Change in Lumbar Muscle Size and Composition on MRI with Long-Duration Spaceflight

Prolonged microgravity results in muscle atrophy, especially among the anti-gravity spinal muscles. How individual paravertebral muscle groups change in size and composition with spaceflight needs further exploration. This study investigates lumbar spine musculature changes among six crewmembers on long-duration space missions using non-invasive measurement of muscle changes with magnetic resonance imaging (MRI). Pre- and post-flight lumbar images were analyzed for changes in cross-sectional area, volume, and fat infiltration of the psoas (PS), quadratus lumborum (QL), and paraspinal [erector spinae and multifidus (ES + MF)] muscles using mixed models. Crewmembers used onboard exercise equipment, including a cycle ergometer (CEVIS), treadmill (T2/COLBERT), and the advanced resistive exercise device (ARED). Correlations were used to assess muscle changes related to exercise modality. There was substantial variability in muscle changes across crewmembers but collectively a significant decrease in paraspinal area (- 9.0 ± 4.8%, p = 0.04) and a significant increase in QL fat infiltration (7.3 ± 4.1%, p = 0.05). More CEVIS time may have protected against PS volume loss (p = 0.05) and PS fat infiltration (p < 0.01), and more ARED usage may have protected against ES + MF volume loss (p = 0.05). Crewmembers using modern onboard exercise equipment may be less susceptible to muscle changes. However, variability between crewmembers and muscle size and quality losses suggest additional research is needed to ensure in-flight countermeasures preserve muscle health.

Association between an electronic health record (EHR)–embedded frailty index and survival among older adults receiving cancer chemotherapy

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Background: Innovative strategies to facilitate rapid frailty screening are critically needed to enhance personalized oncology care among vulnerable older patients. An electronic frailty index (eFI) holds promise as a passive measure of frailty. The eFI was initially designed for primary care. The objective of this study was to establish feasibility, estimate prevalence of frailty, and evaluate the predictive value of the eFI for overall survival (OS) among older adults with cancer planned to receive chemotherapy. Methods: Consecutive patients (N = 509) aged 65+ with newly diagnosed lung, colorectal or breast cancer treated with chemotherapy were identified from our cancer registry between 2017 and 2020. Calculation of the eFI requires at least two ambulatory visits over a 2-year period and utilizes demographic information, vital signs, smoking status, ICD-10 diagnosis codes, select outpatient laboratory measurements, and functional information (if available from Medicare Annual Wellness Visits) during the 2 years prior to diagnosis. Frailty status is categorized as fit (eFI ≤0.10), pre-frail (0.10 < eFI≤0.21), and frail (eFI > 0.21) based on the proportion of deficits present over the total number evaluated (score range 0-1). Non-calculable scores indicate insufficient historical primary care data within two years prior to cancer diagnosis. OS was estimated by eFI category using Kaplan Meier curves and compared using log rank testing. Cox proportional hazards models evaluated the adjusted association between eFI categories and mortality. Results: The cohort included 509 adults (median age 72.2 yrs, 55% female, 83.5% white, 13.4% black, 45.8% stage 4) with lung (N = 312), colorectal (N = 111) and breast (N = 86) cancer. Distribution of eFI categories at diagnosis were fit (25.9%), pre-frail (41.1%), frail (17.3 %) and not calculable (15.7%). The proportion of patients categorized as “fit” differed by disease type (19.9% lung, 30.6% colorectal, 41.9% breast, p < 0.0001). In univariate analyses, eFI frailty category was associated with OS (median OS for fit, pre-frail, frail and not calculable were > 54, 25, 19 and 10 months respectively, p < 0.0001.). Adjusting for age, gender, race, stage, and cancer type, the hazard of death was higher for pre-frail (Hazard Ratio, [HR] 1.7, 95% Confidence Interval [CI] 1.2-2.4), frail (HR 2.3, 95% CI 1.5-3.4) and not calculable eFI categories (HR 2.8, 95% CI 1.8-4.2) compared to fit patients. Conclusions: Calculating an EHR embedded eFI at the time of diagnosis among older adults treated with chemotherapy was feasible and identified nearly one-fifth of patients as frail. eFI-defined frailty status was associated with survival, with poorer survival among the most frail supporting eFI validity. The eFI is a promising scalable tool to efficiently conduct frailty screening in oncology clinical practice.

Organ Weights in Relation to Age and Sex in Cynomolgus Monkeys (Macaca fascicularis)

Laboratory animal research is an important contributor to both human and animal medicine. Currently, there is extensive use of cynomolgus monkeys (Macaca fascicularis) in pathology and toxicology research. The purpose of this study was to define reference values for absolute and percentage organ weights in M fascicularis of different ages and sex. Organ weights were obtained from necropsies of 1022 cynomolgus monkeys at the Wake Forest School of Medicine from 1997 to 2018. Distributions of absolute and percentage weights for each organ were described; sex and age groups were compared using analysis of variance. Age effects on percentage of body weights for each organ were analyzed within each sex. Diet effects were also analyzed. This evaluation showed that male body weights and absolute organ weights were greater for all age groups; however, female organ to body weight percentages were greater for most organs. Percentage of organ weight to body weight declined for the adrenals, brain, lung, thyroid and thymus during maturation, whereas percentage weight of pancreas, prostate, testes, and uterus increased. Animals consuming a high-fat, Western-type diet had a lower body weight than animals consuming a carbohydrate-rich chow diet. This information will be useful for further toxicology and pathology studies concerning cynomolgus monkeys.

Feasibility and Acceptability of a Multi-Modality Self-Management Intervention for Head and Neck Cancer Caregivers: A Pilot Randomized Trial

BACKGROUND

Head and neck cancer (HNC) patients undergoing radiation therapy (RT) experience significant side effects, presenting challenging care tasks for their informal (unpaid) caregivers. HNC caregivers report low caregiving self-efficacy, high distress, and interest in supportive care interventions.

OBJECTIVE

This randomized pilot trial assessed the feasibility and acceptability of a 6 to 7 week supported self-management intervention (Prepare to Care) offering psychoeducation and stress management skills building for caregivers of patients receiving RT for HNC.

METHODS

Caregivers were randomized to Prepare to Care or standard of care. Primary feasibility measures included participation and retention percentages. Assessments were completed before the intervention, at intervention completion, and 6-weeks later after intervention completion.

RESULTS

Caregivers (N = 38) were predominantly female (88.6%), an average age of 56 years old, and a spouse/partner to the patient (71.4%). Participation percent was 42.2%; retention at intervention conclusion was 80% and 77% at the 6-week follow-up. Quantitative and qualitative results support acceptability, with 64% to 88% reporting each intervention module was helpful (quite a bit or very). Intervention caregivers reported a significantly greater improvement in self-efficacy for progressive muscle relaxation (PMR).

CONCLUSIONS

Prepare to Care and the randomized pilot trial methods are feasible and acceptable for HNC caregivers of patients receiving RT. A significant treatment effect was observed for self-efficacy for PMR, and findings were in the expected direction regarding improved caregiving self-efficacy. Further research is necessary to determine the efficacy of this intervention with a focus on increased engagement strategies and longer-term outcomes.

TRIAL REGISTRATION

NCT03032250.

Eutectic Mixture of Lidocaine and Prilocaine Decreases Movement and Propofol Requirements for Pediatric Lumbar Puncture During Deep Sedation: A Randomized, Placebo-Controlled, Double Blind Trial

Deep sedation/general anesthesia is commonly used in pediatric oncology patients undergoing lumbar puncture (LP). Propofol is often used for sedation, with or without a narcotic. We hypothesized that eutectic mixture of lidocaine and prilocaine (EMLA) would allow for lower cumulative doses of propofol and less movement. We performed a prospective, randomized, double blind, placebo-controlled trial in children undergoing sedation for LP. Standard initial weight-based doses of propofol and fentanyl were administered, with either EMLA cream or a placebo cream applied topically. The primary outcome was the total dose of propofol administered to each patient. We also tracked patient movement and complications. Twenty-seven patients underwent 152 LPs. Patients randomized to EMLA cream (n=75) were significantly more likely to receive a lower dose of propofol (2.94 mg/kg, SE=0.25, vs. 3.22 mg/kg, SE=0.19; P=0.036) and to not require additional propofol doses (probability 0.49, SE=0.08 vs. 0.69, SE=0.06; P=0.001) compared with patients randomized to placebo cream (n=77). In addition, patients with EMLA cream were significantly less likely to demonstrate minor or major movement. EMLA cream results in less movement and less propofol administration in pediatric oncology patients undergoing sedation for LP.

A Randomized Controlled Pilot Study of Yoga Skills Training Versus an Attention Control Delivered During Chemotherapy Administration

CONTEXT

It is important to address fatigue and co-occurring symptoms during chemotherapy to preserve quality of life in patients with gastrointestinal (GI) cancer.

OBJECTIVE

To conduct a randomized controlled pilot study of a Yoga Skills Training (YST) intervention compared to an attention control (AC) among adults diagnosed with GI cancer.

METHODS

YST consisted of four 30-minute sessions delivered individually during chemotherapy plus home practice. AC provided empathic attention plus home diaries. Patient-reported (PROMIS T-score) assessments of fatigue, depressive symptoms, sleep disturbances, and psychological stress (Perceived Stress Scale) were collected at chemotherapy visits: baseline, Week 8, Week 10 and Week 14, and analyzed using a mixed effects model. Inflammatory cytokines were assessed at baseline and Week 10.

RESULTS

Forty-four of 77 adults approached agreed to participate (57%; YST n = 23; AC n = 21). Participants' mean age was 58 years and 48% were men. Participants randomized to YST reported a larger decline in fatigue (-2.4 difference, d = 0.30) and depressive symptoms (-2.5 difference, d = 0.30) than AC participants from baseline to Week 10 and sleep disturbances at Week 8 (-3.9 difference, d = 0.50). Differences in magnitude of change in symptoms were consistent with or exceeded a minimally important difference. Psychological stress decreased more in the AC at Week 10 (d = 0.30). Reductions in inflammatory cytokines (IL-6, sTNF R1) were larger in the YST group than AC.

CONCLUSION

YST showed promise for improving fatigue, depressive symptoms, sleep disturbances, and inflammation. YST is also feasible and reaches patients underrepresented in yoga research (i.e., GI cancer, men), thus warranting further examination.

The Total Nutrient Index is a Useful Measure for Assessing Total Micronutrient Exposures Among US Adults

BACKGROUND

Most dietary indices reflect foods and beverages and do not include exposures from dietary supplements (DS) that provide substantial amounts of micronutrients. A nutrient-based approach that captures total intake inclusive of DS can strengthen exposure assessment.

OBJECTIVES

We examined the construct and criterion validity of the Total Nutrient Index (TNI) among US adults (≥19 years; nonpregnant or lactating).

METHODS

The TNI includes 8 underconsumed micronutrients identified by the Dietary Guidelines for Americans: calcium; magnesium; potassium; choline; and vitamins A, C, D, and E. The TNI is expressed as a percentage of the RDA or Adequate Intake to compute micronutrient component scores; the mean of the component scores yields the TNI score, ranging from 0-100. Data from exemplary menus and the 2003-2006 (≥19 years; n = 8861) and 2011-2014 NHANES (≥19 years; n = 9954) were employed. Exemplary menus were used to determine whether the TNI yielded high scores from dietary sources (women, 31-50 years; men ≥ 70 years). TNI scores were correlated with Healthy Eating Index (HEI) 2015 overall and component scores for dairy, fruits, and vegetables; TNI component scores for vitamins A, C, D, and E were correlated with respective biomarker data. TNI scores were compared between groups with known differences in nutrient intake based on the literature.

RESULTS

The TNI yielded high scores on exemplary menus (84.8-93.3/100) and was moderately correlated (r = 0.48) with the HEI-2015. Mean TNI scores were significantly different for DS users (83.5) compared with nonusers (67.1); nonsmokers (76.8) compared with smokers (70.3); and those living with food security (76.6) compared with food insecurity (69.1). Correlations of TNI vitamin component scores with available biomarkers ranged from 0.12 (α-tocopherol) to 0.36 (serum 25-hydroxyvitamin D), and were significantly higher than correlations obtained from the diet alone.

CONCLUSIONS

The evaluation of validity supports that the TNI is a useful construct to assess total micronutrient exposures of underconsumed micronutrients among US adults.

Effect of Dietary Protein Intake on Bone Mineral Density and Fracture Incidence in Older Adults in the Health, Aging, and Body Composition Study

BACKGROUND

Dietary recommendations may underestimate the protein older adults need for optimal bone health. This study sought to determine associations of protein intake with bone mineral density (BMD) and fracture among community-dwelling White and Black older adults.

METHOD

Protein as a percentage of total energy intake (TEI) was assessed with a Food Frequency Questionnaire in 2160 older adults (73.5 ± 2.8 years; 51.5% women; 35.8% Black) in the Health, Aging, and Body Composition prospective cohort. Hip, femoral neck, and whole body BMD was assessed by dual-energy x-ray absorptiometry at baseline and 4 years, and lumbar trabecular, cortical, and integral BMD was assessed by computed tomography at baseline and 5 years. Fragility fractures over 5 years were adjudicated from self-report data collected every 6 months. Associations with tertiles of protein intake were assessed using analysis of covariance for BMD and multivariate Cox regression for fracture, adjusting for confounders.

RESULTS

Participants in the upper protein tertile (≥15% TEI) had 1.8%-6.0% higher mean hip and lumbar spine BMD compared to the lower protein tertile (<13% TEI; p < .05). Protein intake did not affect change in BMD at any site over the follow-up period. Participants in the upper protein tertile had a reduced risk of clinical vertebral fracture over 5 years of follow-up (hazard ratio: 0.36 [95% confidence interval: 0.14, 0.97] vs lower protein tertile, p = .04).

CONCLUSIONS

Older adults with higher protein intake (≥15% TEI) had higher BMD at the hip, whole body, and lumbar spine, and a lower risk of vertebral fracture.

Predicting Future Mobility Limitation in Older Adults: A Machine Learning Analysis of Health ABC Study Data

BACKGROUND

Mobility limitation in older adults is common and associated with poor health outcomes and loss of independence. Identification of at-risk individuals remains challenging because of time-consuming clinical assessments and limitations of statistical models for dynamic outcomes over time. Therefore, we aimed to develop machine learning models for predicting future mobility limitation in older adults using repeated measures data.

METHODS

We used annual assessments over nine years of follow-up from the Health, Aging, and Body Composition study to model mobility limitation, defined as self-report of any difficulty walking a quarter mile or climbing 10 steps. We considered 46 predictors, including demographics, lifestyle, chronic conditions and physical function. With a split sample approach, we developed mixed models (generalized linear and Binary Mixed Model forest) using: 1) all 46 predictors, 2) a variable selection algorithm, and 3) the top five most important predictors. Age was included in all models. Performance was evaluated using area under the receiver operating curve (AUC) in two internal validation datasets.

RESULTS

AUC ranged from 0.80-0.84 for the models. The most important predictors of mobility limitation were ease of getting up from a chair, gait speed, self-reported health status, body mass index and depression.

CONCLUSIONS

Machine learning models using repeated measures had good performance for identifying older adults at-risk of developing mobility limitation. Future studies should evaluate the utility and efficiency of the prediction models as a tool in clinical settings for identifying at-risk older adults who may benefit from interventions aimed to prevent or delay mobility limitation.

A narrative review of nutrient based indexes to assess diet quality and the proposed total nutrient index that reflects total dietary exposures

A priori dietary indices provide a standardized, reproducible way to evaluate adherence to dietary recommendations across different populations. Existing nutrient-based indices were developed to reflect food/beverage intake; however, given the high prevalence of dietary supplement (DS) use and its potentially large contribution to nutrient intakes for those that use them, exposure classification without accounting for DS is incomplete. The purpose of this article is to review existing nutrient-based indices and describe the development of the Total Nutrient Index (TNI), an index developed to capture usual intakes from all sources of under-consumed micronutrients among the U.S. population. The TNI assesses U.S. adults' total nutrient intakes relative to recommended nutrient standards for eight under-consumed micronutrients identified by the Dietary Guidelines for Americans: calcium, magnesium, potassium, choline, and vitamins A, C, D, E. The TNI is scored from 0 to 100 (truncated at 100). The mean TNI score of U.S. adults (≥19 y; n = 9,954) based on dietary data from NHANES 2011-2014, was 75.4; the mean score for the index ignoring DS contributions was only 69.0 (t-test; p < 0.001). The TNI extends existing measures of diet quality by including nutrient intakes from all sources and was developed for research, monitoring, and policy purposes.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2021.1967872.

Association of food insecurity with dietary intakes and nutritional biomarkers among US children, National Health and Nutrition Examination Survey (NHANES) 2011-2016

BACKGROUND

Food insecurity is associated with poorer nutrient intakes from food sources and lower dietary supplement use. However, its association with total usual nutrient intakes, inclusive of dietary supplements, and biomarkers of nutritional status among US children remains unknown.

OBJECTIVE

The objective was to assess total usual nutrient intakes, Healthy Eating Index-2015 (HEI-2015) scores, and nutritional biomarkers by food security status, sex, and age among US children.

METHODS

Cross-sectional data from 9147 children aged 1-18 y from the 2011-2016 NHANES were analyzed. Usual energy and total nutrient intakes and HEI-2015 scores were estimated using the National Cancer Institute method from 24-h dietary recalls.

RESULTS

Overall diet quality was poor, and intakes of sodium, added sugars, and saturated fat were higher than recommended limits, regardless of food security status. Food-insecure girls and boys were at higher risk of inadequate intakes for vitamin D and magnesium, and girls also had higher risk for inadequate calcium intakes compared with their food-secure counterparts, when total intakes were examined. Choline intakes of food-insecure children were less likely to meet the adequate intake than those of their food-secure peers. No differences by food security status were noted for folate, vitamin C, iron, zinc, potassium, and sodium intakes. Food-insecure adolescent girls aged 14-18 y were at higher risk of micronutrient inadequacies than any other subgroup, with 92.8% (SE: 3.6%) at risk of inadequate intakes for vitamin D. No differences in biomarkers for vitamin D, folate, iron, and zinc were observed by food security status. The prevalence of iron deficiency was 12.7% in food-secure and 12.0% in food-insecure adolescent girls.

CONCLUSIONS

Food insecurity was associated with compromised intake of some micronutrients, especially among adolescent girls. These results highlight a need for targeted interventions to improve children's overall diet quality, including the reduction of specific nutrient inadequacies, especially among food-insecure children. This study was registered at clinicaltrials.gov as NCT03400436.

Association of Visceral Adipose Tissue and Insulin Resistance with Incident Metabolic Syndrome Independent of Obesity Status: The IRAS Family Study

OBJECTIVE

Although increasing evidence suggests that visceral adipose tissue (VAT) is a major underlying cause of metabolic syndrome (MetS), few studies have measured VAT at multiple time points in diverse populations. VAT and insulin resistance were hypothesized to differ by MetS status within BMI category in the Insulin Resistance Atherosclerosis Study (IRAS) Family Study and, further, that baseline VAT and insulin resistance and increases over time are associated with incident MetS.

METHODS

Generalized estimating equations were used for differences in body fat distribution and insulin resistance by MetS status. Mixed effects logistic regression was used for the association of baseline and change in adiposity and insulin resistance with incident MetS across 5 years, adjusted for age, sex, race/ethnicity, and family correlation.

RESULTS

VAT and insulin sensitivity differed significantly by MetS status and BMI category at baseline. VAT and homeostatic model assessment of insulin resistance (HOMA-IR) at baseline (VAT odds ratio [OR] = 1.16 [95% CI: 1.12-2.31]; HOMA-IR OR = 1.85 [95% CI: 1.32-2.58]) and increases over time (VAT OR = 1.55 [95% CI: 1.22-1.98]; HOMA-IR OR = 3.23 [95% CI: 2.20-4.73]) were associated with incident MetS independent of BMI category.

CONCLUSIONS

Differing levels of VAT may be driving metabolic heterogeneity within BMI categories. Both overall and abdominal obesity (VAT) may play a role in the development of MetS. Increased VAT over time contributed additional risk.

Phase I Study of Muscadine Grape Extract for Patients With Advanced Cancer

OBJECTIVE

Preclinical studies with muscadine grape extract (MGE) show antitumor activity and decreased systemic inflammation. This phase I study (NCT02583269) assessed safety and tolerability of a proprietary MGE preparation in patients with advanced solid tumors.

METHODS

Patients with metastatic or unresectable cancers who were progressing on standard therapies were assigned to MGE in a standard 3+3 design. Five dose levels were tested (320 to 1600 mg total phenolics/d). Safety and maximum-tolerated dose were assessed after 4 weeks. Patients were evaluated for response at 8 weeks and continued on MGE if clinically stable. Secondary outcomes were response, survival, adherence, fatigue, and quality of life (QOL).

RESULTS

In total, 23 patients (lung, n=7; gastrointestinal, n=7; genitourinary, n=6; other, n=3) received MGE capsules by mouth twice daily. The cohort [median age 72 years, 48% Eastern Cooperative Oncology Group (ECOG) 2] was heavily pretreated. After 4 weeks on MGE, possibly attributable adverse events grade 2 or higher were fatigue (n=1), decreased lymphocyte count (n=1), and constipation (n=2), including 1 dose-limiting toxicity for grade 3 constipation. Maximum-tolerated dose was not reached. No partial responses were observed. Median time on therapy was 8 weeks, with 29% of patients treated beyond 16 weeks and a median overall survival of 7.2 months. QOL and fatigue levels were stable from baseline to 8 weeks. Higher MGE dose was correlated with improvement in self-reported physical well-being QOL at 8 weeks (r=0.6; P=0.04).

CONCLUSIONS

MGE is safe and well-tolerated in heavily pretreated and older cancer patients.  The potential anticancer properties and the effects of MGE on physical well-being and QOL metrics will be evaluated in future studies.

Targeted eHealth Intervention to Reduce Breast Cancer Survivors' Fear of Recurrence: Results from the FoRtitude Randomized Trial

Background

Fear of recurrence (FoR) is a prevalent concern among breast cancer survivors (BCS), yet few accessible interventions exist. This study evaluated a targeted eHealth intervention, “FoRtitude,” to reduce FoR using cognitive behavioral skills training and telecoaching.

Methods

BCS (N  = 196) were recruited from an academic medical center and 3 National Cancer Institute Community Oncology Research Program community sites, had stage 0-III breast cancer, were 1-10 years postprimary treatment, with moderate to high FoR and familiarity with the internet. Using the Multiphase Optimization Strategy, participants were independently randomly assigned to 3 cognitive behavioral skills (relaxation, cognitive restructuring, worry practice) vs an attention control condition (health management content [HMC]) and to telecoaching (motivational interviewing) vs no telecoaching. Website content was released across 4 weeks and included didactic lessons, interactive tools, and a text-messaging feature. BCS completed the Fear of Cancer Recurrence Inventory at baseline and at 4 and 8 weeks. Fear of Cancer Recurrence Inventory scores over time were compared using mixed-effects models. All statistical tests were 2-sided.

Results

FCRI scores [SD] decreased statistically significantly from baseline to postintervention (T0 = 53.1 [17.4], T2 = 41.9 [16.2], P < .001). The magnitude of reduction in FCRI scores was comparable across cognitive behavior therapy (CBT) and attention control HMC conditions and was predicted by increased self-efficacy. Telecoaching was associated with lower attrition and greater website use (mean adherence score [SD] = 26.6 [7.2] vs 21.0 [10.5], P < .001).

Conclusions

BCS experienced statistically significant reductions in FoR postintervention, but improvements were comparable between CBT and attention controls. Telecoaching improved adherence and retention. Future research is needed on optimal integration of CBT and HMC, dose, and features of eHealth delivery that contributed to reducing FoR. In the COVID-19 era, remote delivery has become even more essential for reaching survivors struggling with FoR.

A symptom-adapted physical activity intervention during induction chemotherapy for older adults with acute myeloid leukemia (AML) to maintain physical function

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Background: Older adults are at risk for physical function decline during therapy for AML. Impaired physical function after induction therapy is associated with shorter survival Interventions designed to maintain function may improve treatment outcomes. We piloted a physical activity (PA) intervention among older adults receiving intensive chemotherapy for AML designed to prevent functional decline. Methods: Single institution randomized pilot study of PA vs. usual care. Eligibility included age ≥60 years, newly-diagnosed AML, ambulatory, planned intensive induction chemotherapy. Intervention participants were offered a PA session five days/week tailored daily to symptoms and conditions during the induction hospitalization. Session options were: 1) Standard (ward-based), walking + balance trahining + resistance exercises; 2) Intermediate (room-based), upper-body ergometer + balance training + resistance exercises; 3) Low-intensity (bed-based), upper-body ergometer + resistance exercises. Behavioral counseling sessions to establish PA goals and overcome barriers were conducted weekly during hospitalization and continued monthly by phone for 6 months. Assessment of physical function occurred at baseline, weekly during hospitalization (approximately 4-6 weeks), 3 months, and 6 months. The primary functional outcome of interest was the Short Physical Performance Battery (SPPB; 5 repeat chair stands, gait speed, balance tests; score 0-12 higher indicates better function). Clinically significant change in physical function was defined as ≥1.0 on the SPPB. Proportions of those that declined, remained stable, or improved on the SPPB were compared by group using an exact test for trend. Results: Among 96 eligible patients 70 enrolled (recruitment rate 73%, average participation 3 sessions/week). The mean age was 72.1±6.3 years, 70% were male. Mean baseline SPPB score was 7.0±3.8. In the surviving intention to treat population (N = 66), more intervention participants, compared to controls, maintained or improved their SPPB score (38% vs. 25%) during induction hospitalization (p = 0.278). Among those who achieved remission (N = 42), function was maintained or improved in a greater proportion of intervention participants (55%) compared to controls (23%), p = 0.047. Maintenance or improvement in SPPB from baseline to last follow-up (3 or 6 months post enrollment) was 62% vs 54% for intervention versus control among the intention to treat cohort (N = 50) and 67% vs. 55% among those who achieved remission (N = 40). Conclusions: A symptom adapted PA intervention with behavioral counseling during induction chemotherapy shows promise in preventing clinically meaningful decline in physical function among older adults with AML who achieve remission. Continued maintenance intervention may sustain benefits. Clinical trial information: NCT01519596.

Diet, obesity, and the gut microbiome as determinants modulating metabolic outcomes in a non-human primate model

BACKGROUND

The objective of this study was to increase understanding of the complex interactions between diet, obesity, and the gut microbiome of adult female non-human primates (NHPs). Subjects consumed either a Western (n=15) or Mediterranean (n=14) diet designed to represent human dietary patterns for 31 months. Body composition was determined using CT, fecal samples were collected, and shotgun metagenomic sequencing was performed. Gut microbiome results were grouped by diet and adiposity.

RESULTS

Diet was the main contributor to gut microbiome bacterial diversity. Adiposity within each diet was associated with subtle shifts in the proportional abundance of several taxa. Mediterranean diet-fed NHPs with lower body fat had a greater proportion of Lactobacillus animalis than their higher body fat counterparts. Higher body fat Western diet-fed NHPs had more Ruminococcus champaneliensis and less Bacteroides uniformis than their low body fat counterparts. Western diet-fed NHPs had significantly higher levels of Prevotella copri than Mediterranean diet NHPs. Western diet-fed subjects were stratified by P. copri abundance (P. copri^HIGH versus P. copri^LOW), which was not associated with adiposity. Overall, Western diet-fed animals in the P. copri^HIGH group showed greater proportional abundance of B. ovatus, B. faecis, P. stercorea, P. brevis, and Faecalibacterium prausnitzii than those in the Western P. copri^LOW group. Western diet P. copri^LOW subjects had a greater proportion of Eubacterium siraeum. E. siraeum negatively correlated with P. copri proportional abundance regardless of dietary consumption. In the Western diet group, Shannon diversity was significantly higher in P. copri^LOW when compared to P. copri^HIGH subjects. Furthermore, gut E. siraeum abundance positively correlated with HDL plasma cholesterol indicating that those in the P. copri^LOW population may represent a more metabolically healthy population. Untargeted metabolomics on urine and plasma from Western diet-fed P. copri^HIGH and P. copri^LOW subjects suggest early kidney dysfunction in Western diet-fed P. copri^HIGH subjects.

CONCLUSIONS

In summary, the data indicate diet to be the major influencer of gut bacterial diversity. However, diet and adiposity must be considered together when analyzing changes in abundance of specific bacterial taxa. Interestingly, P. copri appears to mediate metabolic dysfunction in Western diet-fed NHPs. Video abstract.

Single-arm phase II study of low-dose paclitaxel and pembrolizumab in platinum-refractory metastatic urothelial carcinoma (UC)

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Background: Single agent checkpoint inhibition is effective in a small proportion of platinum-refractory UC patients but improvements are needed. UC is highly inflammatory, and low-dose chemotherapy may enhance the response to immunotherapy. We evaluated whether combination therapy with low-dose paclitaxel and pembrolizumab is more efficacious than single-agent pembrolizumab which had an objective response rate (ORR) of 21% in a similar patient population in the KEYNOTE-045 study. We also incorporated multiple novel biomarker studies to explore immune regulatory mechanisms in UC. Methods: This is a prospective, single-arm phase II trial (NCT02581982) of pembrolizumab combined with low-dose paclitaxel in patients with platinum-refractory metastatic UC. Key inclusion criteria included measurable progression of disease within 12 months of platinum therapy and ECOG ≤1. Patients received pembrolizumab 200mg day 1 and paclitaxel 80 mg/m2 days 1 and 8 of a 21 day cycle for up to 8 cycles unless clinical or radiographic disease progression or unacceptable adverse events (AEs) were observed. Responding patients could remain on pembrolizumab maintenance for up to 2 years. The primary endpoint was ORR; key secondary endpoints included overall survival (OS), 6-month progression free survival (PFS), and safety. Results: Twenty-seven patients were treated between 4/2016 - 6/2020, with a median follow up of 9.9 months. At baseline, the median age was 68 years (range 49-80), with 81% men and 78% non-Hispanic white. The majority (59%) were ECOG 1. Twenty-one of 27 (78%) received prior definitive therapy: chemoradiation in 24% and surgery in 76%. The majority (78%) of patients received prior cisplatin. 70% progressed on a cisplatin-based regimen while 30% progressed on carboplatin-based regimen within 12 months of study entry. The ORR by intention to treat was 9 of 27 patients (33%) and in patients evaluable for response by imaging was 9 of 25 (36%), including 3 with complete response. Disease control rate in evaluable patients was 72%. Six-month PFS was 46.8% (95% CI: 27.2%, 64.2%) and median OS was 11.7 months (95% CI: 8.7 mo, NR). Common ≥ grade 2 AEs were anemia (44%), lymphopenia (37%), hyperglycemia (33%), and fatigue (33%). Possible treatment-related at least grade 3 or 4 AEs occurred in 56% of subjects, including 2 immune-mediated AEs (pneumonitis and nephritis) resulting in therapy cessation but a durable partial response. There were no grade 5 events. Conclusions: This study illustrates that the addition of low-dose paclitaxel to pembrolizumab improves outcomes in patients with platinum-refractory UC, relative to single-agent pembrolizumab. No unanticipated safety signals emerged. Exploratory analyses including PDL1 status, tumor mutational burden, and change in circulating microRNAs and in immune cell populations are ongoing. Clinical trial information: NCT02581982.

Association between 25-Hydroxyvitamin D and Metabolic Syndrome in Older Adults: The Health, Aging and Body Composition Study

OBJECTIVE

Low 25-hydroxyvitamin D (25[OH]D) levels and metabolic syndrome (MetS) are prevalent among older adults; however, longitudinal studies examining 25(OH)D status and MetS are lacking. We explore the association of 25(OH)D levels with prevalent and incident MetS in white and black older adults. Research Design and Methods. A total of 1620 white and 1016 black participants aged 70-79 years from the Health ABC cohort with measured 25(OH)D levels and data on MetS and covariates of interest were examined. The association between 25(OH)D levels and prevalent MetS at baseline and incident MetS at 6-year follow-up was examined in whites and blacks separately using logistic regression adjusting for demographics, lifestyle factors, and renal function.

RESULTS

At baseline, 635 (39%) white and 363 (36%) black participants had prevalent MetS. In whites, low 25(OH)D levels were associated with prevalent MetS (adjusted OR (95% CI), 1.85 (1.47, 2.34)) and 1.96 (1.46, 2.63) for 25(OH)D of 20-<30 and <20 vs. ≥30 ng/ml, respectively). The association was attenuated after adjustment for BMI but remained significant. No association was found between 25(OH)D levels and prevalent MetS in blacks. Among those without MetS at baseline (765 whites, 427 blacks), 150 (20%) whites and 87 (20%) blacks had developed MetS at 6-year follow-up. However, 25(OH)D levels were not associated with incident MetS in whites or blacks.

CONCLUSION

In older adults, low 25(OH)D levels were associated with increased odds of prevalent MetS in whites but not in blacks. No association was observed between 25(OH)D levels and incident MetS in either whites or blacks.

Abstract PO-078: Delaying and forgoing care due to cost among rural cancer survivors

Purpose: Financial hardship, including delaying/forgoing services because of cost, is reported by approximately 30% of an estimated 16.9 million cancer survivors. However, hardship is poorly assessed and interventions sporadically implemented for survivors. The objective of this study is to assess factors associated with delaying and forgoing care services due to cost to inform a patient navigation program for rural cancer survivors. Methods: Adults with a cancer diagnosis who were 6 months or more post-definitive treatment or were receiving on-going maintenance therapy were identified for a cross-sectional mailed survey through the electronic medical record. Participants were predominately residents of one of eight priority rural counties in Northwest North Carolina (all resided in a zip-code defined by a Rural- Urban Commuting Area [RUCA] code of 4-10). Items from the 2019 National Health Information Survey (NHIS) assessed delayed/foregone medical care. Univariate statistics described the sample distribution and prevalence of delaying/forgoing care. Participants were randomized into two incentive groups ($2 bill with the survey mailing vs a $10 gift card upon completion). Chi-square tests examined the factors associated with delaying/forgoing services by demographic and cancer characteristics. Results: The survey response rate was 22.0%; 451 complete surveys were included in the present analyses. Enrolled survivors (49.7% female) were predominately non-Hispanic white (96.2%), with a mean age of 69 years, and 69.0% were 5 years or more post diagnosis. The most common cancer sites were prostate (21.5%), breast (19.7%), and colorectal (7.3%). Delayed medical care was reported by 16.2% of the sample. The prevalence of forgoing care due to cost was 6.4% for medical care, 12.3% for medications, 6.4% for mental health, and 7.0% for medical tests. Chi-square tests found significant differences by age, gender, and radiation treatment status (yes/no), with higher prevalence of delaying care among survivors aged 41-64 vs younger and older survivors (34.1% vs 27.2% and 8.8%, P&lt;0.001), females vs males (22.4% vs 10.4%, P&lt;0.001), and those treated with radiation therapy compared to those who were not (21.0% vs 13.2%, P=0.03). Survivors aged 18-40 compared to older survivors (18.8% vs 13.4% [aged 41-64] and 3.2% [aged 65+], P&lt;0.001), and females vs male survivors (10.7% vs 3.2%, P=0.006) were also more likely to report forgoing care due to cost. Discussion: A minority of post- treatment rural cancer survivors report delaying and forgoing medical care because of cost. Patient navigation programs should prioritize ongoing screening efforts for financial hardship among younger and female rural survivors after initial treatment completion.

Citation Format: Derek S. Falk, Karen E. Winkfield, Janet A. Tooze, Kelsey Shore, Carla Strom, Kathryn E. Weaver. Delaying and forgoing care due to cost among rural cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-078.

Older adults with obesity have higher risks of some micronutrient inadequacies and lower overall dietary quality compared to peers with a healthy weight, National Health and Nutrition Examination Surveys (NHANES), 2011-2014

OBJECTIVE

To evaluate total usual intakes and biomarkers of micronutrients, overall dietary quality and related health characteristics of US older adults who were overweight or obese compared with a healthy weight.

DESIGN

Cross-sectional study.

SETTING

Two 24-h dietary recalls, nutritional biomarkers and objective and subjective health characteristic data were analysed from the National Health and Nutrition Examination Survey 2011-2014. We used the National Cancer Institute method to estimate distributions of total usual intakes from foods and dietary supplements for eleven micronutrients of potential concern and the Healthy Eating Index (HEI)-2015 score.

PARTICIPANTS

Older adults aged ≥60 years (n 2969) were categorised by sex and body weight status, using standard BMI categories. Underweight individuals (n 47) were excluded due to small sample size.

RESULTS

A greater percentage of obese older adults compared with their healthy-weight counterparts was at risk of inadequate Mg (both sexes), Ca, vitamin B6 and vitamin D (women only) intakes. The proportion of those with serum 25-hydroxyvitamin D < 40 nmol/l was higher in obese (12 %) than in healthy-weight older women (6 %). Mean overall HEI-2015 scores were 8·6 (men) and 7·1 (women) points lower in obese than in healthy-weight older adults. In addition, compared with healthy-weight counterparts, obese older adults were more likely to self-report fair/poor health, use ≥ 5 medications and have limitations in activities of daily living and cardio-metabolic risk factors; and obese older women were more likely to be food-insecure and have depression.

CONCLUSIONS

Our findings suggest that obesity may coexist with micronutrient inadequacy in older adults, especially among women.

Rural cancer survivors' health information needs post-treatment

OBJECTIVE

This study describes the most common cancer-related health information needs among rural cancer survivors and characteristics associated with reporting more information needs.

METHODS

Rural breast, prostate, and colorectal cancer survivors, two to five years post-diagnosis, identified from an institutional cancer registry, completed a mailed/telephone-administered survey. Respondents were asked about 23 health information needs in eight domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupational, emotional, and insurance). Poisson regression models were used to assess relationships between number of health information needs and demographic and cancer characteristics.

RESULTS

Participants (n = 170) reported an average of four health information needs, with the most common domains being: side effects and symptoms (58 %), health promotion (54 %), and tests and treatment (41 %). Participants who were younger (compared to 5-year increase, rate ratio [RR] = 1.11, 95 % CI = 1.02-1.21), ethnic minority (RR = 1.89, 95 % CI = 1.17-3.06), less educated (RR = 1.49, 95 % CI = 1.00-2.23), and financially stressed (RR = 1.87, 95 % CI = 1.25-2.81) had a greater number of information needs.

CONCLUSIONS

Younger, ethnic minority, less educated, and financially strained rural survivors have the greatest need for informational support.

PRACTICE IMPLICATIONS

The provision of health information for rural cancer survivors should consider type of cancer, treatments received, and sociocultural differences to tailor information provided.

STRATOS guidance document on measurement error and misclassification of variables in observational epidemiology: Part 2-More complex methods of adjustment and advanced topics

We continue our review of issues related to measurement error and misclassification in epidemiology. We further describe methods of adjusting for biased estimation caused by measurement error in continuous covariates, covering likelihood methods, Bayesian methods, moment reconstruction, moment-adjusted imputation, and multiple imputation. We then describe which methods can also be used with misclassification of categorical covariates. Methods of adjusting estimation of distributions of continuous variables for measurement error are then reviewed. Illustrative examples are provided throughout these sections. We provide lists of available software for implementing these methods and also provide the code for implementing our examples in the Supporting Information. Next, we present several advanced topics, including data subject to both classical and Berkson error, modeling continuous exposures with measurement error, and categorical exposures with misclassification in the same model, variable selection when some of the variables are measured with error, adjusting analyses or design for error in an outcome variable, and categorizing continuous variables measured with error. Finally, we provide some advice for the often met situations where variables are known to be measured with substantial error, but there is only an external reference standard or partial (or no) information about the type or magnitude of the error.