Racial Differences in Burdensome Transitions in Heart Failure Patients with Palliative Care: A Propensity-Matched Analysis

Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. Participants: This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. Methods: We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Results: Propensity matching of our cohort (n = 5638) yielded 796 Black and White Veterans (total n = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans (n = 218, 27.4% vs. n = 174, 21.9%; p = 0.011) over the six-month follow-up period. Conclusions: This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.

869 Colorectal Cancer Referral Pathways: Impact of First Months of COVID-19

Introduction

Whilst daily living has adapted to the “new normal” during Covid-19, colorectal cancer pathways are yet to be revised to reflect this transformation. Government advice to stay at home, hospital avoidance and reduced healthcare access, may be masking a significant proportion of population at risk. We aim to identify changes in colorectal cancer target pathways.

Method

All cancer referrals during the initial Covid-19 period were retrospectively analysed, recording type and date of first clinic and investigation, MDT discussion and decision to treat dates. A comparison was made with referral and treatment data from the same referral period in 2019.

Results

338 referrals were received during March-April 2020, compared to 542 in 2019, indicating a 37.6% decrease. A high proportion of patients were reviewed by telephone clinic (63.4%) rather than face-to-face (23.8%), representing a significant shift in practice. An increasing number of patients were initially investigated by CT(40.2%) instead of endoscopy (37.8%). 51(15.5%) patients were not investigated, with COVID-19 being the commonest reason. 25 patients were diagnosed with colorectal cancer, of which 8(32.0%) breached the investigation and 13(52.0%) the treatment date, both usually postponed due to the pandemic. There was a 66.7% reduction in surgical management compared to 2019.

Conclusions

Two-week wait pathways are strained in the era of Covid-19. As the fight against the global pandemic continues, patients are mostly seen virtually and receive non-gold standard investigation. With fewer patient presentations and elective surgeries, it is important to continue colorectal cancer surveillance and timely treatment, considering possible alternative pathways.

Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members

BACKGROUND

Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low.

OBJECTIVES

We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity.

METHODS

Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models.

RESULTS

Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT).

CONCLUSIONS

HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Participation, retention and uptake in a multicentre pre-exposure prophylaxis cohort using online, smartphone-compatible data collection

Objectives

The aim of the study was to assess the feasibility of a national pre‐exposure prophylaxis (PrEP) programme using smartphone‐compatible data collection.

Methods

This was a multicentre cohort study (NCT03893188) enrolling individuals interested in PrEP in Switzerland. All centres participate in the SwissPrEPared programme, which uses smartphone‐compatible data collection. Feasibility was assessed after centres had enrolled at least one participant. Participants were HIV‐negative individuals presenting for PrEP counselling. Outcomes were participation (number enrolled/number eligible), enrolment rates (number enrolled per month), retention at first follow‐up (number with first follow‐up/number enrolled), and uptake (proportion attending first visit as scheduled). Participant characteristics were compared between those retained after baseline assessment and those who dropped out.

Results

Between April 2019 and January 2020, 987 individuals were assessed for eligibility, of whom 969 were enrolled (participation: 98.2%). The median enrolment rate was 86 per month [interquartile range (IQR) 52–137]. Retention at first follow‐up and uptake were both 80.7% (782/969 and 532/659, respectively). At enrolment, the median age was 40 (IQR 33–47) years, 95% were men who have sex with men, 47% had a university degree, and 75.5% were already taking PrEP. Most reported multiple casual partners (89.2%), previous sexually transmitted infections (74%) and sexualized drug use (73.1%). At baseline, 25.5% tested positive for either syphilis, gonorrhoea or chlamydia. Participants who dropped out were at lower risk of HIV infection than those retained after baseline assessment.

Conclusions

In a national PrEP programme using smartphone‐compatible data collection, participation, retention and uptake were high. Participants retained after baseline assessment were at considerable risk of HIV infection. Younger, less educated individuals were underrepresented in the SwissPrEPared cohort.

Integration of functional imaging in brachytherapy

Functional imaging allows the evaluation of numerous biological properties that could be considered at all steps of the therapeutic management of patients treated with brachytherapy. Indeed, it enables better initial staging of the disease, and some parameters may also be used as predictive biomarkers for treatment response, allowing better selection of patients eligible for brachytherapy. It may also improve the definition of target volumes with the aim of dose escalations by dose-painting. Finally, it could be useful during the follow-up to assess response to treatment. In this review, we report how functional imaging is integrated at the present time during the brachytherapy procedure, and what are its potential future contributions in the main tumour locations where brachytherapy is recommended. Functional imaging has great potential in the contact of brachytherapy, but still, several issues remain to be resolved before integrating it into clinical practice, especially as a biomarker or in dose painting strategies.

National Health Service interventions in England to improve care to Armed Forces veterans

Armed Forces veterans (AFVs) are first and foremost citizens of the UK and are therefore—like all UK residents—entitled to universal healthcare, free at the point of need. This means that AFVs have nearly all their healthcare needs met by the NHS, which provides access to a full range of generic services. However, since 2013 there has been an Armed Forces team that can also support veterans. This review is an assessment of the work of this group over the last eight years. The health needs of AFVs have been investigated and are not significantly different from those of their demographically matched peers. However, due to their demographics, selection at recruitment and their roles, AFVs compared with the general population are more likely to be male, white and old and have fewer pre-existing or hereditary conditions. However, they do suffer from higher rates of musculoskeletal injury, different patterns of mental health illness and have historically been higher users—and abusers—of alcohol and tobacco. In addition to supporting mainstream services used by AFVs, the NHS in England commissions a bespoke range-specific ‘Priority’ NHS services such as those for mental health or for rehabilitation of veterans using prostheses. New interventions are continuing to be developed to improve AFVs’ healthcare and are aligned to the NHS Long Term Plan and the restoration and recovery plans after the COVID-19 pandemic.

Multi O- and S-isotopes as tracers of black crusts formation under volcanic and non-volcanic atmospheric conditions in Sicily (Italy)

The deterioration of monument or building stone materials is mostly due to the growth of black crusts that cause blackening and disaggregation of the exposed surface. This study reports on new oxygen (δ¹⁷O, δ¹⁸O and Δ¹⁷O) and sulphur (δ³³S, δ³⁴S, δ³⁶S, Δ³³S and Δ³⁶S) isotopic analyses of black crust sulphates formed on building stones in Sicily (Southern Italy). The measurements are used to identify the possible influence of volcanic emissions on black crust formation. Black crusts were mostly sampled on carbonate stone substrate in different locations subject to various sulphur emission sources (marine, anthropogenic and volcanic). Unlike atmospheric sulphate aerosols that mostly exhibit Δ³³S > 0‰, here most of the analysed black crust sulphates show negative Δ³³S. This confirms that black crust sulphates do not result from deposition of sulphate aerosols or of rainwater but mostly from the oxidation of dry deposited SO₂ onto the stone substrate. The δ³⁴S and δ¹⁸O values indicate that most of black crust sulphate originates from anthropogenic activities. Δ¹⁷O values are found to be related to the sampling location. The largest ¹⁷O-anomalies (up to ~4‰) are measured in black crust from areas highly influenced by volcanic emissions, which demonstrates the strong involvement of ozone in the formation of black crusts in volcanically influenced environments.

Eating Timing: Associations with Dietary Intake and Metabolic Health

BACKGROUND

Emerging research indicates that eating timing may influence dietary intake and metabolic health. However, studies to date have not examined the association of multiple measures of eating timing with both dietary intake and metabolic health in adults with overweight and obesity.

OBJECTIVE

To examine the association of multiple measures of eating timing with dietary intake (ie, dietary composition, diet quality, and eating frequency) and metabolic health (ie, body composition and cardiometabolic risk).

DESIGN

This is a cross-sectional analysis of baseline data from a weight loss and maintenance intervention collected from May 2015 to January 2018.

PARTICIPANTS/SETTING

Participants were women with overweight or obesity who were dependents of active duty and retired military personnel (N = 229; mean ± standard error, BMI = 34.7 ± 0.4 kg/m², age = 40.9 ± 0.7 years). The study was conducted at military installations in Massachusetts, Connecticut, New York, Colorado, and Kentucky.

MAIN OUTCOME MEASURES

Eating timing variables examined included daily eating interval (time between first and last eating occasion), time-restricted eating (≤11 hours daily eating interval), early energy eaters (eating ≥60% of energy during the first half of time awake), and bedtime eaters (eating within 2 hours of bedtime).

STATISTICAL ANALYSIS

The main analysis was limited to those reporting plausible energy intake (64% of total sample [n = 146]). Linear, quantile, or logistic regression models were used to determine the association of eating timing with measures of dietary intake and metabolic health.

RESULTS

In individuals reporting plausible energy intake, each additional 1 hour in daily eating interval was associated with 53 kcal higher energy intake, higher glycemic load, eating frequency, and waist circumference (P < 0.05 for all). Significant associations were observed for: time-restricted eating and a lower energy intake, glycemic load, and eating frequency; early energy eating and higher carbohydrate intake; bedtime eating and a higher energy intake, glycemic load, and eating frequency.

CONCLUSIONS

These findings lend support for the mechanistic targeting of eating timing in behavioral interventions aimed at improving dietary intake and body composition.

Visual word form processing deficits driven by severity of reading impairments in children with developmental dyslexia

The visual word form area (VWFA) in the left ventral occipito-temporal (vOT) cortex is key to fluent reading in children and adults. Diminished VWFA activation during print processing tasks is a common finding in subjects with severe reading problems. Here, we report fMRI data from a multicentre study with 140 children in primary school (7.9-12.2 years; 55 children with dyslexia, 73 typical readers, 12 intermediate readers). All performed a semantic task on visually presented words and a matched control task on symbol strings. With this large group of children, including the entire spectrum from severely impaired to highly fluent readers, we aimed to clarify the association of reading fluency and left vOT activation during visual word processing. The results of this study confirm reduced word-sensitive activation within the left vOT in children with dyslexia. Interestingly, the association of reading skills and left vOT activation was especially strong and spatially extended in children with dyslexia. Thus, deficits in basic visual word form processing increase with the severity of reading disability but seem only weakly associated with fluency within the typical reading range suggesting a linear dependence of reading scores with VFWA activation only in the poorest readers.

Immune checkpoint inhibitors versus second line chemotherapy for patients with lung cancer refractory to first line chemotherapy

PURPOSE

Anti Programmed Death-ligand (PD1/PD-L1) directed immune-checkpoint-inhibitors (ICI) are widely used to treat patients with advanced non-small cell lung cancer (NSCLC) who progress after first line chemotherapy. The best strategy after early progression under first line has not been specifically studied.

PATIENTS AND METHODS

We conducted a multicenter, retrospective study including all consecutive NSCLC patients progressing within the first 3 months following introduction of first-line chemotherapy and being treated with second line ICI monotherapy or chemotherapy between March 2010 and November 2017. We analysed the clinicopathological data and outcome under second line chemotherapy vs. second line ICI: objective response rate (ORR), progression-free survival (PFS), overall survival (OS.

RESULTS

We identified 176 patients with refractory disease, 99 who received subsequent immunotherapy and 77 undergoing chemotherapy. The 2 populations were comparable regarding the main prognostic criteria, median age was 60, main histology was adenocarcimoma (68.2%). PFS was not significantly different between both treatments 1.9 [1.8-2.1] versus 1.6 month [1.4-2.0] (P=0.125). Compared to chemotherapy, ICI treated patients had a superior OS (P=0.03) (Median [95% CI] OS 4.6 [2.8-6.7] versus 4.2 months [3.4-5.9] and a non-significant improvement in ORR (17.2% versus 7.9%, respectively, P=0.072). Poor performance status (ECOG PS≥2) and a higher number of metastatic sites (≥3) were associated with poorer prognosis. KRAS-mutated patients did not seem to benefit more from ICI than chemotherapy.

CONCLUSIONS

ICI appears to be the preferred second-line treatment for patients who are refractory to first line chemotherapy.