Virtual Intervention for Caregivers of Persons With Lewy Body Dementia: Pilot Quasi-Experimental Single-Arm Study

BACKGROUND

Compared to other types of dementia, family caregivers of people with Lewy body dementia (LBD) report higher stress levels and more severe depressive symptoms. Although several digital support interventions for caregivers of persons with dementia exist, few target LBD specifically or leverage a fully remote and asynchronous approach suitable for pandemic circumstances.

OBJECTIVE

We performed a pilot evaluation of a digital intervention designed to help caregivers of people with LBD address challenges they have experienced, with the end goal of reducing psychological distress in this population.

METHODS

We recruited 15 family caregivers of people with LBD to participate in the quasi-experimental, single-arm, mixed methods study titled Virtual Online Communities for Aging Life Experience-Lewy Body Dementia (VOCALE-LBD). The study offers an 8-week web-based intervention that uses a digital discussion platform and involves moderation, peer-to-peer support, didactic training, and problem-solving skill enactment.

RESULTS

Participants' baseline characteristics were the following: mean age 66 (SD 8) years; 14 of 15 (93%) of them were female; all (15/15, 100%) were White; and 8 (53%) of them had at least a postgraduate degree. Throughout the intervention, participants engaged in weekly web-based discussions, generating a total of 434 posts (average 4 posts per week). Attrition was 20% (3/15). Upon study exit, participants showed the following average improvements: 3.0 (SD 6.0) in depression, 8.3 (SD 16.7) in burden, 2.9 (SD 6.8) in stress, and 0.3 (SD 0.8) in loneliness. When looking at the proportion of participants with clinically significant improvement versus those with a worsening of ≥0.5 SD for each outcome, we observed net improvements of 50% (6/12), 33% (4/12), 25% (3/12), and 25% (3/12) in depression, loneliness, burden, and stress, respectively. In terms of the benefits of participation, participants reported that participation helped them "a great deal" to (1) improve their understanding of LBD (9/12, 75%), (2) gain confidence in dealing with difficult behaviors of the care recipient (6/12, 50%), and (3) improve in one's abilities to provide care to the care recipient (4/12, 33%).

CONCLUSIONS

The study generated promising feasibility and preliminary efficacy data for a low-cost, web-based intervention designed for caregivers of persons with LBD. Though the study was not powered for significance, we observed nominal average and net improvements in important psychological outcomes. Moreover, many caregivers reported that study participation helped them better understand the disease, feel more confident in dealing with difficult behaviors of the care recipient, and improve their ability to care for the care recipient. If validated in future studies, the intervention could be an accessible, on-demand resource for caregivers, enabling them to engage in moderated remote discussions with peers at their own convenience in terms of location, time of the day, and frequency.

Challenges and Opportunities in Conducting Research with Older Adults with Dementia during COVID ‐19 and Beyond

The coronavirus disease 19 (COVID‐19) pandemic has created significant and new challenges for the conduct of clinical research involving older adults with Alzheimer's disease and related dementias (ADRD). It has also stimulated positive adaptations in methods for engaging older adults with ADRD in research, particularly through the increased availability of virtual platforms. In this paper, we describe how we adapted standard in‐person participant recruitment and qualitative data collection methods for virtual use in a study of decision‐making experiences in older adults with ADRD. We describe key considerations for the use of technology and virtual platforms and discuss our experience with using recommended strategies to recruit a diverse sample of older adults. We highlight the need for research funding that supports the community‐based organizations on which improving equity in ADRD research participation often depends.

Simplified data science approach to extract social and behavioural determinants: a retrospective chart review

OBJECTIVES

We aim to extract a subset of social factors from clinical notes using common text classification methods.

DESIGN

Retrospective chart review.

SETTING

We collaborated with a local level I trauma hospital located in an underserved area that has a housing unstable patient population of about 6.5% and extracted text notes related to various social determinants for acute care patients.

PARTICIPANTS

Notes were retrospectively extracted from 43 798 acute care patients.

METHODS

We solely use open source Python packages to test simple text classification methods that can potentially be easily generalisable and implemented. We extracted social history text from various sources, such as admission and emergency department notes, over a 5-year timeframe and performed manual chart reviews to ensure data quality. We manually labelled the sentiment of the notes, treating each text entry independently. Four different models with two different feature selection methods (bag of words and bigrams) were used to classify and predict housing stability, tobacco use and alcohol use status for the extracted clinical text.

RESULTS

From our analysis, we found overall positive results and metrics in applying open-source classification techniques; the accuracy scores were 91.2%, 84.7%, 82.8% for housing stability, tobacco use and alcohol use, respectively. There were many limitations in our analysis including social factors not present due to patient condition, multiple copy-forward entries and shorthand. Additionally, it was difficult to translate usage degrees for tobacco and alcohol use. However, when compared with structured data sources, our classification approach on unstructured notes yielded more results for housing and alcohol use; tobacco use proved less fruitful for unstructured notes.

An Online Community Intervention for Older Persons with Pre-Frailty and Frailty: Pilot Studies

Online community interventions can support self-management in older populations but have rarely targeted symptomology of pre-frailty and frailty. To support older adults’ pre-frailty/frailty symptom management, we iteratively refined an approach entitled Virtual Online Community for Aging Life Experience (VOCALE) in three consecutive pilot studies (2018-2020). These studies employed asynchronous online discussions in which participants were asked to respond to weekly prompts. A study facilitator moderated the discussion, encouraging participants to respond to both the prompts and comments of other participants. In the first pilot (n=8), participants engaged in a collective exploration of different symptoms of pre-frailty and frailty. The second (n=10) and third (n=10) pilots employed a hybrid approach including collaborative exploration and learning of different problem-solving therapy skills over eight weeks. The mean age of participants of the three pilots combined was 80.6 (SD = 7.0). Most participants were female (71%). Participant attrition ranged from 20-25%. Many participants who completed the study noted that they enjoyed the discussions. The participants also found the moderators' follow-up questions and support timely and engaging. Additionally, we observed small but positive changes in self-efficacy measures. These pilot studies have confirmed that older adults with pre-frailty and frailty are interested, and can successfully engage in online community interventions, with the technical support and moderation provided, even during the initial stages of the COVID-19 pandemic, when lockdown policies were rolled out. Participation in the intervention was also associated with increased awareness of the need to be proactive in self-management concerning frailty-related symptoms.

USABILITY OF AN ONLINE DISCUSSION PLATFORM: DEVELOPMENT OF A CODING SCHEME

Online discussion platforms have the potential to support or even improve older adults’ well-being. Nonetheless, potential health benefits are often shaped by the usability of such platforms. Improving usability is imperative to maximize these potential benefits. As a part of a qualitative analysis of a study of an online community for older adults with frailty symptoms, we developed and refined a coding scheme targeting usability. The scheme was derived by reviewing contemporary literature on user experience, usability, and health information technology in older adults. Our review revealed challenges to apply commonly used terms to summarize our qualitative data. For example, the concept of perceived usability has different meanings and definitions in existing frameworks as they pertain to user engagement and technology adoption (specifically, the Technology Acceptance Model) than usability in an online discussion context for older adults. Because none of the meanings of usability fully encompassed the breadth of this concept for older users, we developed a coding scheme that is practical and captures a broad range of older adults’ perceptions of usability. Through qualitative analysis of the online discussion content using the newly developed coding scheme, new themes emerged such as confusing layout (e.g., difficulty in locating discussion boxes), insufficient instruction or training (trouble posting discussions), unwanted results (e.g., pressed a wrong key), and memory issues and cognitive burden. This presentation describes the process of developing a coding scheme, illustrates nuances of meanings in concepts related to usability, and presents preliminary results of our qualitative analysis.

VIRTUAL ONLINE COMMUNITIES FOR AGING LIFE EXPERIENCE (VOCALE) APPROACH: PILOT STUDIES

Emerging evidence suggests behavioral strategies focusing on symptom management can reduce frailty symptoms and improve quality of life. Unfortunately, these interventions are rarely scalable for implementation in geriatric care. Contemporary online technologies have tremendous potential for addressing this need. We developed and pilot tested an approach entitled Virtual Online Community for Aging Life Experience (VOCALE). The approach had two stages. In the first stage, we piloted the use of a Facebook platform to engage older adults with frailty symptoms in ten-week moderated discussions on health-related topics. In the second study, we used data from stage one to develop a prototypical persona of a person with frailty symptoms. The persona was then incorporated into an eight-week Facebook intervention informed by problem solving therapy to facilitate self-management in another group of older adults with frailty symptoms. The results from both rounds showed that it was feasible to recruit, engage, and retain persons ages 69-92 into virtual online community interventions. Attrition ranged from 25% to 33% in rounds one and two. In both rounds, we observed positive trends of change in health measures such as general health self-efficacy, disease self-efficacy, and health literacy. Throughout the studies, older adults shared multiple posts concerning their experience with age-related symptoms and described their self-management practices. These projects, which leveraged a common social media platform, demonstrated preliminary efficacy of an online intervention for frailty management. If confirmed, this approach might provide a viable model for other medically complex geriatric conditions where self-management is essential.

Abstract A33: Population and evolutionary genomics of prostate cancer-associated variants: implications for health disparities in men of African descent

To determine why African men are more likely to suffer from prostate cancer (CaP), we integrated GWAS results and scans of selection with allele frequency data from 64 global populations. Despite substantial overlap in genetic risk scores across populations, we find that predicted CaP risk is highest in West Africans and that a small number of loci drive these differences in risk. There is a strong concordance between genetic risk scores and clinical estimates of CaP mortality. Although most CaP-associated loci are evolving neutrally, we find multiple instances where alleles have hitchhiked to high frequencies with linked locally adaptive alleles.

Citation Format: Joseph Lachance, Ali Berens, Matthew Hansen, Andrew Teng, Sarah Tishkoff, Timothy Rebbeck. Population and evolutionary genomics of prostate cancer-associated variants: implications for health disparities in men of African descent [abstract]. In: Proceedings of the AACR International Conference: New Frontiers in Cancer Research; 2017 Jan 18-22; Cape Town, South Africa. Philadelphia (PA): AACR; Cancer Res 2017;77(22 Suppl):Abstract nr A33.

Physician behaviors surrounding the implementation of decision and communication AIDS in a breast cancer clinic: a qualitative analysis of staff intern perceptions

The aim of this paper is to examine how physician behavior facilitated or impeded our implementation of decision and communication aids in a breast cancer clinic. Staff interns provided decision and communication aids to patients and wrote up case notes for each patient they served. We used grounded theory to code our staff interns' case notes. We then identified barriers and facilitators to our program's implementation from each category we generated in the coding. Facilitators included physicians reading patient questions and then bringing the staff interns to the consultation. Barriers included physicians forgetting to bring the staff interns to the appointments and discouraging interns from speaking during the consultation. Physicians vary in their cooperation with our program. Our next steps will be to inquire directly with physicians about how to adapt our program design. We will also seek to position the staff interns as mentees to increase physician commitment to our program.

Medical staff's knowledge of pulse oximetry: a prospective survey conducted in a tertiary children's hospital

OBJECTIVES

To assess the knowledge of pulse oximetry of senior (SMO) and junior medical officers (JMO) in a tertiary paediatric hospital.

METHODS

A 16-item multiple choice questionnaire was administered to SMO and JMO without prior notice or instruction in the area. The questions were completed voluntarily and anonymously, then proctored and collated by the principal investigator.

RESULTS

The mean test scores for SMO and JMO were 70 +/- 15% and 65 +/- 13%, respectively (P = 0.06). A significant negative correlation was found between the test scores and the years of paediatric experience with the SMO.

CONCLUSIONS

The results of the survey showed there is an insufficiency of knowledge and understanding among medical staff concerning the principles, clinical applications and limitations of pulse oximetry. More emphasis needs to be placed on teaching these principles to ensure quality care for patients.

nCPAP improves abnormal autonomic function in at-risk-for-SIDS infants with OSA

We evaluated cardiovascular autonomic control and arousability during sleep in infants with obstructive sleep apnea (OSA) before and after 10 +/- 4 (mean +/- SD) days of treatment with nasal continuous positive airway pressure (nCPAP). Six OSA infants and 12 age-matched control infants were studied with polygraphic sleep studies at the age of 13 +/- 4 wk. During the study, 45 degrees head-up tilt tests were performed in slow-wave and rapid eye movement sleep. Blood pressure (BP) and heart rate (HR) were continuously monitored. All OSA infants had decreased initial BP and HR responses, followed by hypotension in two and hypertension in two. OSA infants displayed higher arousal thresholds in response to the tilt in rapid eye movement sleep (P < 0.005) and higher baseline HR (P < 0.05) than controls. nCPAP treatment normalized BP and HR responses as well as arousal thresholds to tilting and stabilized HR levels. OSA in infants may be linked with cardiovascular autonomic control disturbances and decreased arousability during sleep. These defects are improved by control of OSA with nCPAP.

Cardiovascular responses to three simple, provocative tests of autonomic activity in sleeping infants

Whereas defective cardiovascular autonomic control has been implicated in the sudden infant death syndrome, relatively little is known about the normal development of autonomic control, due to the inability to measure blood pressure in infants noninvasively. We studied 12 normal infants [age: 13 +/- 2 (SD) wk] using a noninvasive method of continuous blood pressure recording and examined the cardiovascular responses to 45 degrees head-up tilting, a modified cold face test, and a loud noise. In head-up tilting, in both slow-wave sleep and rapid eye movement sleep, all infants displayed a rapid biphasic heart rate response (mean increase of 16% and mean decrease of 21%) and blood pressure response (mean increase of 16% and mean decrease of 16%), with a return to pretest values within 20 s. Both ice and noise caused a less pronounced biphasic response. In conclusion, at 3 mo, infants show the adult pattern of response to postural challenge. The short latency of the response suggests that neural inputs, apart from baroreceptors, are involved in the initial phase of the response.

[Expression of adhesion molecules on CD34(+) hematopoietic precursor cells from normal human bone marrow, cord blood and mobilized blood]

OBJECTIVE

To investigate the expression of adhesion molecules on CD(34)(+) hematopoietic precursor cells from normal human bone marrow, cord blood and mobilized peripheral blood, and the mechanism of peripheral blood precursor cells mobilization.

METHODS

CD(34)(+) hematopoietic cells were separated from bone marrow, cord blood and mobilized peripheral blood by CD(34) MultiSort Kit immunomagnetic bead system. The purity was examined by FACSort. The CD(34)(+) cells and post-short-term cultured CD(34)(+) cells were labeled in an indirect immuno-fluorescence procedure with adhesion molecules CD(11a), CD(18), CD(44), CD(49d), CD(54), CD(58) and CD(62L) monoclonal antibodies and assayed by FACSort.

RESULTS

The expression of CD(11a), CD(18), CD(49d), CD(54), CD(58) and CD(62L) of mobilized peripheral blood CD(34)(+) cells was lower than that of bone marrow ones, especially for CD(49d) and CD(62L). Similar to mobilized peripheral blood CD(34)(+) cells, cord blood CD(34)(+) cells also showed a lower expression of CD(11a), CD(18), CD(44), CD(49d), CD(62L) than that of bone marrow ones, especially for CD(62L), but expression of CD(54) was higher than that of bone marrow and mobilized peripheral blood CD(34)(+) cells.

CONCLUSION

The expressions of cell adhesion molecules on CD(34)(+) cells in normal bone marrow, cord blood and mobilized peripheral blood were quite different, the mechanism of peripheral blood precursors mobilization might be related to downregulation of cell adhesion molecule expression.

Is dipalmitoylphosphatidylcholine a substrate for convertase?

Convertase has homology with carboxylesterases, but its substrate(s) is not known. Accordingly, we determined whether dipalmitoylphosphatidylcholine (DPPC), the major phospholipid in surfactant, was a substrate for convertase. We measured [(3)H]choline release during cycling of the heavy subtype containing [(3)H]choline-labeled DPPC with convertase, phospholipases A(2), B, C, and D, liver esterase, and elastase. Cycling with liver esterase or peanut or cabbage phospholipase D produced the characteristic profile of heavy and light peaks observed on cycling with convertase. In contrast, phospholipases A(2), B, and C and yeast phospholipase D produced a broad band of radioactivity across the gradient without distinct peaks. [(3)H]choline was released when natural surfactant containing [(3)H]choline-labeled DPPC was cycled with yeast phospholipase D but not with convertase or peanut and cabbage phospholipases D. Similarly, yeast phospholipase D hydrolyzed [(3)H]choline from [(3)H]choline-labeled DPPC after incubation in vitro, whereas convertase, liver esterase, or peanut and cabbage phospholipases D did not. Thus convertase, liver esterase, and plant phospholipases D did not hydrolyze choline from DPPC either on cycling or during incubation with enzyme in vitro. In conclusion, conversion of heavy to light subtype of surfactant by convertase may require a phospholipase D type hydrolysis of phospholipids, but the substrate in this reaction is not DPPC.

Dibutyl phthalate purged autologous bone marrow transplant in the treatment of leukemia

It has been proved that di-N-butyl phthalate (DBP) is singular in killing leukemic cells selectively or accelerating the deterioration of residual leukemic cells in long-term marrow culture in vitro. Based on this principle, the DBP-purged autologous bone marrow transplant has been applied to the treatment of a group of 14 patients suffering from acute nonlymphocytic leukemia. After 5-10 days of in vitro co-culture of marrow cells with DBP at a concentration of 50 micrograms/ml, the recovery of total nucleated cells and the amount of CFU-GM were 67.5% and 68.1%, respectively. In all patients, the reconstitution of hematopoiesis was observed after pre-conditioning and transfusion of purged marrow cells. Among these, two patients had a relapse, two patients died from complications of transplant, one patient died from non-leukemic disease, and the others are all alive and free of disease; the mean survival time as calculated recently was 15 months. These preliminary clinical data support that marrow culture in the presence of DBP is a safe and effective measure for treating leukemia in purged autologous bone marrow transplant.

Trisomy 18 phenotype in a patient with an isopseudodicentric 18 chromosome

We report a female patient with a typical trisomy 18 phenotype who has a 46,XX, -18, +isopseudodic(18)(p11) karotype. The lack of features of the 18p- syndrome suggests that a significant amount of short arm material is present and that the Turner-like features associated with 18p- may be determined by monosomy for 18p11. The phenotype-genotype correlations in abnormalities affecting chromosome 18 are reviewed.