Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases

BACKGROUND

A large number of observational epidemiological studies have reported generally positive associations between circulating mass and activity levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular diseases. Few studies have been large enough to provide reliable estimates in different circumstances, such as in different subgroups (e.g., by age group, sex, or smoking status) or at different Lp-PLA2 levels. Moreover, most published studies have related disease risk only to baseline values of Lp-PLA2 markers (which can lead to substantial underestimation of any risk relationships because of within-person variability over time) and have used different approaches to adjustment for possible confounding factors.

OBJECTIVES

By combination of data from individual participants from all relevant observational studies in a systematic 'meta-analysis', with correction for regression dilution (using available data on serial measurements of Lp-PLA2), the Lp-PLA2 Studies Collaboration will aim to characterize more precisely than has previously been possible the strength and shape of the age and sex-specific associations of plasma Lp-PLA2 with coronary heart disease (and, where data are sufficient, with other vascular diseases, such as ischaemic stroke). It will also help to determine to what extent such associations are independent of possible confounding factors and to explore potential sources of heterogeneity among studies, such as those related to assay methods and study design. It is anticipated that the present collaboration will serve as a framework to investigate related questions on Lp-PLA2 and cardiovascular outcomes.

METHODS

A central database is being established containing data on circulating Lp-PLA2 values, sex and other potential confounding factors, age at baseline Lp-PLA2 measurement, age at event or at last follow-up, major vascular morbidity and cause-specific mortality. Information about any repeat measurements of Lp-PLA2 and potential confounding factors has been sought to allow adjustment for possible confounding and correction for regression dilution. The analyses will involve age-specific regression models. Synthesis of the available observational studies of Lp-PLA2 will yield information on a total of about 15 000 cardiovascular disease endpoints.

Frailty and Cognition

Frailty is a common, heterogeneous, geriatric syndrome associated with adverse health events. Over the last years, a growing debate has emerged concerning the inclusion of cognitive impairment in the definition of frailty. In fact, cognitive impairment has been increasingly recognized as a potential contributor to the clinical vulnerability of older persons. This review presents key studies describing the interrelationships between cognition and frailty; in particular we examine the clinical relevance of cognitive impairment in the determination of the frailty syndrome.

Prevalence of Frailty and Mobility Limitation in a Rural Setting in France

BACKGROUND

The prevalence of frailty is variable according to the adopted operational definition, the tested population, and the setting where it is explored.

OBJECTIVE

To estimate the prevalence of frailty and mobility disability in community-dwelling persons aged 60 years and older.

DESIGN

Cross-sectional analyses.

SETTING

The rural area of Labastide-Murat (France).

PARTICIPANTS

All community-dwelling persons aged 60 years and older living in the area and answering to the study survey (n=572/1022).

MEASUREMENTS

The study questionnaire included questions defining mobility disability (as ability to walk 400 meters and climb up 2 flights of stairs) and frailty (according to the FRAIL instrument and a modified version of the original definition proposed by Fried and colleagues).

RESULTS

Mean age of participants was 72.4 years old. Mobility disability was reported by 47 (8.3%) participants. The sedentariness criterion of frailty was the most prevalent in the present population. Overall, according to the FRAIL instrument, 77.6%, 14.0%, and 8.3% could be defined as robust, pre-frail/frail, and disabled, respectively. When the alternative definition of frailty mirroring the definition proposed in the Cardiovascular Health Study was adopted, the prevalence of frailty increased and showed gender-specific differences (p=0.02).

CONCLUSIONS

A relevant number of older persons living in rural areas experiences physical impairments and presents an increased risk for major negative health-related events. These results may support the ongoing clinical and research actions aimed at preventing the functional decline in elders.

Gender Specific Associations between Frailty and Body Composition

BACKGROUND

Frailty is a widespread geriatric syndrome, but its relationship with body composition is largely unknown.

OBJECTIVES

Assess the relationship between body composition and frailty in older persons.

DESIGN, PARTICIPANTS AND SETTING

Cross-sectional data analyses in 120 community-dwelling older persons (50 men, 70 women, mean age 78.5 ± 6 yr).

MEASUREMENTS

Frailty was measured according to Fried's criteria and calculated as a score, and also a binary variable. Anthropometric measures were obtained (height, weight), and body composition (total lean body mass, appendicular skeletal muscle mass (ASM), total fat mass, and percentage fat), assessed by dual energy x-ray absorptiometry. Multiple regression and logistic regression analyses stratified by gender were conducted.

RESULTS

Frailty, as a binary measure, was more prevalent in women than men (67.1% vs 46% p=0.04). Prevalence of low muscle mass (ASM/ht2) was higher in men than in women (40.0% vs 32.9%, p=0.04). Using gender-specific percentage fat cut-scores (27% men, 38% women, respectively) obesity was more prevalent in women than men (58.6% vs 34%, respectively, p=0.01). Multiple regression models showed age as an independent associated factor of frailty in men (β 0.310, p=0.009) and women (β .581 p<0.001). ASM/ht2 was a significant associated factor in men (β -0.517, p<0.001) and trended towards significance in women (β -0.188, p=0.06). Percentage fat was a significant associated factor in women only (β 0.234, p=0.02). Logistic regression with frailty as a binary dependent variable yielded similar results.

CONCLUSION

In this sample of older adults, the significant associated factor of frailty in men was ASM/ht2, whereas it was percentage fat in women. These associations were independent of age. With increasing longevity and the high prevalence of sarcopenia and obesity in older populations, these findings have public health implications. Larger sample and specifically designed studies are needed in order to confirm and extend these findings.

Gemcitabine and docetaxel in relapsed and unresectable high-grade osteosarcoma and spindle cell sarcoma of bone

BACKGROUND

Few new compounds are available for relapsed osteosarcoma. We retrospectively evaluated the activity of gemcitabine (G) plus docetaxel (D) in patients with relapsed high-grade osteosarcoma and high-grade spindle cell sarcoma of bone (HGS).

METHODS

Patients receiving G 900 mg/m(2) d 1, 8; D 75 mg/m(2) d 8, every 21 days were eligible. Primary end-point: progression-free survival (PFS) at 4 months; secondary end-point: overall survival (OS) and response rate.

RESULTS

Fifty-one patients were included, with a median age of 17 years (8-71), 26 (51%) were pediatric patients. GD line of treatment: 2nd in 14 patients, ≥3rd in 37. 25 (49%) patients had metastases limited to lungs, 26 (51%) multiple sites.

HISTOLOGY

40 (78%) osteosarcoma, 11 (22%) HGS. Eight (16%) patients achieved surgical complete response (sCR2) after GD. Four-month PFS rate was 46%, and significantly better for patients with ECOG 0 (ECOG 0: 54% vs ECOG 1: 43% vs ECOG 2: 0%; p = 0.003), for patients undergoing metastasectomy after GD (sCR2 75% vs no-sCR2 40 %, p = 0.02) and for osteosarcoma (osteosarcoma 56% vs HGS 18%; p = 0.05), with no differences according to age, line of treatment, and pattern of metastases. Forty-six cases had RECIST measurable disease: 6 (13%) patients had a partial response (PR), 20 (43%) had stable disease (SD) and 20 (43%) had progressive disease (PD). The 1-year OS was 30%: 67% for PR, 54% for SD and 20% for PD (p = 0.005).

CONCLUSIONS

GD is an active treatment for relapsed high-grade osteosarcoma, especially for ECOG 0 patients, and should be included in the therapeutic armamentarium of metastatic osteosarcoma.

The European Union Geriatric Medicine Society (EUGMS) Working Group on «Frailty in Older Persons»

The concept of frailty was introduced in literature to help atclinically depicting the transition of a robust older individualinto a different clinical phenotype of risk (1-5). Frailty isgenerally described as a multisystemic impairment responsiblefor a state of increased vulnerability to endogenous andexogenous stressors (6, 7). This syndrome may represent thefirst step towards the evident and clinically relevant functionaldisability (a cornerstone outcome for geriatric medicine)8, andhas shown to be predictive of major negative health-relatedevents, including

Frailty and Pain: Two Related Conditions

Frailty is a multidimensional syndrome, involving functional, nutritional, biological and psychological aspects. This condition, defined as a decreased resistance to internal and external stressors, is predictive of adverse health outcomes, including disability and mortality. Importantly, the frailty syndrome is usually considered a reversible condition, thus amenable of specific preventive interventions. Persistent pain in older adults is very common and has multiple determinants. This symptom represents a determinant of accelerated aging. In the present paper, we discuss available evidence examining the association between these two conditions. Despite the high prevalence of these two conditions and their shared underlying mechanisms, our search only retrieved few relevant studies. Most of them reported a relationship between pain (or analgesics consumption) and different operational definitions of frailty. Pain may represent a relevant risk factor as well as a potential target for interventions against the frailty syndrome, but further studies are needed.

Association between the Mediterranean-style Dietary Pattern Score and Physical Performance: Results from TRELONG Study

OBJECTIVE

To determine the association between Mediterranean-Style Dietary Pattern Score and physical performance.

DESIGN

Data analysis of a longitudinal study of a representative, age stratified, population sample.

SETTING

The TREVISO LONGEVA (TRELONG) Study, in Treviso, Italy.

PARTICIPANTS

In 2010, 123 men and 181 women, age 77 years and over (mean age 86.3 ± 6.8 years).

MEASUREMENTS

Performing a logistic regression in a multivariate analysis, hand grip strength and Short Physical Performance Battery (SPPB) were tested in relation to Mediterranean-Style Dietary Pattern Score (MSDPS).

RESULTS

The hand grip mean value was 10.9 kg (± 9.5) and the SPPB score was 6.3 (± 3.8). The MSDPS mean value in this study sample was 38.1/100 (± 8.1). A significant association (p=0.036) between a high adherence to the Mediterranean diet (fourth quartile) and higher performance lower limbs (SPPB>7) was found. No correlation was reported for the hand grip strength.

CONCLUSION

We found an association statistically significant between a high adherence to the Mediterranean diet and higher physical performance.

Body Composition and Anti-Neoplastic Treatment in Adult and Older Subjects - A Systematic Review

BACKGROUND

The estimation of the risk of poor tolerance and overdose of antineoplastic agents protocols represents a major challenge in oncology, particularly in older patients. We hypothesize that age-related modifications of body composition (i.e. increased fat mass and decreased lean mass) may significantly affect tolerance to chemotherapy.

METHOD

We conducted a systematic review for the last 25 years (between 1990 and 2015), using US National library of Medicine Medline electronic bibliographic database and Embase database of cohorts or clinical trials exploring (i) the interactions of body composition (assessed by Dual X-ray Absorptiometry, Bioelectrical Impedance Analyses, or Computerized Tomography) with pharmacokinetics parameters, (ii) the tolerance to chemotherapy, and (iii) the consequences of chemotherapies or targeted therapies on body composition.

RESULTS

Our search identified 1504 articles. After a selection (using pre-established criteria) on titles and abstract, 24 original articles were selected with 3 domains of interest: impact of body composition on pharmacokinetics (7 articles), relationship between body composition and chemotoxicity (14 articles), and effect of anti-cancer chemotherapy on body composition (11 articles). The selected studies suggested that pharmacokinetic was influenced by lean mass, that lower lean mass could be correlated with toxicity, and that sarcopenic patients experienced more toxicities that non-sarcopenic patients. Regarding fat mass, results were less conclusive. No studies specifically explored the topic of body composition in older cancer patients.

CONCLUSIONS

Plausible pathophysiological pathways linking body composition, toxicity, and pharmacokinetics are sustained by the actual review. However, despite the growing number of older cancer patients, our review highlighted the lack of specific studies in the field of anti-neoplastic agents toxicity regarding body composition conducted in elderly.

Is the 25-Hydroxy-Vitamin D Serum Concentration a Good Marker of Frailty?

INTRODUCTION

The phenotype proposed by Fried and colleagues is a widely used operational definition of frailty defining such state of extreme vulnerability of older persons. Low serum 25-hydroxy-vitamin D (25(OH)D) has been suggested as biomarker of frailty in literature.

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To explore the association of 25(OH)D concentrations with the frailty phenotype and its criteria.

METHODS

321 subjects referred by their general practitioner to a geriatric frailty clinic were assessed between January 1, 2013 and September 23, 2013. Adjusted logistic regression models were performed between serum concentrations of 25(OH)D and the frailty phenotype (global score as well as its specific criteria). Receivers operating curves were established in order to explore the existence of a possible threshold of vitamin D levels highly predictive of frailty.

RESULTS

Two hundred forty-one (75%) participants had 25(OH)D levels lower than 22 ng/ml. No significant association was reported between 25(OH)D levels and frailty. Among the five criteria of frailty, 25(OH)D was only associated with sedentariness (odds ratio 0.97 [95% confidence interval 0.95-0.99]).

CONCLUSION

In our sample, no association was found between 25(OH)D levels and phenotype of frailty or the different frailty criterion except for sedentariness.

Operationalization of the physical frailty & sarcopenia syndrome: rationale and clinical implementation

Over the years, different operational definitions have been elaborated to identify frail older persons, but none of them has received unanimous consensus. This, in turn, has hampered the clinical implementation of frailty as well as the design of targeted interventions. To overcome the current limitations in the field, a novel operationalization of physical frailty (PF) is proposed which grounds its roots in the recognition of sarcopenia as its central biological substrate. This conceptualization is based on the fact that the clinical picture of PF overlaps substantially with that of sarcopenia. The two conditions may therefore be merged into a new clinical entity, the PF & sarcopenia (PF&S) syndrome, in which muscle loss represents both the biological substrate for the development of PF and a major pathway whereby the negative health outcomes of PF occur. All of the components defining the PF&S syndrome are measurable in an objective manner, which will facilitate its incorporation into standard practice. The recognition of a precise biological substratum for PF&S (i.e., skeletal muscle decline) also opens new venues for the development of preventive and therapeutic interventions.

Treating cancer in older and oldest old patients

The so-called "silver tsunami" is a metaphor that the individuals 65 and older represent the most rapidly growing segment of the Western world population. Aging is an ongoing process that leads to the loss of functional reserve of multiple organ systems, increased susceptibility to stress, it is associated with increased prevalence of chronic disease, and functional dependence. Determined by a combination of genetic and environmental factors, this process is highly individualized and poorly reflected in chronologic age. The heterogeneity and the complexity of the older old population represent the main challenge to the treatment of cancer in those patients. We should discern "fit" elderly in whom standard cancer treatment appears to be comparable to a younger population and "unfit" or "frail" elderly, in which the risks of the treatment may overwhelm potential benefits. There are many aspects that have to be assessed before treating an elderly patient, or before to choose the treatment itself. In our review we will try to explain and describe the meaning and the most important aspects related to the oldest old complex patients, and how to manage those patients.

Electrical resistance of human soft tissue sarcomas: an ex vivo study on surgical specimens

This paper presents a study about electrical resistance, which using fixed electrode geometry could be correlated to the tissue resistivity, of different histological types of human soft tissue sarcomas measured during electroporation. The same voltage pulse sequence was applied to the tumor mass shortly after surgical resection by means of a voltage pulse generator currently used in clinical practice for electrochemotherapy that uses reversible electroporation. The voltage pulses were applied by means of a standard hexagonal electrode composed by seven, 20-mm-long equispaced needles. Irrespective of tumor size, the electrode applies electric pulses to the same volume of tissue. The resistance value was computed from the voltage and current recorded by the pulse generator, and it was correlated with the histological characteristics of the tumor tissue which was assessed by a dedicated pathologist. Some differences in resistance values, which could be correlated to a difference in tissue resistivity, were noticed according to sarcoma histotype. Lipomatous tumors (i.e., those rich in adipose tissue) displayed the highest resistance values (up to 1700 Ω), whereas in the other soft tissue sarcomas, such as those originating from muscle, nerve sheath, or fibrous tissue, the electrical resistance measured was between 40 and 110 Ω. A variability in resistance was found also within the same histotype. Among lipomatous tumors, the presence of myxoid tissue between adipocytes reduced the electrical resistance (e.g., 50-100 Ω). This work represents the first step in order to explore the difference in tissue electrical properties of STS. These results may be used to verify whether tuning electric field intensity according to the specific STS histotype could improve tissue electroporation and ultimately treatment efficacy.

Validation of the Mini Nutritional Assessment-Short Form in a Population of Frail Elders without Disability. Analysis of the Toulouse Frailty Platform Population in 2013

OBJECTIVE

To assess the validity of the Mini Nutritional Assessment-Short Form (MNA-SF) in elderly patients from the Toulouse Frailty Platform.

PARTICIPANTS

Overall, 267 patients aged 65 and over, without severe cognitive impairment (i.e. Mini Mental Status Examination > 20 and CDR<1), no physical disability (i.e. Activities of Daily Living ≥ 5) and no active cancer history (over the past 12 months) were included in 2013.

MEASUREMENTS

Receiver operating characteristic (ROC) analyses were used to assess the predictive validity of the French version of the MNA-SF for good nutritional status (defined as a full MNA score≥24/30). Analyses were conducted in the overall sample and then in subgroups of frail and pre-frail subjects according to the frailty phenotype. Optimal cut-off points were determined to obtain the best sensitivity/specificity ratio and the highest number of correctly classified subjects.

RESULTS

Among 267 patients, mean age=81.5±5.8; women=67.0%; 138 (51.7%) were frail, 98 (36.7%) were pre-frail and 31 (11.6%) were robust. Given their MNA-SF scores, 201 (75.3%) had a good nutritional status, 61 (22.8%) were at risk of malnutrition and 5 (1.9%) were malnourished. In the overall sample, but also in subgroups of pre-frail or frail elders, the areas under ROC curves were 0.954, 0.948 and 0.958 respectively. The 11 points cut-off provided the best correct classification ratio (91.4%); sensitivity=94.0%, specificity=83.3%.

CONCLUSION

The MNA-SF appeared to be a validated and effective tool for malnutrition screening in frail elders. Implementing this tool in clinical routine should contribute to improving the screening of malnourished frail individuals.

The Mini Nutritional Assessment-Short Form and mortality in nursing home residents--results from the INCUR study

OBJECTIVES

To examine whether the Mini Nutritional Assessment-Short Form (MNA-SF) score and its individual items are predictors of mortality in a nursing home population.

DESIGN

Prospective, secondary analysis from the Incidence of pNeumonia and related ConseqUences in nursing home Residents (INCUR) study with 1-year follow-up.

PARTICIPANTS

A total of 773 older persons (women 74.4%) living in 13 French nursing homes.

MEASUREMENTS

At baseline, nutritional status was assessed with the MNA-SF. Overall mortality rate was measured over a 12-month follow-up period after the baseline assessment visit. Cox proportional hazard models were performed to test the predictive capacity of the MNA-SF score and its single components for mortality.

RESULTS

Mean age of participants was 86.2 (standard deviation, SD 7.5) years. Mean MNA-SF score was 9.8 (SD 2.4). Among participants, 198 (25.6%) presented a normal nutritional status (12-14 points), 454 (58.7%) were at risk of malnutrition (8-11 points), and 121 (15.7%) were malnourished. After one year of follow-up, 135 (17.5%) participants had died. Age, female gender, baseline weight, BMI and MNA-SF were significant predictors of mortality whereas no specific chronic disease was. The total MNA-SF score was a significant predictor of mortality (Hazard Ratio=0.83; 95% CI 0.75-0.91; p<0.001), even after adjustment for potential confounders. Four individual items: weight loss, decrease in food intake, recent stress and BMI were independent predictors of mortality.

CONCLUSIONS

The MNA-SF appears to be an accurate predictor of one-year mortality in nursing home residents. Thus, this tool may be regarded not only as a nutritional screening tool, but also as an instrument for identifying the most-at-risk individuals in this population.