"The System Tends to Scoop You Up and Spit You Out and They're Done With You": The Intersection of Intellectual/Developmental Disability and Homelessness From the Perspectives of Service Providers

People with intellectual and developmental disabilities (IDD) experience elevated risk for poor health and social outcomes in adulthood and are at risk for experiencing homelessness and housing instability. Although the exact prevalence of IDD among homeless populations is unknown, a small body of literature related to the intersection of IDD and homelessness suggests differential health needs and service use patterns, with a need for targeted health and social services. In this study, we explore the perceptions and experiences of 18 homeless or disability service providers about (a) their clients at the intersection of IDD and homelessness and (b) their role and the services provided at the intersection of IDD and homelessness. Participants struggled to provide appropriate, accessible services for this population, owing to lack of training and awareness of specific needs, fragmented systems, and inadequately funded healthcare and housing support. Our findings also reveal that clients at this intersection have high contact with public systems, which places them at risk for losing their right to self-determination. Recommendations center on systems transformation to facilitate the ability of providers to collaborate and to make data-driven decisions to deliver person-centered care.

Revision and Psychometric Evaluation of the Diabetes Knowledge Questionnaire for People With Type 2 Diabetes

Objective

Diabetes knowledge is associated with health, including lower A1C levels. The Diabetes Knowledge Questionnaire (DKQ-24), developed 30 years ago for Mexican Americans with type 2 diabetes and since used with diverse samples in many countries, contains outdated items that no longer accurately assess current knowledge needed for diabetes self-management. We revised the DKQ-24 and tested psychometric properties of the DKQ-Revised (DKQ-R) with a diverse sample.

Methods

We conducted a five-phase instrumentation study as follows: 1) DKQ-24 items were revised to reflect current diabetes care standards; 2) the Delphi method was used to evaluate the DKQ-R's content validity (n = 5 experts); 3) cognitive interviews were conducted with people with type 2 diabetes (n = 5) to assess their interpretations of DKQ-R items; 4) cross-sectional administration of the DKQ-R to adults with type 2 diabetes was carried out to assess internal consistency reliability and convergent validity; and 5) an item analysis was conducted using discrimination index and point biserial analysis.

Results

After receiving the experts' feedback and conducting the cognitive interviews, 39 items were administered to 258 participants with type 2 diabetes (42.2% women; 29.1% Latino, 42.6% Asian, mean age 55.7 years). To select the final items, we considered the item discrimination index, as well as item-to-total correlations, content area, and participant feedback. The final 22-item DKQ-R uses the same yes/no/I don't know response format as the DKQ-24. The DKQ-R is strongly correlated with the DKQ-24 (r = 0.71, P <0.01) and is weakly correlated with diabetes numeracy (r = 0.23, P <0.01), indicating adequate convergent validity; a Kuder-Richardson-20 coefficient of 0.77 indicated good reliability.

Conclusion

The DKQ-R is a reliable and valid updated measure of diabetes knowledge for diverse populations with type 2 diabetes.

Investigating the Health and Health-Related Quality of Life Impacts of the Criminal Legal System on Families: A Scoping Review

A scoping review was conducted to present the state of the science regarding the health and health-related quality of life (HRQOL) effects of having a family member in contact with the criminal legal system (CLS). The review examined how the following have been studied: 1) types of family relationships, 2) the point of CLS contact, 3) mental health outcomes, 4) physical health outcomes, and 5) HRQOL outcomes. The final sample of 40 studies was largely secondary analyses of datasets (93%; n=37) that investigated a parent-child relationship (78%; n=31). Incarceration was the most frequently measured point of CLS contact (85%; n=34). Mental health outcomes were measured in 68% of the studies (n=27). Physical health outcomes were measured in 28% of the studies (n=11). Health-related quality of life outcomes were included in half of the studies (50%; n=20). Study findings indicate exposure to the CLS through a family member is associated with poorer health and HRQOL outcomes.

Patterns and Correlates of Physical Symptoms among People with Peripheral Neuropathy

Background

As the population ages and more people are affected by multiple chronic conditions, the prevalence of Peripheral Neuropathy (PN) has also rapidly increased. This swift rise in PN leaves clinicians and patients challenged by a lack of consistent diagnosis and treatment guidelines.

Purpose

To assist those affected by PN, it is imperative to understand the breadth of symptoms, experiences, and factors related to the quality of life. The primary aims of this study are to (1) characterize the symptoms of PN in a nationwide sample; (2) discern differences in symptom clusters, given perceived causes of PN; and (3) identify significant physiological symptoms related to the quality of life for people with PN.

Methods

An online survey of people in online PN support groups. Participants were recruited primarily via an open request sent to recipients of web-based communications from nationally recognized online PN support groups. Inclusion criteria were as follows: Self-reported diagnosis of PN, ability to read English or Spanish, residence in the U.S., and age ≥ 18 years.

Results

A total of 608 individuals with PN were included in the analysis. This sample represents 49 U.S. states and the District of Colombia; 221 were male and 387 female. Their disease severity and etiology were similar to previously reported information on this population, with 53.3% of respondents suffering from PN without a known cause. Among known causes, diabetes was the most common (19.6%), followed by chemotherapy (6.9%) and autoimmune diseases (3.6%). Factors affecting the quality of life among people with PN included lower extremity mobility, upper extremity mobility, sleep disturbance, depressive symptoms, and patient activation.

Lessons Learned from Rapid Community Needs Assessment in the African American Community During the COVID-19 Pandemic

BACKGROUND

With the accelerated spread of COVID-19 and current shelter-in-place orders from many local governments, African American (AA) communities see to be more vulnerable as emerging data show disproportionate rates of infection and mortality among AAs across the nation.

OBJECTIVES

In a sample of AA church members, to conduct a rapid community assessment during the early phase of the coronavirus disease 2019 pandemic.

METHODS

Our community-based participatory research team, partnering with the local AA church community and including trained lay health workers, conducted the assessment via telephone and online.

RESULTS

Although most participants reported high confidence regarding recommendations for physical distancing, more than 60% reported elevated anxiety and stress, and 10% indicated that they needed more information about staying healthy and safe during the pandemic.

CONCLUSIONS

Community-based participatory research with lay health workers is an effective method to implement a community needs assessment, problem-solve with community members, and build community health infrastructure during a public health crisis.

A 30-Day Adjunct Wellness Intervention for the Management of Extra-Articular Symptoms of Rheumatoid Arthritis: A Formative Study

Individuals with rheumatoid arthritis (RA) continually fall short of treatment targets using standard drug therapies alone. There is growing evidence that emphasizing physical and mental wellness is equally crucial for improving functioning among people with RA. The purpose of this formative study is to examine the feasibility of offering the wellness-based intervention (“KickStart30”) in patients with RA. Thirteen individuals with RA on targeted immune modulators (a biologic or JAK inhibitor) enrolled in the KickStart30 program. Participants completed self-report measures of RA-specific disability (eg, pain) and other functional areas (eg, mood) in a pre- versus post- intervention design. Paired samples t-tests (and Related-Samples Wilcoxon Signed Rank Tests for non-normal distributions) detected statistically significant results for 10 of 12 measures, including reductions in pain (M = 4.54 to M = 3.54; p = .025; BPI), functional disability (M = 0.94 to M = 0.73, p = .032; HAQ-II), cognitive and physical dysfunction (M = 25.46 to M = 13.54, p < .001; CPFQ), depressive symptoms (M = 9.31 to M = 5.54, p = .003; PHQ-9), anxiety (M= 5.69 to M = 3.23, p = .005; GAD-7), insomnia (M = 11.62 to M = 17.32, p = .007; Note: higher scores on the SCI indicate less insomnia), stress-related eating (M = 75.46 to M = 84.54, p = .021; Note: higher scores on the EADES indicate less stress-related eating), along with significant increases in mindfulness (M = 62.54 to M = 67.85, p = .040; MAAS), mental wellness (M = 4.46 to M = 5.69; HERO), and well-being (M_d = 8.00 to M_d = 5.00, p = .004; WHO-5). All significant measures had medium to large effect sizes (Cohen's d). The study gives preliminary support for the possibility that the adjunct intervention may have an effect.

A randomized phase II trial of CRLX101 in combination with bevacizumab versus standard of care in patients with advanced renal cell carcinoma

BACKGROUND

Nanoparticle-drug conjugates enhance drug delivery to tumors. Gradual payload release inside cancer cells augments antitumor activity while reducing toxicity. CRLX101 is a novel nanoparticle-drug conjugate containing camptothecin, a potent inhibitor of topoisomerase I and the hypoxia-inducible factors 1α and 2α. In a phase Ib/2 trial, CRLX101 + bevacizumab was well tolerated with encouraging activity in metastatic renal cell carcinoma (mRCC). We conducted a randomized phase II trial comparing CRLX101 + bevacizumab versus standard of care (SOC) in refractory mRCC.

PATIENTS AND METHODS

Patients with mRCC and 2-3 prior lines of therapy were randomized 1 : 1 to CRLX101 + bevacizumab versus SOC, defined as investigator's choice of any approved regimen not previously received. The primary end point was progression-free survival (PFS) by blinded independent radiological review in patients with clear cell mRCC. Secondary end points included overall survival, objective response rate and safety.

RESULTS

In total, 111 patients were randomized and received ≥1 dose of drug (CRLX101 + bevacizumab, 55; SOC, 56). Within the SOC arm, patients received single-agent bevacizumab (19), axitinib (18), everolimus (7), pazopanib (4), sorafenib (4), sunitinib (2), or temsirolimus (2). In the clear cell population, the median PFS on the CRLX101 + bevacizumab and SOC arms was 3.7 months (95% confidence interval, 2.0-4.3) and 3.9 months (95% confidence interval 2.2-5.4), respectively (stratified log-rank P = 0.831). The objective response rate by IRR was 5% with CRLX101 + bevacizumab versus 14% with SOC (Mantel-Haenszel test, P = 0.836). Consistent with previous studies, the CRLX101 + bevacizumab combination was generally well tolerated, and no new safety signal was identified.

CONCLUSIONS

Despite promising efficacy data on the earlier phase Ib/2 trial of mRCC, this randomized trial did not demonstrate improvement in PFS for the CRLX101 + bevacizumab combination when compared with approved agents in patients with heavily pretreated clear cell mRCC. Further development in this disease is not planned.

CLINICAL TRIAL IDENTIFICATION

NCT02187302 (NIH).

Sunitinib in combination with docetaxel and prednisone in patients (pts) with metastatic hormone-refractory prostate cancer (mHRPC)

5166

Background: Overexpression of VEGF and PDGF has been implicated in prostate cancer progression and bone metastases. Sunitinib is an oral, multitargeted inhibitor of VEGFRs, PDGFRs, and other tyrosine kinases which may improve the efficacy of chemotherapy in pts with mHRPC. We performed a multicenter phase I/II study of sunitinib in combination with docetaxel and prednisone as first-line therapy in pts with mHRPC. The combination dose was established in phase I (Zurita et al, ECCO. 2007). Final results from phase II will be reported. Methods: Pts received treatment in a 21-day cycle: sunitinib 37.5 mg/d on days 1–14, docetaxel 75 mg/m2 on day 1, and prednisone 5 mg BID on days 1–21. Dose reductions were permitted for treatment-related toxicity. The primary endpoint was PSA response rate (PSA Working Group Criteria). Secondary endpoints included tumor response rate (RECIST), safety and patient-reported outcomes. Results: Fifty-five pts were enrolled and 13 remained on study at the time of the data cutoff (1 Oct 08). Thirty-six discontinued from the study due to disease progression (16), adverse events (AEs; 13), consent withdrawal (6) and other (1). Six pts completed the study (16 cycles) and continued treatment on another protocol. Pts received a median of 23 weeks of therapy (range, 2–84). The most common treatment-related grade 3–4 AEs were neutropenia (75%), febrile neutropenia (15%), fatigue (15%), stomatitis (7%), and anorexia (7%). Sunitinib dose reduction to 25 mg/d was required in 14 pts (26%), and 3 pts (6%) had a further dose reduction to 12.5 mg/d. Docetaxel dose reduction to 60 mg/m2 was required in 18 pts (33%). PSA responses occurred in 31 pts (56%), with a preliminary median time to PSA progression of 42.1 weeks. Out of 33 pts with measurable disease, thirteen (39%) had a confirmed partial response (PR) and another 7 (21%) had an initial PR. The median progression-free and overall survivals have not been reached, but the probability of survival at 48 weeks is 92.4% (95% CI: 77.5, 97.6). Patient-reported assessments of pain and quality of life will be reported. Conclusions: Sunitinib in combination with docetaxel and prednisone is tolerated and has antitumor activity in pts with mHRPC, as indicated by both PSA and RECIST-defined tumor responses.

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Patient-reported outcomes in a randomized trial of everolimus with metastatic renal cell carcinoma patients

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Background: Patient-reported outcomes (PRO), including health-related quality of life (HRQL), were assessed in a Phase III trial of everolimus in metastatic renal cell carcinoma (mRCC) patients. Methods: Patients with mRCC were randomized (n=416) to receive everolimus or placebo plus best supportive care. Patients completed the FACT-Kidney Symptom Index- Disease Related Symptoms (FKSI-DRS) and EORTC-QLQ C30 at baseline and monthly during treatment. Karnofsky Performance Status (KPS) was also assessed at baseline and monthly during treatment. Primary analyses included time to deterioration defined as a decrease from baseline of at least 3 points for FKSI-DRS, at least 10% for EORTC Physical Function (PF) and Global Quality of Life (QL) scales, and at least 10 points for KPS. Secondary analyses considered tumor progressions that occurred prior to deterioration or censoring date as FKSI deterioration events and compared time to PRO deterioration by tumor progression. Comparisons were made using stratified log-rank tests and Cox proportional hazard models. Results: Time to deterioration in KPS was longer in the everolimus arm, and time to deterioration in FKSI-DRS was slightly longer ( Table ). There was no difference in time to deterioration in PF or QL. Secondary analyses showed median time to deterioration in FKSI-DRS was approximately doubled for the everolimus arm compared to placebo, and patients who progressed experienced a more rapid deterioration in FKSI-DRS and QL scores. Conclusions: Compared to placebo everolimus delayed progression of disease-related symptoms and KPS. No effect on time to deterioration of PF or QL could be determined. Secondary analyses suggest a delay in deterioration in kidney cancer related symptoms via tumor control.

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A phase II trial of gemcitabine and docetaxel in hormone-refractory metastatic prostate cancer

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Background: Docetaxel is a microtubule stabilizing agent with demonstrated ability to improve survival in patients (pts) with hormone refractory metastatic prostate cancer (HRMPC). Gemcitabine is a nucleoside analogue that exhibits broad antitumor activity, although as a single agent has modest activity in advanced prostate cancer. The combination of docetaxel and gemcitabine has demonstrated significant activity in a variety of chemotherapy resistant neoplasms. We performed a phase II study of this combination to assess its safety and antitumor activity in chemotherapy naïve patients with HRMPC. Methods: Eligible pts had HRMPC with radiologic and/or biochemical evidence of progression following antiandrogen withdrawal with castrate testosterone levels, ECOG PS 0–2 and adequate organ function; no prior chemotherapy was permitted. Gemcitabine (800 mg/m2) was administered on days 1 and 8 and docetaxel (75mg/m2) on day 8 every 21 days for a maximum of 6 cycles. Results: Twenty-nine pts have been enrolled to date with 22 currently evaluable for response, all are evaluable for toxicity. The median age was 68. The average number of cycles completed was 4.9. Nine pts have experienced grade 4 neutropenia (1 neutropenic fever admission). Twelve of 29 pts have required dose delays secondary to wbc or platelets, two pts have required dose modification. Non-hematologic grade 3/4 toxicities include 1 pt with a PE, 1 grade 4 dyspnea, 1 grade 4 GI bleed. Four pts (18%) achieved measurable disease + PSA, partial response (PR), 7 (32%) additional pts had >50% decline in PSA, for a composite overall response rate of 50%. Conclusions: The combination of gemcitabine and docetaxel is moderately toxic primarily impacting bone marrow reserve. Although there is evidence of significant antitumor activity, the ulitmiate utility of this doublet remains undefined. Accrual to this study is ongoing.

[Table: see text]