequent deterioration, the patient was successfully treated with ertapenem and amikacin.

CONCLUSION

This case highlights that automated AST by VITEK® 2 can over-report meropenem resistance for IMP carbapenemase-producers compared with Etest and BMD. Clinicians need to be cautious deciding against carbapenem treatment based on VITEK® 2 susceptibility testing results for IMP-positive Enterobacterales. Tigecycline was inferior to carbapenem treatment for pyelonephritis caused by isolates expressing IMP carbapenemases, however specific evidence guiding the treatment of these infections is lacking.

The short physical performance battery and incident heart failure among older women: the OPACH study

OBJECTIVE

Reduced functional capacity is a hallmark of early pre-clinical stages of heart failure (HF). The Short Physical Performance Battery (SPPB) is a valid measure of lower extremity physical function, has relatively low implementation burden, and is associated with cardiovascular disease and mortality. However, the SPPB-HF association is understudied in older women among whom HF burden is high.

METHODS

Women (n = 5325; mean age 79 ± 7 years; 34% Black, 18% Hispanic, and 49% White) without prior HF completed the SPPB consisting of standing balance, strength, and walking tests that were summarized as a composite score from 0 (lowest) to 12 (highest), categorized as very low (0-3), low (4-6), medium (7-9), or high (10-12). Participants were followed for up to 8 years for incident HF (306 cases identified). Cox proportional hazards regression estimated hazard ratios (HR) adjusting for age, race/ethnicity, education, smoking, alcohol, diabetes, hypertension, COPD, osteoarthritis, depression, BMI, systolic blood pressure, lipids, glucose, and accelerometer-measured moderate-vigorous physical activity (MVPA) and sedentary time.

RESULTS

Incident HF cases (crude rate per 1000 person-years) in the four SPPB categories (very low to high) were 34 (26.0), 79 (14.5), 128 (9.3), and 65 (5.6). Corresponding multivariable-adjusted HRs (95% CIs) were 2.22 (1.34-3.66), 1.63 (1.11-2.38), 1.39 (1.00-1.94), and 1.00 (referent; P-trend<0.001). Higher HF risk was associated with lower SPPB in women with major modifiable HF risk factors including obesity (HR per 3-unit SPPB decrement: present HR = 1.41, absent HR = 1.41), hypertension (present HR = 1.45, absent HR = 1.30), diabetes (present HR = 1.32, absent HR = 1.44), and lower accelerometer-measured MVPA (<45 min/day HR = 1.29, ≥45 min/day HR = 1.60); all P-interaction>0.10.

CONCLUSION

Lower SPPB scores were associated with greater risk of incident HF in older women even after accounting for differences in HF risk factors and objectively measured PA. Implementing the SPPB in clinical settings could potentially enhance individual-level HF risk assessment, which should be further explored.

Cyclophosphamide and prednisolone for chemotherapy naïve B cell multicentric lymphoma in dogs: 32 cases (2017-2021)

OBJECTIVES

The aim of this study was to characterise the response rate and toxicity profile of cyclophosphamide and prednisolone given to dogs with newly diagnosed, chemotherapy naïve, B cell multicentric lymphoma.

MATERIALS AND METHODS

Dogs with diagnosed with B cell lymphoma naïve to chemotherapy treatment were prospectively identified at the author's institution (2017 to 2021) and given cyclophosphamide as their initial chemotherapeutic agent in combination with prednisolone with owner's consent. Signalment, laboratory findings, stage, treatment response and toxicity were recorded.

RESULTS

Thirty-two dogs were included in the study. The overall response rate in this population of dogs was 84%. Twenty dogs (62%) had a partial response, three dogs (9%) had a complete response, four dogs (12%) had stable disease and five dogs (15%) had progressive disease. Side effects were noted in 47% of patients, with neutropaenia being the most commonly reported.

CLINICAL SIGNIFICANCE

Cyclophosphamide and prednisolone were well-tolerated with limited side effects. The response rate observed in this cohort of dogs with chemotherapy-naïve B cell multicentric lymphoma is promising. Further comparative studies are required to confirm the safety and effectiveness of this intervention.

Séroprévalence SARS-Cov-2 chez les professionnels de santé : étude multicentrique avec analyse des facteurs de risque professionnels et extraprofessionnels

Introduction

L’objectif de notre étude était d’évaluer la séroprévalence SARS-Cov-2 chez les professionnels de santé, après la première vague Covid-19, et d’analyser les facteurs professionnels et extraprofessionnels modifiant cette prévalence.

Matériels et méthodes

Suite aux instructions gouvernementales proposant de réaliser une sérologie Covid-19 à tout professionnel de santé après la première vague, nous avons réalisé une étude transversale, multicentrique. Tous les professionnels volontaires des quatre centres participants étaient invités à réaliser une sérologie et à remplir un questionnaire concernant leurs données démographiques, leurs caractéristiques professionnelles, l’utilisation des équipements de protection individuelle et l’exposition extra professionnelle au Covid-19. Nous avons calculé la prévalence SARS-Cov-2 et utilisé une régression logistique en appliquant un effet centre.

Résultats

Un total de 3454 professionnels ont participé à l’étude dont 83,4 % de femmes. L’âge moyen était de 40,6 ans [31,8–50,3]. En médiane, la prévalence sérologique SARS-Cov-2 était de 5 % (95 % IC, 4,3 %–5,8 %). Les facteurs associés à une plus forte séroprévalence étaient : l’âge < 30 ans (aOR = 1,59, (95 % IC, 1,06–2,37)), le statut d’étudiant (aOR = 3,38, (95 % IC, 1,62–7,05)) avec une séroprévalence de 16,9 % dans cette catégorie. L’unité de travail, y compris le fait d’avoir travaillé en unité Covid ou en réanimation, ainsi que l’exposition à des patients (quel que soit leur statut infectieux) n’étaient pas associé à une augmentation de la séroprévalence. Par contre les professionnels rapportant un contact avec un patient Covid, sans protection adaptée, ou ayant pratiqué des taches aérosolisantes, y compris avec un masque FFP2, avaient un surrisque d’infection Covid-19 (respectivement aOR à 1,66 et 1,7). Enfin, l’exposition à un collègue infecté ou à un cas familial était également associée à une augmentation de la prévalence sérologique.

Conclusion

Les mesures mises en place pour limiter la transmission du SARS-Cov-2 des patients aux professionnels de santé semblent efficaces. En complément de la vaccination, l’éviction systématique des professionnels infectés, la formation des étudiants et le rappel des mesures d’hygiène durant les temps de pause pourraient limiter la contamination des professionnels de santé.

Increased Risk of Autopsy-Proven Pneumonia with Sex, Season and Neurodegenerative Disease

There has been a markedly renewed interest in factors associated with pneumonia, a leading cause of death worldwide, due to its frequent concurrence with pandemics of influenza and Covid-19 disease. Reported predisposing factors to both bacterial pneumonia and pandemic viral lower respiratory infections are wintertime occurrence, older age, obesity, pre-existing cardiopulmonary conditions and diabetes. Also implicated are age-related neurodegenerative diseases that cause parkinsonism and dementia. We investigated the prevalence of autopsy-proven pneumonia in the Arizona Study of Aging and Neurodegenerative Disorders (AZSAND), a longitudinal clinicopathological study, between the years 2006 and 2019 and before the beginning of the Covid-19 pandemic. Of 691 subjects dying at advanced ages (mean 83.4), pneumonia was diagnosed postmortem in 343 (49.6%). There were 185 subjects without dementia or parkinsonism while clinicopathological diagnoses for the other subjects included 319 with Alzheimer's disease dementia, 127 with idiopathic Parkinson's disease, 72 with dementia with Lewy bodies, 49 with progressive supranuclear palsy and 78 with vascular dementia. Subjects with one or more of these neurodegenerative diseases all had higher pneumonia rates, ranging between 50 and 61%, as compared to those without dementia or parkinsonism (40%). In multivariable logistic regression models, male sex and a non-summer death both had independent contributions (ORs of 1.67 and 1.53) towards the presence of pneumonia at autopsy while the absence of parkinsonism or dementia was a significant negative predictor of pneumonia (OR 0.54). Male sex, dementia and parkinsonism may also be risk factors for Covid-19 pneumonia. The apolipoprotein E4 allele, as well as obesity, chronic obstructive pulmonary disease, diabetes, hypertension, congestive heart failure, cardiomegaly and cigarette smoking history, were not significantly associated with pneumonia, in contradistinction to what has been reported for Covid-19 disease.

Retour d’expérience de deux structures d’urgences de centres hospitaliers généraux pendant la crise de la Covid-19

La Covid-19 s’est abattue sur l’Alsace en quelques jours, mettant à mal les hôpitaux de Mulhouse et de Colmar. Bien que proches, des différences notables existent au sein de ces deux structures en termes architecturaux et de ressources humaines. Comment cette vague a-t-elle modifié les organisations de chacun ? Quelles alternatives ont pu être mises en place ? Après la présentation de chaque site sont analysées les adaptations nécessaires afin d’absorber les flux de patients et leur proposer une prise en charge décente malgré des conditions parfois très dégradées. Nouvelles filières, modifications organisationnelles, renforts de personnel en interne puis en externe, augmentation capacitaire nette, recherches de solutions alternatives aux voies classiques d’approvisionnement des matériels… ont été une partie de la solution. Malgré les alertes du terrain, l’action nationale est restée en décalage de compréhension de la gravité de la situation locale, avec des recommandations et des actions soit inapplicables, soit trop tardives. Les établissements et professionnels de santé ont eu un sentiment d’isolement, renforcé par l’absence de représentant des tutelles et notamment de l’Agence régionale de santé sur le terrain. Deux éléments majeurs peuvent être mis en avant : une cohésion majeure de l’ensemble du centre hospitalier avec travail d’équipe et de terrain entre soignants et direction, et une implication de l’ensemble des acteurs de la médecine d’urgence (public, privé, libéraux, service départemental d’incendie et de secours) ; ils ont été les déterminants dans notre capacité à faire face à cet événement inédit.

Whole Blood DNA Methylation Signatures of Diet Are Associated With Cardiovascular Disease Risk Factors and All-Cause Mortality

BACKGROUND

DNA methylation patterns associated with habitual diet have not been well studied.

METHODS

Diet quality was characterized using a Mediterranean-style diet score and the Alternative Healthy Eating Index score. We conducted ethnicity-specific and trans-ethnic epigenome-wide association analyses for diet quality and leukocyte-derived DNA methylation at over 400 000 CpGs (cytosine-guanine dinucleotides) in 5 population-based cohorts including 6662 European ancestry, 2702 African ancestry, and 360 Hispanic ancestry participants. For diet-associated CpGs identified in epigenome-wide analyses, we conducted Mendelian randomization (MR) analysis to examine their relations to cardiovascular disease risk factors and examined their longitudinal associations with all-cause mortality.

RESULTS

We identified 30 CpGs associated with either Mediterranean-style diet score or Alternative Healthy Eating Index, or both, in European ancestry participants. Among these CpGs, 12 CpGs were significantly associated with all-cause mortality (Bonferroni corrected P<1.6×10-3). Hypermethylation of cg18181703 (SOCS3) was associated with higher scores of both Mediterranean-style diet score and Alternative Healthy Eating Index and lower risk for all-cause mortality (P=5.7×10-15). Ten additional diet-associated CpGs were nominally associated with all-cause mortality (P<0.05). MR analysis revealed 8 putatively causal associations for 6 CpGs with 4 cardiovascular disease risk factors (body mass index, triglycerides, high-density lipoprotein cholesterol concentrations, and type 2 diabetes mellitus; Bonferroni corrected MR P<4.5×10-4). For example, hypermethylation of cg11250194 (FADS2) was associated with lower triglyceride concentrations (MR, P=1.5×10-14).and hypermethylation of cg02079413 (SNORA54; NAP1L4) was associated with body mass index (corrected MR, P=1×10-6).

CONCLUSIONS

Habitual diet quality was associated with differential peripheral leukocyte DNA methylation levels of 30 CpGs, most of which were also associated with multiple health outcomes, in European ancestry individuals. These findings demonstrate that integrative genomic analysis of dietary information may reveal molecular targets for disease prevention and treatment.

Letrozole and palbociclib versus chemotherapy as neoadjuvant therapy of high-risk luminal breast cancer

Background

Palbociclib is a CDK4/6 inhibitor with demonstrated efficacy and safety in combination with endocrine therapy in advanced luminal breast cancer (LBC). We evaluated the respective efficacy and safety of chemotherapy and letrozole-palbociclib (LETPAL) combination as neoadjuvant treatment in patients with high-risk LBC.

Patients and methods

NeoPAL (UCBG10/4, NCT02400567) is a randomised, parallel, non-comparative phase II study. Patients with ER-positive, HER2-negative, Prosigna®-defined luminal B, or luminal A and node-positive, stage II-III breast cancer, not candidate for breast-conserving surgery, were randomly assigned to either letrozole (2.5 mg daily) and palbociclib (125 mg daily, 3 weeks/4) during 19 weeks, or to FEC100 (5FU 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2)×3 21-day courses followed by docetaxel 100 mg/m2×3 21-day courses. Primary end point was residual cancer burden (RCB 0-I rate). Secondary end points included clinical response, proliferation-based markers, and safety.

Results

Overall, 106 patients were randomised [median Prosigna® ROR Score 71 (22-93)]. RCB 0-I was observed in four and eight patients in LETPAL [7.7% (95% CI 0.4-14.9)] and chemotherapy [15.7% (95% CI 5.7-25.7)] arms, respectively. Pathological complete response rates were 3.8% and 5.9%. Clinical response (75%) and breast-conserving surgery rates (69%) were similar in both arms. Preoperative Endocrine Prognostic Index 0 scores (breast cancer-specific survival) were observed in 17.6% and 8.0% of patients in LETPAL and chemotherapy arms, respectively. Safety profile was as expected, with 2 versus 17 serious adverse events (including 11 grade 4 serious AEs in the chemotherapy arm).

Conclusion

LETPAL combination was associated with poor pathological response but encouraging clinical and biomarker responses in Prosigna®-defined high-risk LBC. Contemporary chemotherapy regimen was associated with poor pathological and biomarker responses, with a much less favourable safety profile. LETPAL combination might represent an alternative to chemotherapy in early high-risk LBC.

Clinical Trial Number

NCT02400567.

Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort

OBJECTIVES

Hydroxychloroquine (HCQ) is a key therapy in systemic lupus erythematosus (SLE). Medication non-adherence is reported in up to 80% of lupus patients and results in increased morbidity, mortality, and health care utilization. HCQ levels are a sensitive and reliable method to assess medication adherence. Our study evaluated the role of HCQ level measurement in routine clinical care and its association with disease activity in a predominantly Hispanic population.

METHODS

SLE patients from the Columbia University Lupus cohort treated with HCQ for ≥ 6 months and reporting medication adherence were included. HCQ levels were measured by whole blood high performance liquid chromatography. Non-adherence was defined as an HCQ level <500 ng/ml. The association between HCQ levels and disease activity measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was evaluated.

RESULTS

One hundred and eight patients were enrolled; the median age was 38 years, 91% were female, and 63% were Hispanic. The median SLEDAI-2K was 4.3 (0-20). Forty-one percent of patients had an HCQ level <500 ng/ml consistent with non-adherence, of which 19% had undetectable levels. A higher SLEDAI-2K score was associated with low HCQ levels (p = 0.003). This association remained significant after adjusting for depression (p = 0.0007).

CONCLUSION

HCQ levels < 500 ng/ml were associated with higher disease activity and accounted for 32% of the SLEDAI-2K variability. HCQ blood measurement is a simple and reliable method to evaluate medication adherence in SLE. Reasons for non-adherence (levels < 500 ng/ml) should be further explored and addressed.

Prognostic factors in patients treated with second-line chemotherapy for advanced gastric cancer: results from the randomized prospective phase III FFCD-0307 trial

AIM

The aim of this study was to determine prognostic factors in patients treated with second-line therapy (L2) for locally advanced or metastatic gastric and gastro-esophageal junction (GEJ) adenocarcinoma in a randomized phase III study with predefined L2.

METHODS

In the FFCD-0307 study, patients were randomly assigned to receive in L1 either epirubicin, cisplatin, and capecitabine (ECX arm) or fluorouracil, leucovorin, and irinotecan (FOLFIRI arm). L2 treatment was predefined (FOLFIRI for the ECX arm and ECX for the FOLFIRI arm). Chi square tests were used to compare the characteristics of patients treated in L2 with those of patients who did not receive L2. Prognostic factors in L2 for progression-free survival (PFS) and overall survival (OS) were analyzed using a Cox model.

RESULTS

Among 416 patients included, 101/209 (48.3%) patients in the ECX arm received FOLFIRI in L2, and 81/207 (39.1%) patients in the FOLFIRI arm received ECX in L2. Patients treated in L2, compared with those who only received L1 had : a better ECOG score (0-1: 90.4% versus 79.7%; p = 0.0002), more frequent GEJ localization (40.8% versus 27.6%; p = 0.005), and lower platelet count (median: 298000 versus 335000/mm³; p = 0.02). In multivariate analyses, age < 60 years at diagnosis (HR 1.49, 95% CI 1.09-2.03, p = 0.013) and ECOG score 2 before L2 (HR 2.62, 95% CI 1.41-4.84, p = 0.005) were the only significant poor prognostic factors for OS.

CONCLUSION

Age ≥ 60 years at diagnosis and ECOG score 0/1 before L2 were the only favorable prognostic factors for OS.

Assessment of conversational pragmatics: A screening tool for pragmatic language impairment in a control population of children aged 6-12 years

Pragmatics can be defined as the way in which language is used to communicate in a given social context. Although there is a lack of a standardized assessment, healthcare professionals find themselves confronted with pragmatic language skill impairments in children with neurodevelopmental disorders or brain injuries. The characterization of language use causes problems in social interactions, which has clinical implications in daily life. However, this is still underestimated because there is currently no quick, easy-to-use screening device to rank these deficits. We have developed a pragmatic deficits screening chart that has been tested on a control population of children aged 6-12 years. The chart comprises 26 items exploring seven areas of pragmatics (intentionality, governance of exchange, organization of information, adaptation strategies, conversational implicit language, nonverbal skills, and paralinguistic aspects). Parents select one of four possible answers to describe how frequently their child demonstrates each type of behavior ("never, rarely, sometimes, often"). We distributed 1666 charts; 760 were returned, of which 552 could be analyzed. Internal consistency as measured with Cronbach's alpha coefficient (0.88) was satisfactory. There was no influence of age on total score, nor of the department/type of schooling. The population distribution was non-Gaussian so the results are presented in percentiles. We propose a first-line screening tool that is quick and easy to complete by family, which facilitates referral to specialists for further investigations into the etiological implications of pragmatic language impairment.