Temporal dynamics of the multi-omic response to endurance exercise training

Regular exercise promotes whole-body health and prevents disease, but the underlying molecular mechanisms are incompletely understood1-3. Here, the Molecular Transducers of Physical Activity Consortium4 profiled the temporal transcriptome, proteome, metabolome, lipidome, phosphoproteome, acetylproteome, ubiquitylproteome, epigenome and immunome in whole blood, plasma and 18 solid tissues in male and female Rattus norvegicus over eight weeks of endurance exercise training. The resulting data compendium encompasses 9,466 assays across 19 tissues, 25 molecular platforms and 4 training time points. Thousands of shared and tissue-specific molecular alterations were identified, with sex differences found in multiple tissues. Temporal multi-omic and multi-tissue analyses revealed expansive biological insights into the adaptive responses to endurance training, including widespread regulation of immune, metabolic, stress response and mitochondrial pathways. Many changes were relevant to human health, including non-alcoholic fatty liver disease, inflammatory bowel disease, cardiovascular health and tissue injury and recovery. The data and analyses presented in this study will serve as valuable resources for understanding and exploring the multi-tissue molecular effects of endurance training and are provided in a public repository ( https://motrpac-data.org/ ).

The dementia care study (D-CARE): Recruitment strategies and demographic characteristics of participants in a pragmatic randomized trial of dementia care

INTRODUCTION

Pragmatic research studies that include diverse dyads of persons living with dementia (PLWD) and their family caregivers are rare.

METHODS

Community-dwelling dyads were recruited for a pragmatic clinical trial evaluating three approaches to dementia care. Four clinical trial sites used shared and site-specific recruitment strategies to enroll health system patients.

RESULTS

Electronic health record (EHR) queries of patients with a diagnosis of dementia and engagement of their clinicians were the main recruitment strategies. A total of 2176 dyads were enrolled, with 80% recruited after the onset of the pandemic. PLWD had a mean age of 80.6 years (SD 8.5), 58.4% were women, and 8.8% were Hispanic/Latino, and 11.9% were Black/African American. Caregivers were mostly children of the PLWD (46.5%) or spouses/partners (45.2%), 75.8% were women, 9.4% were Hispanic/Latino, and 11.6% were Black/African American.

DISCUSSION

Health systems can successfully enroll diverse dyads in a pragmatic clinical trial.

Impact of Geroscience on Therapeutic Strategies for Older Adults With Cardiovascular Disease: JACC Scientific Statement

Geroscience posits that cardiovascular disease (CVD) and other chronic diseases result from progressive erosion of the effectiveness of homeostatic mechanisms that oppose age-related accumulation of molecular damage. This hypothetical common root to chronic diseases explains why patients with CVD are often affected by multimorbidity and frailty and why older age negatively affects CVD prognosis and treatment response. Gerotherapeutics enhance resilience mechanisms that counter age-related molecular damage to prevent chronic diseases, frailty, and disability, thereby extending healthspan. Here, we describe the main resilience mechanisms of mammalian aging, with a focus on how they can affect CVD pathophysiology. We next present novel gerotherapeutic approaches, some of which are already used in management of CVD, and explore their potential to transform care and management of CVD. The geroscience paradigm is gaining traction broadly in medical specialties, with potential to mitigate premature aging, reduce health care disparities, and improve population healthspan.

Skeletal Muscle Bioenergetics in Critical Limb Ischemia and Diabetes

INTRODUCTION

Mitochondrial dysfunction is implicated in the metabolic myopathy accompanying peripheral artery disease (PAD) and critical limb ischemia (CLI). Type-2 diabetes mellitus (T2DM) is a major risk factor for PAD development and progression to CLI and may also independently be related to mitochondrial dysfunction. We set out to determine the effect of T2DM in the relationship between CLI and muscle mitochondrial respiratory capacity and coupling control.

METHODS

We studied CLI patients undergoing revascularization procedures or amputation, and non-CLI patients with or without T2DM of similar age. Mitochondrial respiratory capacity and function were determined in lower limb permeabilized myofibers by high-resolution respirometry.

RESULTS

Fourteen CLI patients (65 ± 10y) were stratified into CLI patients with (n = 8) or without (n = 6) T2DM and were compared to non-CLI patients with (n = 18; 69 ± 5y) or without (n = 19; 71 ± 6y) T2DM. Presence of CLI but not T2DM had a marked impact on all mitochondrial respiratory states in skeletal muscle, adjusted for the effects of sex. Leak respiration (State 2, P < 0.025 and State 4o, P < 0.01), phosphorylating respiration (P < 0.001), and maximal respiration in the uncoupled state (P < 0.001), were all suppressed in CLI patients, independent of T2DM. T2DM had no significant effect on mitochondrial respiratory capacity and function in adults without CLI.

CONCLUSIONS

Skeletal muscle mitochondrial respiratory capacity was blunted by ∼35% in patients with CLI. T2DM was not associated with muscle oxidative capacity and did not moderate the relationship between muscle mitochondrial respiratory capacity and CLI.

Postabsorptive muscle protein synthesis is higher in outpatients as compared to inpatients

Several factors affect muscle protein synthesis (MPS) in the postabsorptive state. Extreme physical inactivity (e.g., bedrest) may reduce basal MPS, whereas walking may augment basal MPS. We hypothesized that outpatients would have a higher postabsorptive MPS than inpatients. To test this hypothesis, we conducted a retrospective analysis. We compared 152 outpatient participants who arrived at the research site the morning of the MPS assessment with 350 Inpatient participants who had an overnight stay in the hospital unit before the MPS assessment the following morning. We used stable isotopic methods and collected vastus lateralis biopsies ∼2 to 3 h apart to assess mixed MPS. MPS was ∼12% higher (P < 0.05) for outpatients than inpatients. Within a subset of participants, we discovered that after instruction to limit activity, outpatients (n = 13) took 800 to 900 steps in the morning to arrive at the unit, seven times more steps than inpatients (n = 12). We concluded that an overnight stay in the hospital as an inpatient is characterized by reduced morning activity and causes a slight but significant reduction in MPS compared with participants studied as outpatients. Researchers should be aware of physical activity status when designing and interpreting MPS results.NEW & NOTEWORTHY The postabsorptive muscle protein synthesis rate is lower in the morning after an overnight inpatient hospital stay compared with an outpatient visit. Although only a minimal amount of steps was conducted by outpatients (∼900), this was enough to increase postabsorptive muscle protein synthesis rate.

Nutritional Interventions: Dietary Protein Needs and Influences on Skeletal Muscle of Older Adults

BACKGROUND

This narrative review describes foundational and emerging evidence of how dietary protein intakes may influence muscle-related attributes of older adults.

METHODS

PubMed was used to identify pertinent research.

RESULTS

Among medically stable older adults, protein intakes below the recommended dietary allowance (RDA) (0.8 g/kg body weight [BW]/d) exacerbate age-related reductions in muscle size, quality, and function. Dietary patterns with total protein intakes at or moderately above the RDA, including one or preferably more meals containing sufficient dietary protein to maximize protein anabolism, promote muscle size and function. Some observational studies suggest protein intakes from 1.0 to 1.6 g/kg BW/d may promote greater muscle strength and function more so than muscle size. Experimental findings from randomized controlled feeding trials indicate protein intakes greater than the RDA (averaging ~1.3 g/kg BW/d) do not influence indices of lean body mass or muscle and physical functions with non-stressed conditions, but positively influence changes in lean body mass with purposeful catabolic (energy restriction) or anabolic (resistance exercise training) stressors. Among older adults with diagnosed medical conditions or acute illness, specialized protein or amino acid supplements that stimulate muscle protein synthesis and improve protein nutritional status may attenuate the loss of muscle mass and function and improve survival of malnourished patients. Observational studies favor animal versus plant protein sources for sarcopenia-related parameters.

CONCLUSIONS

Quantity, quality, and patterning of dietary protein consumed by older adults with varied metabolic states, and hormonal and health status influence the nutritional needs and therapeutic use of protein to support muscle size and function.

Optimizing the Design of Clinical Trials to Evaluate the Efficacy of Function-Promoting Therapies

BACKGROUND

Several candidate molecules that may have application in treating physical limitations associated with aging and chronic diseases are in development. Challenges in the framing of indications, eligibility criteria, and endpoints and the lack of regulatory guidance have hindered the development of function-promoting therapies.

METHODS

Experts from academia, pharmaceutical industry, National Institutes of Health (NIH), and Food and Drug Administration (FDA) discussed optimization of trial design including the framing of indications, eligibility criteria, and endpoints.

RESULTS

Mobility disability associated with aging and chronic diseases is an attractive indication because it is recognized by geriatricians as a common condition associated with adverse outcomes, and it can be ascertained reliably. Other conditions associated with functional limitation in older adults include hospitalization for acute illnesses, cancer cachexia, and fall injuries. Efforts are underway to harmonize definitions of sarcopenia and frailty. Eligibility criteria should reconcile the goals of selecting participants with the condition and ensuring generalizability and ease of recruitment. An accurate measure of muscle mass (eg, D3 creatine dilution) could be a good biomarker in early-phase trials. Performance-based and patient-reported measures of physical function are needed to demonstrate whether treatment improves how a person lives, functions, or feels. Multicomponent functional training that integrates training in balance, stability, strength, and functional tasks with cognitive and behavioral strategies may be needed to translate drug-induced muscle mass gains into functional improvements.

CONCLUSIONS

Collaborations among academic investigators, NIH, FDA, pharmaceutical industry, patients, and professional societies are needed to conduct well-designed trials of function-promoting pharmacological agents with and without multicomponent functional training.

Considerations When Designing and Implementing Pragmatic Clinical Trials That Include Older Hispanics

Introduction

Pragmatic clinical trials (PCTs) are designed to connect researchers with clinicians to assess the real-world effectiveness and feasibility of interventions, treatments, or health care delivery strategies in routine practice. Within PCTs larger, more representative sampling is possible to improve the external validity of the research. Older adults from underrepresented groups can benefit from PCTs given their historically lower engagement in clinical research. The current article focuses on older Hispanic adults with Alzheimer disease and related dementias (ADRDs). Older Hispanic adults represent 19% of the US population and have a higher prevalence of ADRDs than Whites. We provide data from 2 PCTs about the recruitment of older Hispanics with ADRDs and discuss unique challenges associated with conducting PCTs and propose strategies to overcome challenges.

Data and Methods

The first PCT outlined is the Patient Priorities Care for Hispanics with Dementia (PPC-HD) trial. PPC-HD is testing the feasibility of implementing a culturally adapted version of the Patient Priorities Care approach for older Hispanic adults with multiple chronic conditions and dementia. The second PCT is the Dementia Care (D-CARE) Study, which is a multisite pragmatic study comparing the effectiveness of a health care system-based approach and a community-based approach to dementia care to usual care in patients with ADRDs and their family caregivers.

Lessons Learned and Recommendations for Future Studies

The lessons learned are summarized according to the various stakeholders that need to work together to effectively recruit diverse participants for PCTs: individuals, health care systems, research teams, and communities. Individual-level considerations include communication, priorities, and flexibility. Health care system-level considerations are grounded in 4 principles of Community-Based Participatory Research and include collaboration/partnership, available resources, priorities of the health care system, and sustainability. Research team-level considerations include team members, intentionality, and communication. Community-level considerations highlight the importance of partnerships, community members, and appropriate incentives.

Discussion

PCTs provide a unique and potentially impactful opportunity to test interventions in real-world settings that must be culturally appropriate to reach underrepresented groups. Collectively, considering variables at multiple levels to address the needs of older adults with ADRDs is crucial, and the examples and suggestions provided in this report are a foundation for future research.

Efficacy of Liposomal Melatonin in sleep EEG in Childhood: A Double Blind Case Control Study

Electroencephalography (EEG) is pivotal in the clinical assessment of epilepsy, and sleep is known to improve the diagnostic yield of its recording. Sleep-EEG recording is generally reached by either partial deprivation or by administration of sleep-inducing agents, although it is still not achieved in a considerable percentage of patients. We conducted a double-blind placebo-controlled study, involving a hundred patients between 1 and 6 years old, randomized into two groups: Group 1 received liposomal melatonin (melatosome) whereas Group 2 received a placebo. Sleep latency (SL), defined as the time span between the onset of a well-established posterior dominant rhythm, considered as a frequency of 3 to 4 Hz, increasing to 4-5 Hz by the age of 6 months, to 5-7 Hz by 12 months, and finally to 8 Hz by 3 years, and the first EEG sleep figures detected, were measured for each patient. A significant difference in SL was observed (10.8 ± 5 vs. 18.1 ± 13.4 min, p-value = 0.002). Within each group, no differences in sleep latency were detected between genders. Furthermore, no difference in EEG abnormality detection was observed between the two groups. Our study confirmed the efficacy and safety of melatonin administration in sleep induction. Nonetheless, liposomal melatonin presents a greater bioavailability, ensuring a faster effect and allowing lower dosages. Such results, never before reported in the literature, suggest that the routine employment of melatonin might improve clinical practice in neurophysiology, reducing unsuccessful recordings.

FOCUSING ON DIVERSITY: UTMB RECRUITMENT STRATEGY FOR THE D-CARE STUDY

The University of Texas Medical Branch (UTMB) is the main healthcare system in Galveston County where about 15% of older adults identify as Hispanic. Our recruitment efforts for the Dementia (D-CARE) study included adapting and translating in Spanish the screening, recruitment, and intervention materials. The study is being conducted by a bilingual team, and actively engages a highly diverse Local Patient and Stakeholder Council. After obtaining a partial HIPAA waiver from the Institutional Review Board, we created a dementia registry in the UTMB Epic (TM) electronic health record which captured patients diagnosed with ICD-9/10 codes of dementia. Referral letters from UTMB primary care and neurology providers authorized us to contact eligible patients. We utilized outpatient clinic appointment schedules, direct referrals, and community outreach to meet our enrollment goal. This recruitment strategy resulted in inclusion of 478 patient-caregiver dyads with 27.4% of participants identifying as Hispanic and 17% as Black.

THE EFFECT OF SHORT DURATION BED REST AND TYPE 2 DIABETES MELLITUS ON ARTERIAL STRUCTURE AND FUNCTION IN OLDER ADULTS

Type 2 diabetes mellitus (T2DM) and inactivity individually accelerate changes related to vascular aging. These changes increase cardiovascular risk and contribute to morbidity and mortality in the elderly. It is unknown if T2DM and bed rest have an additive, deleterious effect on vascular structure and function in older adults. The objective of this study is to determine the magnitude of the effect of bed rest on vascular structure in older adults with T2DM compared to healthy controls and determine if resistance exercise is protective of this effect. So far, we have recruited T2DM (n=9) and healthy control (n=17) subjects (age: 67.0 ± 6.7 years) to undergo five days of bed rest. During bed rest, subjects were randomized to receive intensive bedside resistance exercise physical therapy or standard of care in-bed passive physical therapy. On bed rest days 1 and 5, popliteal artery diameter, area, blood velocity, and blood flow were measured using Doppler ultrasonography. Our preliminary data show that the T2DM, non-exercise group had significantly greater decreases in popliteal artery diameter (-0.59 mm ± 0.18) than the control, non-exercise group (-0.17 mm ± 0.11). Resistance exercise did not prevent artery size changes in either controls or T2DM. Resistance exercise showed a trend in preventing blood velocity and flow reduction in both T2DM and control groups. These preliminary data suggest that older adults with T2DM had greater structural popliteal artery changes compared to controls. Resistance exercise appears to help maintain blood flow by maintaining/increasing popliteal artery blood velocity, but not size.

Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life

BACKGROUND

Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk.

METHODS

We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL.

RESULTS

For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months.

CONCLUSIONS

Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects.

CLINICALTRIALS

gov identifier: NCT02475850.

Improvements in sleep quality and fatigue are associated with improvements in functional recovery following hospitalization in older adults

Study objectives

Poor sleep quality, a frequent problem in older adults, has been shown to be associated with reduced physical function and wellbeing. However, little is known about the relationship between sleep quality and the recovery of physical function following hospitalization. Thus, we conducted this study to examine the association between sleep quality and functional recovery after an acute hospitalization in community dwelling older adults.

Methods

Older adult patients (N = 23, mean age = 74 ± 9 years) were recruited during an acute hospitalization (average length of stay 3.9 days) with a cardiovascular (56%), pulmonary (22%), or metabolic (13%) admission diagnosis. Objective physical function was measured using the Short Physical Performance Battery (SPPB) and self-reported function was assessed with Katz Index of Independence in Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living Scale (IADL). Sleep quality was measured using Pittsburgh Sleep Quality Index (PSQI) global score and Iowa Fatigue Score (IFS). Testing was performed prior to discharge (baseline) and 4-weeks post-discharge (follow-up).

Results

Regression models showed PSQI Subjective Sleep Quality change scores from baseline to 4-week follow-up predicted a change in ADL (β = -0.22); PSQI Use of Sleep Medications change scores predicted a change in SPPB Total (β = 1.62) and SPPB Chair Stand (β = 0.63); IFS change scores predicted SPPB Total (β = -0.16) and SPPB Chair Stand performance (β = -0.07) change scores.

Conclusions

For older adults, changes in sleep medication use, daytime dysfunction, and fatigue were associated with improvements in functional recovery (including physical performance and independence) from acute hospitalization to 4-week follow-up. These results suggest that interventions focused on improving sleep quality, daytime consequences, and fatigue might help enhance physical functioning following hospitalization.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT02203656.

The Design and Rationale of a Phase 2b, Randomized, Double-Blinded, and Placebo-Controlled Trial to Evaluate the Safety and Efficacy of Lomecel-B in Older Adults with Frailty

BACKGROUND

Frailty in older adults is a rapidly growing unmet medical need. It is an aging-related syndrome characterized by physical decline leading to higher risk of adverse health outcomes.

OBJECTIVES

To evaluate the efficacy of Lomecel-B, an allogeneic medicinal signaling cell (MSC) formulation, in older adults with frailty.

DESIGN

This multicenter, randomized, parallel-arm, double-blinded, and placebo-controlled phase 2b trial is designed to evaluate dose-range effects of Lomecel-B for frailty on physical functioning, patient-reported outcomes (PROs), frailty status, and biomarkers.

SETTING

Eight enrolling clinical research centers, including the Miami Veterans Affairs Medical Center.

PARTICIPANTS

Target enrollment is 150 subjects aged 70-85 years of any race, ethnicity, or gender. Enrollment criteria include a Clinical Frailty Score of 5 ("mild") or 6 ("moderate"), a 6MWT of 200-400 m, and serum tumor necrosis factor-alpha (TNF-α) ≥2.5 pg/mL.

INTERVENTION

A single intravenous infusion of Lomecel-B (25, 50, 100, or 200 million cells) or placebo (N=30/arm). Patients are followed for 365 days for safety, and the efficacy assessments performed at 90, 180, and 270 days.

MEASUREMENTS

The primary endpoint is change in 6MWT in the Lomecel-B-treated arms versus placebo at 180 days post-infusion. Secondary and exploratory endpoints include change in: 6MWT and other physical function measures at all time points; PROs; frailty status; cognitive status; and an inflammatory biomarkers panel. A pre-specified sub-study examines vascular/endothelial biomarkers. Safety is evaluated throughout the trial.

RESULTS

The trial is conducted under a Food and Drug Administration Investigational New Drug (IND), with Institutional Review Board approval, and monitoring by an NIH-appointed independent Data Safety Monitoring Board.

CONCLUSION

This clinical trial investigates the use of a regenerative medicine strategy for frailty in older adults. The results will further the understanding of the potential for Lomecel-B in the geriatric condition of frailty.

A Photography-based, Social Media Walking Intervention Targeting Autonomous Motivations for Physical Activity: Semistructured Interviews With Older Women

BACKGROUND

Older adult women are at risk for negative health outcomes that engaging in sustained physical activity can help prevent. However, promoting long-term maintenance of physical activity in this population has proven to be a challenge. Increasing autonomous motivations (ie, intrinsic, integrated, and identified regulations) for physical activity may facilitate enduring behavior change. Digitally delivered games for health that take a celebratory technology approach, that is, using technology to create new ways to experience valued behaviors and express valued beliefs, may be a useful way to target autonomous motivations for physical activity. Formative research with the target population is needed to design compelling intervention content.

OBJECTIVE

The objective of this study is to investigate older adult women's reactions to and thoughts about a photography-based, social media walking game targeting autonomous motivations for physical activity.

METHODS

During an individual semistructured interview, a moderator solicited feedback from 20 older adult women (age range 65-74 years) as part of formative research to develop a social media game featuring weekly walking challenges. The challenges were designed to target autonomous motivations for physical activity. Interviews were audio-recorded and transcribed verbatim. Two reviewers conducted thematic content analysis on interview transcripts.

RESULTS

We identified 3 overarching themes in qualitative data analysis. These reflected the playful experiences, value, and acceptability associated with the intervention challenges. Generally, participants understood what the challenges were asking them to do, proffered appropriate example responses, and indicated that the challenges would be enjoyable. Participants reported that the intervention content afforded many and varied playful experiences (eg, competition, discovery, exploration, expression, fellowship, humor, nurture, sensation). Further, participants indicated that the intervention increased their motivation for physical activity, occasioned meaningful shifts in perspective, increased their knowledge of various topics of interest, provided an opportunity to create valued connection with others, and provided health-related benefits. Participants suggested the intervention emphasize local history, nature, and cultural events.

CONCLUSIONS

The photography-based, social media walking game with relatively simple game mechanics was well received and judged to be apt to bring about a wide variety of emotive experiences. A clear, geographically specific identity emerged as a key driver of interest for intervention content. Taking a celebratory technology approach holds promise for targeting autonomous motivations for physical activity in older adult women.

Biology of Activating Transcription Factor 4 (ATF4) and Its Role in Skeletal Muscle Atrophy

Activating transcription factor 4 (ATF4) is a multifunctional transcription regulatory protein in the basic leucine zipper superfamily. ATF4 can be expressed in most if not all mammalian cell types, and it can participate in a variety of cellular responses to specific environmental stresses, intracellular derangements, or growth factors. Because ATF4 is involved in a wide range of biological processes, its roles in human health and disease are not yet fully understood. Much of our current knowledge about ATF4 comes from investigations in cultured cell models, where ATF4 was originally characterized and where further investigations continue to provide new insights. ATF4 is also an increasingly prominent topic of in vivo investigations in fully differentiated mammalian cell types, where our current understanding of ATF4 is less complete. Here, we review some important high-level concepts and questions concerning the basic biology of ATF4. We then discuss current knowledge and emerging questions about the in vivo role of ATF4 in one fully differentiated cell type, mammalian skeletal muscle fibers.

Exercise Intolerance in Older Adults With Heart Failure With Preserved Ejection Fraction: JACC State-of-the-Art Review

Exercise intolerance (EI) is the primary manifestation of chronic heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure among older individuals. The recent recognition that HFpEF is likely a systemic, multiorgan disorder that shares characteristics with other common, difficult-to-treat, aging-related disorders suggests that novel insights may be gained from combining knowledge and concepts from aging and cardiovascular disease disciplines. This state-of-the-art review is based on the outcomes of a National Institute of Aging-sponsored working group meeting on aging and EI in HFpEF. We discuss aging-related and extracardiac contributors to EI in HFpEF and provide the rationale for a transdisciplinary, "gero-centric" approach to advance our understanding of EI in HFpEF and identify promising new therapeutic targets. We also provide a framework for prioritizing future research, including developing a uniform, comprehensive approach to phenotypic characterization of HFpEF, elucidating key geroscience targets for treatment, and conducting proof-of-concept trials to modify these targets.

Intranasal Oxytocin Improves Lean Muscle Mass and Lowers LDL Cholesterol in Older Adults with Sarcopenic Obesity: A Pilot Randomized Controlled Trial

OBJECTIVES

Obesity is associated with sarcopenia in older adults, and weight loss can lead to further muscle mass loss. Oxytocin decreases with age, and animal studies suggest that oxytocin administration has trophic effects on skeletal muscle cells and reduces adiposity. We conducted a clinical trial to examine the safety and preliminary efficacy of intranasal oxytocin for older adults with sarcopenic obesity.

DESIGN

A double-blind, placebo-controlled randomized controlled trial of intranasal oxytocin (24 IU 4 times per day) for 8 weeks.

SETTING AND PARTICIPANTS

Twenty-one older (67.5 ± 5.4 years), obese (30-43 kg/m2), sedentary (<2 strenuous exercise per week) adults with slow gait speed (<1 m/s, proxy measure of sarcopenia) were recruited.

MEASURES

Generalized estimating equations were used to evaluate the effect of oxytocin on safety/tolerability of oxytocin administration and whole body muscle and fat mass.

RESULTS

At baseline, body mass index (BMI) was 36.8 ± 3.6 kg/m2, fat mass 46.09 ± 6.99 kg, lean mass 50.98 ± 11.77 kg, fasting plasma glucose (FPG) 92.0 ± 8.9 mg/dL, hemoglobin A1c (HbA1c) 5.7% ± 0.4%, low density lipoprotein (LDL) 111.3 ± 41.5 mg/dL, high-density lipoprotein (HDL) 47.85 ± 10.96 mg/dL, and triglycerides 140.55 ± 83.50 mg/dL. Oxytocin administration was well tolerated without any significant adverse events. Oxytocin led to a significant increase of 2.25 kg in whole body lean mass compared with placebo (P < .01) with a trend toward decreasing fat mass, and a significantly reduced plasma LDL cholesterol by -19.3 mg/dL (P = .023) compared against placebo. There were no significant changes in BMI, appetite scores, glycemia, plasma HDL, triglycerides, or depressive symptoms.

CONCLUSIONS AND IMPLICATIONS

This proof-of-concept study indicates that oxytocin may be useful for the treatment of sarcopenic obesity in older adults. Oxytocin administration may also provide additional cardiovascular benefits.

Dietary Intake Patterns of Community-Dwelling Older Adults after Acute Hospitalization

BACKGROUND

Malnutrition and sarcopenia are a growing concern in community-dwelling older adults. Hospitalization increases the risk of malnutrition and leads to a decline in functional and nutritional status at discharge. Persistent malnutrition after hospital discharge may worsen post-hospital outcomes, including readmissions. The aim of this study was to determine dietary intakes and nutrient distribution patterns of community-dwelling older adults after acute hospitalization.

METHODS

Participants (≥65 yrs old, n=85) were enrolled during acute hospitalization and dietary 24-hour recalls were collected weekly for one month post-discharge. Analysis included: change in dietary intake over recovery timeframe; daily intake of energy, protein, fruit, vegetables, and fluids; comparison of intake to recommendations; distribution of energy and protein across mealtimes; and analysis of most common food choices.

RESULTS

Most participants did not meet current recommendations for energy, fruit, vegetables, or fluids. Average protein consumption was significantly higher than the current recommendation of 0.8g/kg/day; however only 55% of participants met this goal and less than 18% met the 1.2 g/kg/day proposed optimal protein intake for older adults. The protein distribution throughout the day was skewed and no one met the 0.4 g/meal protein recommendation at all meals.

CONCLUSIONS

Our findings indicate that community-dwelling older adults did not meet their nutritional needs during recovery after hospitalization. These data highlight the need for better nutritional evaluation and support of geriatric patients recovering from hospitalization.

Effect of the lysosomotropic agent chloroquine on mTORC1 activation and protein synthesis in human skeletal muscle

Background

Previous work in HEK-293 cells demonstrated the importance of amino acid-induced mTORC1 translocation to the lysosomal surface for stimulating mTORC1 kinase activity and protein synthesis. This study tested the conservation of this amino acid sensing mechanism in human skeletal muscle by treating subjects with chloroquine—a lysosomotropic agent that induces in vitro and in vivo lysosome dysfunction.

Methods

mTORC1 signaling and muscle protein synthesis (MPS) were determined in vivo in a randomized controlled trial of 14 subjects (10 M, 4 F; 26 ± 4 year) that ingested 10 g of essential amino acids (EAA) after receiving 750 mg of chloroquine (CHQ, n = 7) or serving as controls (CON, n = 7; no chloroquine). Additionally, differentiated C2C12 cells were used to assess mTORC1 signaling and myotube protein synthesis (MyPS) in the presence and absence of leucine and the lysosomotropic agent chloroquine.

Results

mTORC1, S6K1, 4E-BP1 and rpS6 phosphorylation increased in both CON and CHQ 1 h post EAA ingestion (P < 0.05). MPS increased similarly in both groups (CON, P = 0.06; CHQ, P < 0.05). In contrast, in C2C12 cells, 1 mM leucine increased mTORC1 and S6K1 phosphorylation (P < 0.05), which was inhibited by 2 mg/ml chloroquine. Chloroquine (2 mg/ml) was sufficient to disrupt mTORC1 signaling, and MyPS.

Conclusions

Chloroquine did not inhibit amino acid-induced activation of mTORC1 signaling and skeletal MPS in humans as it does in C2C12 muscle cells. Therefore, different in vivo experimental approaches are required for confirming the precise role of the lysosome and amino acid sensing in human skeletal muscle.

Trial registration NCT00891696. Registered 29 April 2009.

A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic

BACKGROUND

Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown.

METHODS

The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density.

RESULTS

Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology.

CONCLUSIONS

Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.

Global-scale massive feature extraction from monthly hydroclimatic time series: Statistical characterizations, spatial patterns and hydrological similarity

Hydroclimatic time series analysis focuses on a few feature types (e.g., autocorrelations, trends, extremes), which describe a small portion of the entire information content of the observations. Aiming to exploit a larger part of the available information and, thus, to deliver more reliable results (e.g., in hydroclimatic time series clustering contexts), here we approach hydroclimatic time series analysis differently, i.e., by performing massive feature extraction. In this respect, we develop a big data framework for hydroclimatic variable behaviour characterization. This framework relies on approximately 60 diverse features and is completely automatic (in the sense that it does not depend on the hydroclimatic process at hand). We apply the new framework to characterize mean monthly temperature, total monthly precipitation and mean monthly river flow. The applications are conducted at the global scale by exploiting 40-year-long time series originating from over 13 000 stations. We extract interpretable knowledge on seasonality, trends, autocorrelation, long-range dependence and entropy, and on feature types that are met less frequently. We further compare the examined hydroclimatic variable types in terms of this knowledge and, identify patterns related to the spatial variability of the features. For this latter purpose, we also propose and exploit a hydroclimatic time series clustering methodology. This new methodology is based on Breiman's random forests. The descriptive and exploratory insights gained by the global-scale applications prove the usefulness of the adopted feature compilation in hydroclimatic contexts. Moreover, the spatially coherent patterns characterizing the clusters delivered by the new methodology build confidence in its future exploitation. Given this spatial coherence and the scale-independent nature of the delivered feature values (which makes them particularly useful in forecasting and simulation contexts), we believe that this methodology could also be beneficial within regionalization frameworks, in which knowledge on hydrological similarity is exploited in technical and operative terms.

Intranasal Oxytocin Improves Lean Muscle Mass in Older Adults With Sarcopenic Obesity: A Pilot Study

Obese older adults often have sarcopenia with increased functional impairments. Unfortunately, conventional weight loss treatments can lead to further muscle mass loss. Increasing evidence from animal studies suggests that the pituitary hormone oxytocin has trophic effects on skeletal muscle cells and can induce weight loss. We piloted a clinical trial testing whether intranasal oxytocin would decrease adiposity without lowering muscle mass in older adults with sarcopenic obesity. Twenty-one older (≥60years), obese (30-43kg/m2), sedentary (<2 strenuous exercises/week) adults with slow gait speed (<1m/sec) were randomized to intra-nasal oxytocin (24IU four times/day) or placebo for 8 weeks. Pre and post body mass index (BMI), 2-hour oral glucose tolerance test (OGTT), hemoglobin A1c (HbA1c), short physical performance battery (SPPB), and whole body lean and fat mass (via dual-energy X-ray absorptiometry) were assessed. Generalized estimation equation method was used to evaluate effects of oxytocin on these continuous measures. At baseline, results were: age 67.5±5.4years, 71% female, BMI 36.0±3.6kg/m2, HbA1c 5.7±0.4%, 2-hr OGTT glucose 140.8±4.1mg/dL, SPPB 9.2±1.9, fat mass 45,429±7,037g, and lean mass was 49,892±10,470g. From baseline to follow-up, total lean mass increased significantly (2,250g) in the oxytocin group (pre- vs. post-treatment difference of -690g in placebo and +1,559g in oxytocin, p<0.01). Oxytocin did not lead to significant changes in other measures. This data suggests that oxytocin leads to significant improvement in whole body lean mass. Future studies in a larger study population will help determine whether older adults with sarcopenic obesity may benefit from intranasal oxytocin to improve lean muscle mass and physical function.

Type 2 Diabetes Reduces the Muscle Anabolic Effect of Resistance Exercise Training in Older Adults

Type 2 Diabetes Mellitus (T2DM) accelerates the incidence and increases the prevalence of sarcopenia in older adults. This suggests an urgent need for identifying effective sarcopenia treatments for older adults with T2DM. It is unknown whether traditional approaches, such as progressive resistance exercise training (PRET), can effectively counteract sarcopenia in older patients with T2DM. To test the efficacy of PRET for the treatment of sarcopenia in older adults with T2DM, 30 subjects (15 T2DM and 15 age- and sex- matched controls) underwent metabolic testing with muscle biopsies before and after a 13-week full-body PRET program. Primary outcome measures included changes in appendicular lean mass, muscle strength, and mixed muscle fractional synthesis rate (FSR). Before PRET, BMI-adjusted appendicular lean mass was significantly lower in the T2DM group (0.7095±0.0381 versus 0.8151±0.0439, p<0.0001). As a result of PRET, appendicular lean mass adjusted for BMI and muscle strength increased significantly in both groups, but to a lesser extent for the T2DM group (p=0.0009) . Preliminary results for FSR (n=25) indicate that subjects with T2DM had lower basal FSR prior to PRET (p=0.0197) . Basal FSR increased significantly in the control group after PRET (p=0.0196), while it did not change in the T2DM group (p=0.3537). These results suggest that in older adults the positive effect of PRET on muscle anabolism and strength is reduced by T2DM . Thus, older adults with T2DM may require more intensive, multimodal and targeted sarcopenia treatment. Funded by NIH R01AG049611 and P30AG024832.

1-Year Rehospitalization and Mortality Rates in Geriatric Patients after Acute Hospitalization

Hospitalization for an acute illness often leads to accelerated sarcopenia, debility, and loss of independence in geriatric patients. These post-hospitalization effects can further deteriorate health and lead to rehospitalizations and sometimes death. To improve health outcomes in these patients, it is important to determine predictive factors for increased readmission and mortality rates. Data regarding readmission and mortality within 1 year post-discharge were collected from the PACE and GRAMS studies (NCT02203656, NCT02990533) conducted at UTMB Galveston (Jan 2014 - Mar 2019). Readmission and mortality rates were analyzed to find associations with total days hospitalized and total number of readmissions within 1 year, demographics (age, highest education level, BMI, percent fat, baseline SPPB score), and interventions (exercise with protein supplementation, exercise with placebo, protein supplementation, placebo supplementation, and testosterone injection). Of the 175 subjects, 63.4% were rehospitalized and 9.7% died within 1 year. We found that patients who were rehospitalized within a year of their initial hospitalization were over 4 times more likely to die that year than patients who were not rehospitalized. Patients who died within one year had twice the amount of hospitalization within the year and spent three times the number of days hospitalized. Of the interventions studied, a single testosterone injection at discharge from the index admission appeared the most effective to reduce rehospitalizations.