Impact of EASO/ESPEN-Defined Sarcopenic Obesity Following a Technology-Based Weight Loss Intervention

BACKGROUND

Sarcopenic Obesity is the co-existence of increased adipose tissue (obesity) and decreased muscle mass or strength (sarcopenia) and is associated with worse outcomes than obesity alone. The new EASO/ESPEN consensus provides a framework to standardize its definition. This study sought to evaluate whether there are preliminary differences observed in weight loss or physical function in older adults with and without sarcopenic obesity taking part in a multicomponent weight loss intervention using these new definitions.

METHODS

A 6-month, non-randomized, non-blinded, single-arm pilot study was conducted from 2018 to 2020 in adults ≥ 65 years with a body mass index (BMI) ≥ 30 kg/m2. Weekly dietitian visits and twice-weekly physical therapist-led exercise classes were delivered using telemedicine. We conducted a secondary retrospective analysis of the parent study (n = 53 enrolled, n = 44 completers) that investigated the feasibility of a technology-based weight management intervention in rural older adults with obesity. Herein, we applied five definitions of sarcopenic obesity (outlined in the consensus) to ascertain whether the response to the intervention differed among those with and without sarcopenic obesity. Primary outcomes evaluated included weight loss and physical function (30-s sit-to-stand).

RESULTS

In the parent study, mean weight loss was - 4.6 kg (95% CI - 3.6, - 5.6; p < 0.001). Physical function measures of 30-s sit-to-stand showed a mean increase of 3.1 in sit-to-stand repetitions (+ 1.9, + 4.3; p < 0.001). In this current analysis, there was a significant decrease in weight and an increase in repetitions between baseline and follow-up within each group of individuals with and without sarcopenia for each of the proposed definitions. However, we did not observe any significant differences in the changes between groups from baseline to follow-up.

CONCLUSIONS

The potential lack of significant differences in weight loss or physical function between older adults with and without sarcopenic obesity participating in a weight loss intervention may suggest that well-designed, multicomponent interventions can lead to similar outcomes irrespective of sarcopenia status in persons with obesity. Fully powered randomized clinical trials are critically needed to confirm these preliminary results.

Protein Supplementation May Dampen Positive Effects of Exercise on Glucose Homeostasis: A Pilot Weight Loss Intervention

BACKGROUND

The role of protein in glucose homeostasis has demonstrated conflicting results. However, little research exists on its impact following weight loss. This study examined the impact of protein supplementation on glucose homeostasis in older adults >65 years with obesity seeking to lose weight.

METHODS

A 12-week, nonrandomized, parallel group intervention of protein (PG) and nonprotein (NPG) arms for 28 older rural adults (body mass index (BMI) ≥ 30 kg/m2) was conducted at a community aging center. Both groups received twice weekly physical therapist-led group strength training classes. The PG consumed a whey protein supplement three times per week, post-strength training. Primary outcomes included pre/post-fasting glucose, insulin, inflammatory markers, and homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

Mean age and baseline BMI were 72.9 ± 4.4 years and 37.6 ± 6.9 kg/m2 in the PG and 73.0 ± 6.3 and 36.6 ± 5.5 kg/m2 in the NPG, respectively. Mean weight loss was -3.45 ± 2.86 kg in the PG and -5.79 ± 3.08 kg in the NPG (p < 0.001). There was a smaller decrease in pre- vs. post-fasting glucose levels (PG: -4 mg ± 13.9 vs. NPG: -12.2 ± 25.8 mg/dL; p = 0.10), insulin (-7.92 ± 28.08 vs. -46.7 ± 60.8 pmol/L; p = 0.01), and HOMA-IR (-0.18 ± 0.64 vs. -1.08 ± 1.50; p = 0.02) in the PG compared to the NPG.

CONCLUSIONS

Protein supplementation during weight loss demonstrated a smaller decrease in insulin resistance compared to the NPG, suggesting protein may potentially mitigate beneficial effects of exercise on glucose homeostasis.

The association between cervical artery dissection and spinal manipulation among US adults

PURPOSE

Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults.

METHODS

Through analysis of health claims data, we employed a case-control study with matched controls, a case-control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6-7 months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group.

RESULTS

We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6 months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week.

CONCLUSION

Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.

Baseline Serum Biomarkers Predict Response to a Weight Loss Intervention in Older Adults with Obesity: A Pilot Study

Caloric restriction and aerobic and resistance exercise are safe and effective lifestyle interventions for achieving weight loss in the obese older population (>65 years) and may improve physical function and quality of life. However, individual responses are heterogeneous. Our goal was to explore the use of untargeted metabolomics to identify metabolic phenotypes associated with achieving weight loss after a multi-component weight loss intervention. Forty-two older adults with obesity (body mass index, BMI, ≥30 kg/m²) participated in a six-month telehealth-based weight loss intervention. Each received weekly dietitian visits and twice-weekly physical therapist-led group strength training classes with a prescription for aerobic exercise. We categorized responders' weight loss using a 5% loss of initial body weight as a cutoff. Baseline serum samples were analyzed to determine the variable importance to the projection (VIP) of signals that differentiated the responder status of metabolic profiles. Pathway enrichment analysis was conducted in Metaboanalyst. Baseline data did not differ significantly. Weight loss was 7.2 ± 2.5 kg for the 22 responders, and 2.0 ± 2.0 kg for the 20 non-responders. Mummichog pathway enrichment analysis revealed that perturbations were most significant for caffeine and caffeine-related metabolism (p = 0.00028). Caffeine and related metabolites, which were all increased in responders, included 1,3,7-trimethylxanthine (VIP = 2.0, p = 0.033, fold change (FC) = 1.9), theophylline (VIP = 2.0, p = 0.024, FC = 1.8), paraxanthine (VIP = 2.0, p = 0.028, FC = 1.8), 1-methylxanthine (VIP = 1.9, p = 0.023, FC = 2.2), 5-acetylamino-6-amino-3-methyluracil (VIP = 2.2, p = 0.025, FC = 2.2), 1,3-dimethyl uric acid (VIP = 2.1, p = 0.023, FC = 2.3), and 1,7-dimethyl uric acid (VIP = 2.0, p = 0.035, FC = 2.2). Increased levels of phytochemicals and microbiome-related metabolites were also found in responders compared to non-responders. In this pilot weight loss intervention, older adults with obesity and evidence of significant enrichment for caffeine metabolism were more likely to achieve ≥5% weight loss. Further studies are needed to examine these associations in prospective cohorts and larger randomized trials.

Adapting natural language processing and sentiment analysis methods for an intervention in older adults: Positive perceptions of health and technology

Background

Older adults frequently participate in behavior change studies, yet it is not clear how to quantify a potential relationship between their perception of the intervention and its efficacy.

Research Aim

We assessed the relationship between participant sentiment toward the intervention from follow-up interviews with physical activity and questionnaires for the perception of health.

Methods

Sentiment was calculated using the transcripts of exit interviews through a bag of words approach defined as the sum of positive and negative words in 28 older adults with obesity (body mass index ≥30kg/m2).

Results

Mean age was 73 years (82% female), and 54% lost ≥5% weight loss. Through linear regression we describe a significant association between positive sentiment about the intervention and weight loss; positive sentiment on technology and change in PROMIS-10 physical health and reduced physical activity time, while controlling for sex and age.

Conclusions

This analysis demonstrates that sentiment analysis and natural language processing in program review identified an association between perception and topics with clinical outcomes.

An analysis of the level of evidence behind treatments recommended by the Danish Medicines Council

OBJECTIVES

We aimed to investigate the quality of evidence and the expected added clinical value of treatments recommended by the Danish Medicines Council (DMC).

STUDY DESIGN

This was an observational study.

METHODS

The DMC prepares reports on drugs considered for possible new standard treatments in Danish hospitals. These reports evaluate the available evidence on efficacy and safety. The quality of evidence is systematically rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, and estimates of added clinical value are presented. The recommendations take into account expected economic implications of new treatments. The publicly available reports up until December 29, 2021, were downloaded from the DMC Web page. Reports on drugs marked "recommended" were included. Data on quality of evidence, expected clinical value, and economic implications were imputed in a Microsoft Excel spreadsheet.

RESULTS

Seventy-nine reports were included in the analysis. In 79% of these, the quality of evidence was rated low (24%) or very low (55%), whereas no recommendations were based on evidence rated as high quality. Three (5%) of recommended treatments were expected to add large clinical value.

CONCLUSIONS

Most recommendations by the DMC are based on evidence formally rated as low or very low quality by GRADE, and no recommendations were based on evidence rated as high quality. The added clinical value of the treatments was often not documented and rarely large. Continued attention to improve the clinical evidence behind national recommendations is necessary.

Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis

BACKGROUND

Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation.

METHODS

We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007-2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6-7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event.

RESULTS

The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar.

CONCLUSION

Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.

Human cytomegalovirus alters immune cell profile with potential implications for patient survival in head and neck cancer

Cytomegalovirus (CMV) is a highly prevalent human herpes virus that exerts a strong influence on immune repertoire which may influence cancer risk. We have tested whether CMV immunoglobulin G (IgG) serostatus is associated with immune cell proportions (n = 132 population controls), human papillomavirus (HPV) co-infection and head and neck cancer risk (n = 184 cancer cases and 188 controls) and patient survival. CMV status was not associated with the proportion of Natural Killer cells, B cells or the neutrophil-to-lymphocyte ratio. However, CD8+ T cells increased with increasing categories of IgG titers (P =1.7 × 10-10), and titers were inversely associated with the CD4:CD8 ratio (P = 5.6 × 10-5). Despite these differences in T cell proportions, CMV was not associated with HPV16 co-infection. CMV seropositivity was similar in cases (52%) and controls (47%) and was not associated with patient survival (hazard ratio [HR] 1.14, 95% confidence interval [CI]: 0.70 to 1.86). However, those patients with the highest titers had the worst survival (HR 1.91, 95% CI: 1.13 to 3.23). Tumor-based data from The Cancer Genome Atlas demonstrated that the presence of CMV transcripts was associated with worse patient survival (HR 1.79, 95% CI: 0.96 to 2.78). These findings confirm that a history of CMV infection alters T cell proportions, but this does not translate to HPV16 co-infection or head and neck cancer risk. Our data suggest that high titers and active CMV virus in the tumor environment may confer worse survival.

Validation of Resting Energy Expenditure Equations in Older Adults with Obesity

It is unclear which energy expenditure prediction equation should guide weight loss interventions in older adults with obesity. We ascertained the validity of four equations commonly used in practice in a series of weight loss studies of adults aged ≥65 with a body mass index ≥30kg/m² using indirect calorimetry data. Diagnostic accuracy was defined as <10% discrepancy between predicted and measured resting metabolic rate (RMR). Mean was 73.4 years. RMR using the ReeVue was 1,643 kCal. With 59.0% accuracy, the WHO equation demonstrated the highest accuracy while the Harris-Benedict yielded 53.5% accuracy. The Owens equation demonstrated the least variability (21.5% overprediction, 27.8% underprediction) with 50.7% accuracy. A SECA bioimpedance analyzer noted the second lowest accuracy of 49.6%. Only 43.1% of measurements were within 10% of the gold-standard indirect calorimetry value using the Mifflin equation. All equations demonstrated <60% accuracy suggesting a great need for estimating energy needs.

The relationship between multimorbidity, obesity and functional impairment in older adults

BACKGROUND

Declining mortality rates and an aging population have contributed to increasing rates of multimorbidity (MM) in the United States. MM is strongly associated with a decline in physical function. Obesity is an important risk factor for the development of MM, and its prevalence continues to rise. Our study aimed to evaluate the associations between obesity, MM, and rates of functional limitations in older adults.

METHODS

We analyzed body mass index (BMI) and self-reported comorbidity data from 7261 individuals aged ≥60 years from the National Health and Nutrition Examination Surveys 2005-2014. Weight status was defined based on standard BMI categories. MM was defined as 2 or more comorbidities, while functional limitations were self-reported. Adjusted logistic regression quantified the association between standard BMI categories and MM. We also examined the difference in the prevalence of limitations between those with and without MM.

RESULTS

The overall proportion of individuals with concomitant MM and obesity was 27.0%. Compared to a normal BMI, older adults with obesity had higher odds of MM (Prevalence odds ratio 1.79, 95% CI 1.49, 2.12). Overall, 67.5% of patients with MM also reported a functional limitation, with rates of functional limitation increasing with increasing BMI. When evaluating functional limitations in those with MM by BMI class, 90% of patients classified as severely obese (BMI ≥40 kg/m² ) with MM also had a concomitant functional limitation.

CONCLUSIONS

Compared to normal weight status, obesity is associated with an increased burden of MM and functional limitation among older adults. Our results underscore the importance of identifying and addressing obesity, MM, and functional limitation patterns and the need for evidence-based interventions that address all three conditions in this population.

Impact of whey protein supplementation in a weight-loss intervention in rural dwelling adults: A feasibility study

BACKGROUND & AIMS

Weight loss in older adults enhances physical function, but may lead to sarcopenia and osteoporosis. Whey protein is a low cost rich source of essential amino acids, may improve physical function. We evaluated the feasibility and acceptability of consuming whey protein in the context of a weight-loss intervention in older adults with obesity.

METHODS

A 12-week pilot feasibility, non-randomized weight loss study of 28 older adults was conducted, consisting of individualized, weekly dietitian visits with twice weekly physical therapist-led group strengthening classes. Half consumed whey protein, three times weekly, following exercise. Preliminary efficacy measures of body composition, sit-to-stand, 6-min walk and grip strength and subjective measures of self-reported health and function were also evaluated.

RESULTS

Of the 37 enrolled, 28 completed the study (50 % in the protein group). Attendance rates for protein vs. non-protein groups were 89.9 ± 11.1 % vs. 95.6 ± 3.4 % (p = 0.08). Protein consumption was high in those attending classes (90.3 %) as was compliance at home (82.6 %). Whey was pleasant (67.3 ± 22.1, range 30-100, above average), had little aftertaste, and was neither salty or sticky. All were compliant (0.64 ± 0.84, range 0-5, low = higher compliance). Both groups lost significant weight (protein vs. no protein, -3.45 ± 2.86 vs. -5.79 ± 3.08, p = 0.47); Sit-to-stand, 6-min walk, and gait speed were no different, grip strength was improved in the protein compared to the non-protein group (-2.63 kg vs. 4.29 kg; p < 0.001).

CONCLUSIONS

Our results suggest that whey protein is a low-cost and readily available nutritional supplement that can be integrated into a weight loss intervention.

Smartwatch Step-Counting App for Older Adults: Development and Evaluation Study (Preprint)

Background

Older adults who engage in physical activity can reduce their risk of mobility impairment and disability. Short amounts of walking can improve quality of life, physical function, and cardiovascular health. Various programs have been implemented to encourage older adults to engage in physical activity, but sustaining their motivation continues to be a challenge. Ubiquitous devices, such as mobile phones and smartwatches, coupled with machine-learning algorithms, can potentially encourage older adults to be more physically active. Current algorithms that are deployed in consumer devices (eg, Fitbit) are proprietary, often are not tailored to the movements of older adults, and have been shown to be inaccurate in clinical settings. Step-counting algorithms have been developed for smartwatches, but only using data from younger adults and, often, were only validated in controlled laboratory settings.

Objective

We sought to develop and validate a smartwatch step-counting app for older adults and evaluate the algorithm in free-living settings over a long period of time.

Methods

We developed and evaluated a step-counting app for older adults on an open-source wrist-worn device (Amulet). The app includes algorithms to infer the level of physical activity and to count steps. We validated the step-counting algorithm in the lab (counting steps from a video recording, n=20) and in free-living conditions—one 2-day field study (n=6) and two 12-week field studies (using the Fitbit as ground truth, n=16). During app system development, we evaluated 4 walking patterns: normal, fast, up and down a staircase, and intermittent speed. For the field studies, we evaluated 5 different cut-off values for the algorithm, using correlation and error rate as the evaluation metrics.

Results

The step-counting algorithm performed well. In the lab study, for normal walking (R²=0.5), there was a stronger correlation between the Amulet steps and the video-validated steps; for all activities, the Amulet’s count was on average 3.2 (2.1%) steps lower (SD 25.9) than the video-validated count. For the 2-day field study, the best parameter settings led to an association between Amulet and Fitbit (R²=0.989) and 3.1% (SD 25.1) steps lower than Fitbit, respectively. For the 12-week field study, the best parameter setting led to an R² value of 0.669.

Conclusions

Our findings demonstrate the importance of an iterative process in algorithm development before field-based deployment. This work highlights various challenges and insights involved in developing and validating monitoring systems in real-world settings. Nonetheless, our step-counting app for older adults had good performance relative to the ground truth (a commercial Fitbit step counter). Our app could potentially be used to help improve physical activity among older adults.

MethylSPWNet and MethylCapsNet: Biologically Motivated Organization of DNAm Neural Networks, Inspired by Capsule Networks

DNA methylation (DNAm) alterations have been heavily implicated in carcinogenesis and the pathophysiology of diseases through upstream regulation of gene expression. DNAm deep-learning approaches are able to capture features associated with aging, cell type, and disease progression, but lack incorporation of prior biological knowledge. Here, we present modular, user-friendly deep-learning methodology and software, MethylCapsNet and MethylSPWNet, that group CpGs into biologically relevant capsules-such as gene promoter context, CpG island relationship, or user-defined groupings-and relate them to diagnostic and prognostic outcomes. We demonstrate these models' utility on 3,897 individuals in the classification of central nervous system (CNS) tumors. MethylCapsNet and MethylSPWNet provide an opportunity to increase DNAm deep-learning analyses' interpretability by enabling a flexible organization of DNAm data into biologically relevant capsules.

A Weight Loss Intervention Augmented by a Wearable Device in Rural Older Adults With Obesity: A Feasibility Study

BACKGROUND

Older persons with obesity aged 65+ residing in rural areas have reduced access to weight management programs due to geographic isolation. The ability to integrate technology into health promotion interventions shows a potential to reach this underserved population.

METHODS

A 12-week pilot in 28 older rural adults with obesity (body mass index [BMI] ≥ 30 kg/m2) was conducted at a community aging center. The intervention consisted of individualized, weekly dietitian visits focusing on behavior therapy and caloric restriction with twice weekly physical therapist-led group strengthening training classes in a community-based aging center. All participants were provided a Fitbit Flex 2. An aerobic activity prescription outside the strength training classes was provided.

RESULTS

Mean age was 72.9 ± 5.3 years (82% female). Baseline BMI was 37.1 kg/m2, and waist circumference was 120.0 ± 33.0 cm. Mean weight loss (pre/post) was 4.6 ± 3.2 kg (4.9 ± 3.4%; p < .001). Of the 40 eligible participants, 33 (75%) enrolled, and the completion rate was high (84.8%). Objective measures of physical function improved at follow-up: 6-minute walk test improved: 35.7 ± 41.2 m (p < .001); gait speed improved: 0.10 ± 0.24 m/s (p = .04); and five-times sit-to-stand improved by 2.1 seconds (p < .001). Subjective measures of late-life function improved (5.2 ± 7.1 points, p = .003), as did Patient-Reported Outcome Measurement Information Systems mental and physical health scores (5.0 ± 5.7 and 4.4 ± 5.0, both p < .001). Participants wore their Fitbit 93.9% of all intervention days, and were overall satisfied with the trial (4.5/5.0, 1-5 low-high) and with Fitbit (4.0/5.0).

CONCLUSIONS

A multicomponent obesity intervention incorporating a wearable device is feasible and acceptable to older adults with obesity, and potentially holds promise in enhancing health.

Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability

BACKGROUND

Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients.

METHODS

A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use.

RESULTS

The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future.

CONCLUSIONS

Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.

BandPass: A Bluetooth-Enabled Remote Monitoring Device for Sarcopenia

As the United States population ages, managing pathologies that largely affect older adults, including sarcopenia (i.e., loss of muscle mass and strength) represents a significant and growing clinical challenge. In addition to increased rates of sarcopenia with age, its incidence and impact increase after acute illness, increasing the risk of functional decline, institutionalization, or death. Resistance-based exercises promote muscle regeneration and strength and are an advised therapy for such patients. Yet, such therapeutic exercises are normally conducted either under direct clinical oversight or unsupervised by patients at home, where compliance rates are low. The presented device, BandPass, aims to create an integrated force data detection and acquisition system for monitoring and transmitting at-home exercise force data to patients and clinicians. A potentiometer-based sensor was integrated to a resistance exercise band through the use of custom designed electronics, which incorporated Bluetooth Low Energy (BLE) for wireless transmission to a mobile 'app'. A protocol for calibrating the device was developed using a range of loads and validated in static benchtop and dynamic testing. Data from a pilot study with 7 older adults was also collected and analyzed to test the device. BandPass is 94% accurate with a coefficient of variation (CoV) of 4.9% and sensitivity of 150g. The pilot study recorded 147 exercises, allowing for analysis on patients' exercise performances. BandPass was successfully able to measure force continuously over time during exercises, measure longitudinal compliance with exercises, and quantify force continuously over time. A mobile health (mHealth) force-sensing system allows for the remote monitoring of prescribed in-home resistance exercise band programs for at-risk older adults, bridging the gap between clinicians and patients.

Usability Assessment of a Bluetooth-Enabled Resistance Exercise Band Among Young Adults

Background

Resistance-based exercises effectively enhance muscle strength, which is especially important in older populations as it reduces the risk of disability. Our group developed a Bluetooth-enabled handle for resistance exercise bands that wirelessly transmits relative force data through low-energy Bluetooth to a local smartphone or similar device. We present a usability assessment that evaluates an exercise system featuring a novel Bluetooth-enabled resistance exercise band, ultimately intended to expand the accessibility of resistance training through technology-enhanced home-based exercise programs for older adults. Although our target population is older adults, we assess the user experience among younger adults as a convenient and meaningful starting point in the testing and development of our device.

Methods

There were 32 young adults participating in three exercise sessions with the exercise band, after which each completed an adapted version of the Usefulness, Satisfaction, and Ease (USE) questionnaire to characterize the exercise system's strengths and weaknesses in usability.

Results

Questionnaire data reflected a positive and consistent user experience, with all 20 items receiving mean scores greater than 5.0 on a seven-point Likert scale. There were no specific areas of significant weakness in the device's user experience.

Conclusions

The positive reception among young adults is a promising indication that the device can be successfully incorporated into exercise interventions and that the system can be further developed and tested for the target population of older adults.

Weight management intervention identifies association of decreased DNA methylation age with improved functional age measures in older adults with obesity

Background

Assessing functional ability is an important component of understanding healthy aging. Objective measures of functional ability include grip strength, gait speed, sit-to-stand time, and 6-min walk distance. Using samples from a weight loss clinical trial in older adults with obesity, we examined the association between changes in physical function and DNA-methylation-based biological age at baseline and 12 weeks in 16 individuals. Peripheral blood DNA methylation was measured (pre/post) with the Illumina HumanMethylationEPIC array and the Hannum, Horvath, and PhenoAge DNA methylation age clocks were used. Linear regression models adjusted for chronological age and sex tested the relationship between DNA methylation age and grip strength, gait speed, sit-to-stand, and 6-min walk.

Results

Participant mean weight loss was 4.6 kg, and DNA methylation age decreased 0.8, 1.1, and 0.5 years using the Hannum, Horvath, and PhenoAge DNA methylation clocks respectively. Mean grip strength increased 3.2 kg. Decreased Hannum methylation age was significantly associated with increased grip strength (β = −0.30, p = 0.04), and increased gait speed (β = 0.02, p = 0.05), in adjusted models. Similarly, decreased methylation age using the PhenoAge clock was associated with significantly increased gait speed (β = 0.02, p = 0.04). A decrease in Horvath DNA methylation age and increase in physical functional ability did not demonstrate a significant association.

Conclusions

The observed relationship between increased physical functional ability and decreased biological age using DNA methylation clocks demonstrate the potential utility of DNA methylation clocks to assess interventional approaches to improve health in older obese adults.

Trial registration: National Institute on Aging (NIA), NCT03104192. Posted April 7, 2017, https://clinicaltrials.gov/ct2/show/NCT03104192

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

OBJECTIVE

Spinal manipulation (SM) is recommended for first-line treatment of patients with low back pain. Inadequate access to SM may result in inequitable spine care for older US adults, but the supply of clinicians who provide SM under Medicare is uncertain. The purpose of this study was to measure temporal trends and geographic variations in the supply of clinicians who provide SM to Medicare beneficiaries.

METHODS

Medicare is a US government-administered health insurance program that provides coverage primarily for older adults and people with disabilities. We used a serial cross-sectional design to examine Medicare administrative data from 2007 to 2015 for SM services identified by procedure code. We identified unique providers by National Provider Identifier and distinguished between chiropractors and other specialties by Physician Specialty Code. We calculated supply as the number of providers per 100 000 beneficiaries, stratified by geographic location and year.

RESULTS

Of all clinicians who provide SM to Medicare beneficiaries, 97% to 98% are doctors of chiropractic. The geographic supply of doctors of chiropractic providing SM services in 2015 ranged from 20/100 000 in the District of Columbia to 260/100 000 in North Dakota. The supply of other specialists performing the same services ranged from fewer than 1/100 000 in 11 states to 8/100 000 in Colorado. Nationally, the number of Medicare-active chiropractors declined from 47 102 in 2007 to 45 543 in 2015. The count of other clinicians providing SM rose from 700 in 2007 to 1441 in 2015.

CONCLUSION

Chiropractors constitute the vast majority of clinicians who bill for SM services to Medicare beneficiaries. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing.

Feasibility and acceptability of a technology-based, rural weight management intervention in older adults with obesity

BACKGROUND

Older adults with obesity residing in rural areas have reduced access to weight management programs. We determined the feasibility, acceptability and preliminary outcomes of an integrated technology-based health promotion intervention in rural-living, older adults using remote monitoring and synchronous video-based technology.

METHODS

A 6-month, non-randomized, non-blinded, single-arm study was conducted from October 2018 to May 2020 at a community-based aging center of adults aged ≥65 years with a body mass index (BMI) ≥30 kg/m2. Weekly dietitian visits focusing on behavior therapy and caloric restriction and twice-weekly physical therapist-led group strength, flexibility and balance training classes were delivered using video-conferencing to participants in their homes. Participants used a Fitbit Alta HR for remote monitoring with data feedback provided by the interventionists. An aerobic activity prescription was provided and monitored.

RESULTS

Mean age was 72.9±3.9 years (82% female). Baseline anthropometric measures of weight, BMI, and waist circumference were 97.8±16.3 kg, 36.5±5.2 kg/m2, and 115.5±13.0 cm, respectively. A total of 142 participants were screened (n=27 ineligible), and 53 consented. There were nine dropouts (17%). Overall satisfaction with the trial (4.7+ 0.6, scale: 1 (low) to 5 (high)) and with Fitbit (4.2+ 0.9) were high. Fitbit was worn an average of 81.7±19.3% of intervention days. In completers, mean weight loss was 4.6±3.5 kg or 4.7±3.5% (p< 0.001). Physical function measures of 30-s sit-to-stand repetitions increased from 13.5±5.7 to 16.7±5.9 (p< 0.001), 6-min walk improved by 42.0±77.3 m (p=0.005) but no differences were observed in gait speed or grip strength. Subjective measures of late-life function improved (3.4±4.7 points, p< 0.001).

CONCLUSIONS

A technology-based obesity intervention is feasible and acceptable to older adults with obesity and may lead to weight loss and improved physical function.

CLINICAL TRIAL REGISTRATION

Registered on Clinicaltrials.gov # NCT03104205 . Registered on April 7, 2017. First participant enrolled on October 1st, 2018.

TBIO-05. GENOME-SCALE NUCLEOTIDE-SPECIFIC CHARACTERIZATION OF 5-HYDROXYMETHYLCYTOSINE IN PEDIATRIC CENTRAL NERVOUS SYSTEM TUMORS

Though aberrant cytosine modifications are prevalent in cancer, nucleotide-specific 5-hydroxymethylcytosine (5hmC) modifications remain understudied, including in pediatric CNS tumors. Brain 5-hydroxymethylation is linked with development and differentiation. We measured genome-scale nucleotide-specific 5hmC in patients with diagnoses of glioma, ependymoma, and embryonal tumors under age 18 (n=36), and in non-tumor pediatric brain tissues (n=3). DNA was processed with tandem oxidative (OxBS) and bisulfite (BS) treatments followed by hybridization to the Illumina Methylation EPIC Array that interrogates over 860,000 CpG sites. We used the OxyBS R package to determine levels of 5hmC and 5mC. Mean 5hmC levels were lower in tumors (gliomas 4.1%, ependymomas 3.9%, and embryonal tumors 3.4%) compared to nontumor tissues (5.3%). We subset to the CpGs with the 5% highest 5hmC content for downstream analyses (37,173 CpGs). These sites were enriched among regulatory elements, including TFBS (Odds Ratio 1.14 p-value 3.57E-20) and super-enhancers (OR 1.93, p-value 1.14E-126). Linear mixed-effects models adjusted for age, sex, and cell type proportions tested the CpG-specific differences in 5hmC between tumor and nontumor samples, as well as between tumor subtypes. 5hmC levels were depleted across tumors compared with nontumor brain tissues, including at CpG islands. Model-based clustering (RPMM) results indicated that patients with low 5hmC patterns have poorer overall survival and increased risk of recurrence. Our results indicate that 5hmC localizes to sites in the DNA critical to gene regulation and is associated with patient outcomes. This study offers an opportunity to potentially contribute to classification markers for childhood brain tumors.

Remote Rehabilitation: A Field-Based Feasibility Study of an mHealth Resistance Exercise Band

Sarcopenia is the age-related loss of muscle mass and strength that is associated with adverse health outcomes. Resistance-based exercises are effective for mitigation and enhancement of strength; however, adherence is low and challenging to measure when patients are at home. In a single-arm, pilot study of seven older adults, we conducted a field-based usability study evaluating the feasibility and acceptability of using a system consisting of a Bluetooth-connected resistance exercise band and tablet-based app which together we call BandPass in completing four different home-based exercises. The system measured a total of 147 exercises by participants with a mean duration of 94±66 seconds, completing an average of 30±20 repetitions. Though not all patients completed each exercise type, patients were positive about use: patient activation measure: 80.7±14; system usability scale: 6.9±2.9; and confidence in use: 7.7±2.7. The BandPass system demonstrated its ability to collect data on exercise type, force during an exercise, and duration of exercise when older adults use it for monitoring exercise at home.

Altered immune phenotype and DNA methylation in panic disorder

Background

Multiple studies have related psychiatric disorders and immune alterations. Panic disorder (PD) has been linked with changes in leukocytes distributions in several small studies using different methods for immune characterization. Additionally, alterations in the methylation of repetitive DNA elements, such as LINE-1, have been associated with mental disorders. Here, we use peripheral blood DNA methylation data from two studies and an updated DNA methylation deconvolution library to investigate the relation of leukocyte proportions and methylation status of repetitive elements in 133 patients with panic disorder compared with 118 controls.

Methods and results

We used DNA methylation data to deconvolute leukocyte cell-type proportions and to infer LINE-1 element methylation comparing PD cases and controls. We also identified differentially methylated CpGs associated with PD using an epigenome-wide association study approach (EWAS), with models adjusting for sex, age, and cell-type proportions. Individuals with PD had a lower proportion of CD8T cells (OR: 0.86, 95% CI: 0.78–0.96, P-adj = 0.030) when adjusting for age, sex, and study compared with controls. Also, PD cases had significantly lower LINE-1 repetitive element methylation than controls (P < 0.001). The EWAS identified 61 differentially methylated CpGs (58 hypo- and 3 hypermethylated) in PD (Bonferroni adjusted P < 1.33 × 10^–7).

Conclusions

These results suggest that those with panic disorder have changes to their immune system and dysregulation of repeat elements relative to controls.

Intensive nutrition counseling as part of a multi-component weight loss intervention improves diet quality and anthropometrics in older adults with obesity

BACKGROUND AND AIMS

Obesity significantly impacts older adults. Intensive nutrition counseling can aid in weight reduction and improve diet quality, but data are sparse in this population. The objective of this intervention is to determine how intensive nutrition counseling affects diet quality and anthropometric measures during a multi-component weight loss intervention in rural older adults with obesity.

METHODS

A series of 12-week, single-arm feasibility pilots were conducted in fall 2017 and winter/spring 2018 in a community aging center in rural Northern New England. Adults were eligible if ≥ 65 years old with a Body Mass Index (BMI) ≥30 kg/m². Exclusion criteria included dementia/cognitive impairment, uncontrolled psychiatric illness, weight-loss surgery, weight loss >5% in previous 6-months, life-threatening illness, palliative/hospice services, current participation in another weight-loss study/program, obesogenic medications, or presence of major chronic conditions. Participants received once-weekly nutrition counseling by a registered dietitian nutritionist (RDN), and twice-weekly exercise sessions by a physical therapist (PT). Primary outcomes were diet quality changes measured by total Rapid Eating and Activity Assessment for Patients-Short Version (REAP-S) and Automated Self-Administered 24-h dietary recall (ASA-24). Secondary outcome measures were changes in weight (kilograms) and waist circumference (centimeters). McNemar test was conducted for all paired categorical data while paired t-tests were conducted for all paired continuous data. All analyses were conducted in R; p-value<0.05 was significant.

RESULTS

Total n = 23. Mean age was 72.2 (5.8) years (73.9% female); mean BMI was 35.9 ± 5.0 kg/m². At 12 weeks, diet quality significantly improved. REAP-S scores increased by 3.53 ± 3.13 points (p < 0.001). Kilocalories, grams fat, grams saturated fat, milligrams sodium, grams added sugar, and grams alcohol via ASA-24 significantly decreased (all p < 0.05). Significant reductions in weight (-5.22 ± 3.13 kg) and waist circumference (-6.88 ± 5.67 cm) were observed (both p < 0.001).

CONCLUSION

Intensive nutrition counseling significantly enhances diet quality and reduces weight and waist circumference in rural older adults with obesity.

A Community-Based Feasibility Study of Weight-Loss in Rural, Older Adults with Obesity

This study was a 12-week feasibility weight-loss intervention consisting of caloric restriction and aerobic/resistance exercise in older adults with obesity (body mass index ≥ 30 kg/m²) in a geographically isolated area. Primary outcomes assessed weight and physical function. Mean age was 71.0 ± 5.1 years (67% female). Individuals completed 100% of all assessments, attended 88% of the physical therapy classes and 89% of the nutrition sessions. Level of satisfaction (5-point Likert) was high (5.0, 1 - low; 5 - high). Weight decreased from 93.7 ± 9.7 to 89.4 ± 4.0 kg (p < 0.001). Mean BMI and waist circumference decreased, respectively, from 35.4 ± 3.4 to 33.6 ± 3.7 (p < 0.001), and 116.3 ± 7.5 to 108.7 ± 9.2 cm (p = 0.002). Grip strength, gait speed, and 5-times sit-to-stand time all improved from 29.2 ± 7.5 to 35.2 ± 6.7 kg (p = 0.006), 1.16 ± 0.21 to 1.35 ± 0.23 m/s (p = 0.004), and 12.5 ± 4.0 to 9.6 ± 1.7s (p = 0.02). The intervention was feasible and acceptable, and holds promise in promoting weight loss with a concomitant improvement in physical function in older adults.

Weight change and risk of the foundation of National Institute of Health Sarcopenia-defined low lean mass: Data from the National Health and Nutrition examination surveys 1999-2004

BACKGROUND

Self-reported weight change may lead to adverse outcomes. We evaluated weight change with cutpoints of low lean mass (LLM) in older adults.

METHODS

Of 4984 subjects ≥60 years from NHANES 1999-2004, we applied LLM cutoffs of appendicular lean mass (ALM):body mass index (BMI) males<0.789, females<0.512. Self-reported weight was assessed at time of survey, and questions asked participants their weight one and 10 years earlier, and at age 25. Weight changes were categorized as greater/less/none than 5%. Logistic regression assessed weight change (gain, loss, no change) on LLM, after adjustment.

RESULTS

Of 4984 participants (56.5% female), mean age and BMI were 71.1 years and 28.2 kg/m2. Mean ALM was 19.7 kg. In those with LLM, 13.5% and 16.3% gained/lost weight in the past year, while 48.9% and 19.4% gained/lost weight in the past decade. Compared to weight at age 25, 85.2 and 6.1% of LLM participants gained and lost ≥5% of their weight, respectively. Weight gain over the past year was associated with a higher risk of LLM (OR 1.35 [0.99,1.87]) compared to weight loss ≥5% over the past year (0.89 [0.70,1.12]). Weight gain (≥5%) over 10-years was associated with a higher risk of LLM (OR 2.03 [1.66, 2.49]) while weight loss (≥5%) was associated with a lower risk (OR 0.98 [0.76,1.28]). Results were robust compared to weight at 25 years (gain OR 2.37 [1.76,3.20]; loss OR 0.95 [0.65,1.39]).

CONCLUSION

Self-reported weight gain suggests an increased risk of LLM. Future studies need to verify the relationship with physical function.

Reported Weight Change in Older Adults and Presence of Frailty

OBJECTIVE

A 5% change in weight is a significant predictor for frailty and obesity. We ascertained how self-reported weight change over the lifespan impacts rates of frailty in older adults.

METHODS

We identified 4,984 subjects ≥60 years with body composition measures from the National Health and Nutrition Examination Survey. An adapted version of Fried's frailty criteria was used as the primary outcome. Self-reported weight was assessed at time current,1 and 10 years earlier and at age 25. Weight changes between each time point were categorized as ≥ 5%, ≤5% or neutral. Logistic regression assessed the impact of weight change on the outcome of frailty.

RESULTS

Among 4,984 participants, 56.5% were female, mean age was 71.1 years, and mean BMI was 28.2kg/m2. A weight loss of ≥ 5% had a higher association with frailty compared to current weight, age 25 (OR 2.94 [1.72,5.02]), 10 years ago (OR 1.68 [1.05,2.69]), and 1 year ago (OR 1.55 [1.02,2.36]). Weight gain in the last year was associated with increased rate of frailty (1.59 [1.09,2.32]).

CONCLUSION

There is an association between frailty and reported weight loss over time while only weight gain in the last year has an association with frailty.

MethylNet: an automated and modular deep learning approach for DNA methylation analysis

BACKGROUND

DNA methylation (DNAm) is an epigenetic regulator of gene expression programs that can be altered by environmental exposures, aging, and in pathogenesis. Traditional analyses that associate DNAm alterations with phenotypes suffer from multiple hypothesis testing and multi-collinearity due to the high-dimensional, continuous, interacting and non-linear nature of the data. Deep learning analyses have shown much promise to study disease heterogeneity. DNAm deep learning approaches have not yet been formalized into user-friendly frameworks for execution, training, and interpreting models. Here, we describe MethylNet, a DNAm deep learning method that can construct embeddings, make predictions, generate new data, and uncover unknown heterogeneity with minimal user supervision.

RESULTS

The results of our experiments indicate that MethylNet can study cellular differences, grasp higher order information of cancer sub-types, estimate age and capture factors associated with smoking in concordance with known differences.

CONCLUSION

The ability of MethylNet to capture nonlinear interactions presents an opportunity for further study of unknown disease, cellular heterogeneity and aging processes.

Relationship Between Food Insecurity and Functional Limitations in Older Adults from 2005-2014 NHANES

Background: Food insecurity refers to the physical, social, and economic inability to access and secure sufficient, safe and nutritious food. Food insecurity has been found to be associated with poor health status, obesity, and chronic disease. To date, a relationship between food insecurity and functional limitations has not been described in of older adults. Methods: We examined 9309 adults ≥60 years old from the 2005-2014 National Health and Nutrition Examination Surveys (NHANES). Food security was categorized as full, marginal, low, and very low. Functional limitations were assessed as having difficulty in physical, basic or instrumental activities of daily living. Results: Of adults ≥60 years old (mean age: 70.5 ± 0.08, 51% female), the prevalence of full, marginal, low, or very low food insecurity was 7572 (81%), 717 (7%), 667 (8%), and 353 (4%), respectively. The prevalence of any functional limitations was 5895 (66.3%). The adjusted odds (OR [95%CI]) of having any functional limitation in marginal, low, and very low food security levels compared to full food security are: 1.08 [1.02-1.13], 1.16 [1.10-1.22], 1.14 [1.07-1.21], respectively. The association between levels of food insecurity and functional limitation is modified by race/ethnicity. Conclusions: Functional limitation is significantly associated with increasing food insecurity in older adults.

Varying Levels of Food Insecurity Associated with Clinically Relevant Depressive Symptoms in U.S. Adults Aged 60 Years and Over: Results from the 2005-2014 National Health and Nutrition Survey

Food insecurity refers to restricted or uncertain access to and ineffective utilization of nutritious and safe foods. Although food insecurity is linked to poorer physical health consequences among older adults, national estimates are not well known on food insecurity and depression. Using the 2005-2014 National Health and Nutrition Examination Survey, this study examines the associations between varying food insecurity levels and clinically relevant depressive symptoms (defined by PHQ-9 ≥ 10) among adults ≥60 years old (n = 7969). Rates of clinically relevant depressive symptoms in marginal, low, and very low food security were 12.3, 16.3, and 25.2%, respectively. Marginal, low, and very low food security were significantly associated with clinically relevant depressive symptoms: odds ratio (OR) = 1.12 (95% confidence intervals [CI] 1.07-1.18), OR = 1.07 (95% CI 1.03-1.12), and OR = 1.24 (95% CI 1.16-1.32), respectively. Given the intersection of food insecurity and depression, geriatric health professionals should work to improve health and nutrition programs for older adults at risk for or experiencing both public health concerns.

Development and Implementation of a Person-Centered, Technology-Enhanced Care Model For Managing Chronic Conditions: Cohort Study

Background

Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this support model unsustainably burdensome on health care systems globally. Mobile health technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being used to their full extent within US health care systems.

Objective

The purpose of this study was to examine the use of staff and costs of a remote monitoring care model in persons with and without a chronic condition.

Methods

At Dartmouth-Hitchcock Health, 2894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a mobile phone app that facilitated digital communication with nursing and health behavior change staff. Health data were collected and automatically analyzed, and behavioral support communications were generated based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per capita expenditures.

Results

Participants averaged 41 years of age; 72.70% (2104/2894) were female and 12.99% (376/2894) had at least one chronic condition. On average each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 39.74% (8587/21,607) of all staff conversations, with higher per capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 and 0.19 per capita conversations, respectively, P<.001). When compared to the same period in the prior year, per capita health care expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls.

Conclusions

The technology-based chronic condition management care model was frequently used and demonstrated potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents

BACKGROUND/OBJECTIVE

In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use.

DESIGN

Retrospective, propensity score-matched, controlled, patient-level observational analysis.

SETTING

A total of 45 nursing homes in Spain.

PARTICIPANTS

A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls.

INTERVENTION

Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid.

MEASUREMENTS

At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use.

RESULTS

Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints.

CONCLUSION

We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Development and Usability Assessment of a Connected Resistance Exercise Band Application for Strength-Monitoring

Resistance exercise bands are a core component of any physical activity strengthening program. Strength training can mitigate the development of sarcopenia, the loss of muscle mass or strength and function with aging. Yet, the adherence of such behavioral exercise strategies in a home-based setting are fraught with issues of monitoring and compliance. Our group developed a Bluetooth-enabled resistance exercise band capable of transmitting data to an open-source platform. In this work, we developed an application to capture this information in real-time, and conducted three usability studies in two mixed-aged groups of participants (n=6 each) and a group of older adults with obesity participating in a weight-loss intervention (n=20). The system was favorable, acceptable and provided iterative information that could assist in future deployment on ubiquitous platforms. Our formative work provides the foundation to deliver home-based monitoring interventions in a high-risk, older adult population.

Development and Usability Assessment of a Connected Resistance Exercise Band Application for Strength-Monitoring

Resistance exercise bands are a core component of any physical activity strengthening program. Strength training can mitigate the development of sarcopenia, the loss of muscle mass or strength and function with aging. Yet, the adherence of such behavioral exercise strategies in a home-based setting are fraught with issues of monitoring and compliance. Our group developed a Bluetooth-enabled resistance exercise band capable of transmitting data to an open-source platform. In this work, we developed an application to capture this information in real-time, and conducted three usability studies in two mixed-aged groups of participants (n=6 each) and a group of older adults with obesity participating in a weight-loss intervention (n=20). The system was favorable, acceptable and provided iterative information that could assist in future deployment on ubiquitous platforms. Our formative work provides the foundation to deliver home-based monitoring interventions in a high-risk, older adult population.

Bring on the Machines: Could Machine Learning Improve the Quality of Patient Education Materials? A Systematic Search and Rapid Review

PURPOSE

Clear and trustworthy information is essential for people who are ill. People with cancer, in particular, are targeted with vast quantities of patient education material, but of variable quality. Machine learning technologies are popular across industries for automated tasks, like analyzing language and spotting readability issues. With the experience of patients with cancer in mind, we reviewed whether anyone has proposed, modeled, or applied machine learning technologies for the assessment of patient education materials and explored the utility of this application.

METHODS

We systematically searched the literature to identify English-language articles published in peer-reviewed journals or as conference abstracts that proposed, used, or modeled the use of machine learning technology to assess patient education materials. Specifically, we searched MEDLINE, Web of Science, CINAHL, and Compendex. Two reviewers assessed study eligibility and performed study screening.

RESULTS

We identified 1,570 publications in our search after duplicate removal. After screening, we included five projects (detailed in nine articles) that proposed, modeled, or used machine learning technology to assess the quality of patient education materials. We evaluated the utility of each application across four domains: multidimensionality (2 of 5 applications), patient centeredness (1 of 5 applications), customizability (0 of 5 applications), and development stage (theoretical, 1 of 5 applications; in development, 3 of 5 applications; complete and available, 1 of 5 applications). Combining points across each domain, the mean utlity score across included projects was 1.8 of 5 possible points.

CONCLUSION

Given its potential, machine learning has not yet been leveraged substantially in the assessment of patient education materials. We propose machine learning systems that can dynamically identify problematic language and content by assessing the quality of patient education materials across a range of flexible, customizable criteria. Assessment may help patients and families decide which materials to use and encourage developers to improve materials overall.

Detection and Monitoring of Repetitions Using an mHealth-Enabled Resistance Band

Sarcopenia is defined as an age-related loss of muscle mass and strength which impairs physical function leading to disability and frailty. Resistance exercises are effective treatments for sarcopenia and are critical in mitigating weight-loss induced sarcopenia in older adults attempting to lose weight. Yet, adherence to home-based regimens, which is a cornerstone to lifestyle therapies, is poor and cannot be ascertained by clinicians as no objective methods exist to determine patient compliance outside of a supervised setting. Our group developed a Bluetooth connected resistance band that tests the ability to detect exercise repetitions. We recruited 6 patients aged 65 years and older and recorded 4 specific, physical therapist-led exercises. Three blinded reviewers examined the findings and we also applied a peak Ending algorithm to the data. There were 16.6 repetitions per exercise across reviewers, with an intraclass correlation of 0.912 (95%CI: 0.853-0.953, p<0.001) between reviewers and the algorithm. Using this novel resistance band, we feasibly detected repetition of exercises in older adults.

Personal history of proliferative breast disease with atypia and risk of multifocal breast cancer

BACKGROUND

A history of proliferative breast disease with atypia (PBDA) may be indicative of an increased risk not just of breast cancer but also of a more aggressive form of breast cancer.

METHODS

Multifocal breast cancer (MFBC), defined as 2 or more tumors in the same breast upon a diagnosis of cancer, is associated with a poorer prognosis than unifocal (single-tumor) breast cancer. PBDA, including atypical ductal hyperplasia and atypical lobular hyperplasia, is a known risk factor for breast cancer. Using New Hampshire Mammography Network data collected for 3567 women diagnosed with incident breast cancer from 2004 to 2014, this study assessed the risk of MFBC associated with a previous diagnosis of PBDA.

RESULTS

Women with a history of PBDA were found to be twice as likely to be subsequently diagnosed with MFBC as women with no history of benign breast disease (BBD; odds ratio [OR], 2.23; 95% confidence interval [CI], 1.08-4.61). Ductal carcinoma in situ on initial biopsy was associated with a 2-fold increased risk of MFBC in comparison with invasive cancer (OR, 2.13; 95% CI, 1.58-2.88). BBD and proliferative BBD without atypia were not associated with MFBC.

CONCLUSIONS

Women with a history of previous PBDA may be at increased risk for MFBC. Women with a history of PBDA may benefit from additional presurgical clinical workup. Cancer 2018;124:1350-7. © 2017 American Cancer Society.

Usability testing of a prototype Phone Oximeter with healthcare providers in high- and low-medical resource environments

To increase the use of pulse oximetry by capitalise on the wide availability of mobile phones, we have designed, developed and evaluated a prototype pulse oximeter interfaced to a mobile phone. Usability of this Phone Oximeter was tested as part of a rapid prototyping process. Phase 1 of the study (20 subjects) was performed in Canada. Users performed 23 tasks, while thinking aloud. Time for completion of tasks and analysis of user response to a mobile phone usability questionnaire were used to evaluate usability. Five interface improvements were made to the prototype before evaluation in Phase 2 (15 subjects) in Uganda. The lack of previous pulse oximetry experience and mobile phone use increased median (IQR [range]) time taken to perform tasks from 219 (160-247 [118-274]) s in Phase 1 to 228 (151-501 [111-2661]) s in Phase 2. User feedback was positive and overall usability high (Phase 1--82%, Phase 2--78%).

Evaluation of left ventricular mass measured by 3D echocardiography using magnetic resonance imaging as gold standard

OBJECTIVE

Increased left ventricular mass (LVM) and presence of left ventricular hypertrophy (LVH) are predictors of cardiovascular morbidity and mortality, but can be reversed with proper treatment of the underlying cause. Therefore accurate as well as reproducible methods for diagnosis and follow-up are needed. We evaluated different modalities by which to measure LVM in patients with no known LVH using magnetic resonance imaging (MRI) as the gold standard: ECG using the formulae proposed by Sokolow-Lyon and Cornell, 2D echocardiography and 3D echocardiography.

METHODS

34 subjects were included in the study; 17 had a history of myocardial infarction, 7 had pulmonary hypertension and 10 were healthy. All patients and controls had a standard 12-lead ECG, a transthoracic 2D and 3D echocardiographic study and a cardiac MRI.

RESULTS

ECG estimates of LVM correlated poorly with LVM by MRI (r = 0.18, NS and 0.16, NS for Sokolow-Lyon and Cornell, respectively), whereas a moderate correlation between 2D and 3D echocardiography and MRI was observed (r = 0.63, p<0.001 and r = 0.74, p<0.001, respectively). All methods were reproducible with no significant bias.

CONCLUSION

LVM measured by 3D echocardiography is highly accurate compared to LVM measured by MRI. LVM calculated from 2D echocardiography also proved useful, whereas estimates of LVM by ECG are inaccurate in a non-hypertrophic population.

Comparison between two artificial shelter units and timed manual collections for detecting peridomestic Triatoma infestans (Hemiptera: Reduviidae) in rural northwestern Argentina

A new artificial shelter unit was compared with segments of bamboo cane lined with pleated filter paper for detecting peridomestic Triatoma infestans Klug at Amamá and nearby rural villages in northwestern Argentina. The new shelter unit consisted of a black plastic, wide-mouthed jar with a screw cap on the top, and a removable central structure made of pleated corrugated paper. In devices exposed from February to December 1999 at 24 sites positive for T. infestans by timed manual collections with an irritant in April 1999, the cumulative percentage of sites with any sign of infestation detected by the shelter unit increased from 71% after 2 mo to 96% after 10 mo, whereas bamboo cane units concurrently detected only 12-42% of the sites. Sensitivity increased with time of exposure and the abundance of T. infestans per site. In 19 sites negative for T. infestans by inspection, shelters increasingly detected infestation at 16-63% of sites after 10 mo, whereas the bamboo canes only detected one infestation. Shelter units inspected three times over an 11-mo period were significantly more sensitive than a single manual search with an irritant performed in March 2000. Our study provided conclusive field evidence that the shelter unit was more sensitive for detecting peridomestic T. infestans than were timed manual searches, the standard reference method, or bamboo cane units. Rapid timed searches by skilled bug collectors during the early surveillance phase overlooked many peridomestic populations that, in the absence of control, inevitably would increase in abundance and repopulate treated areas.

Serial changes in atrial natriuretic peptide and endothelin-1 concentrations. Their relationships to the cardiac performance of patients hospitalized for acute myocardial infarction

AIM

The study was designed to assess temporal changes in atrial natriuretic peptide (ANP) and endothelin-1 (ET) concentrations in patients hospitalized for acute myocardial infarction (AMI) and their relationships to cardiac performance determined by radionuclide ventriculography.

PATIENTS AND METHODS

20 patients with first AMI were studied. Blood samples were drawn within the first 4-18 h, after 18-24 h, and on days 2, 3 and 6. Plasma concentrations of ANP and ET were measured in blood samples taken simultaneously. Radionuclide ventriculography was performed on the day of discharge to determine left-ventricular ejection fraction (LVEF), left-ventricular end-diastolic volume index, end-systolic volume index and left-ventricular stroke volume index.

RESULTS

Median concentrations of ET decreased from 2.15 pmol/l on admission to 1.45 pmol/l at discharge (32%, p < 0.001). Median ANP rose from 29 to 79 pg/ml (172%, p < 0.001). The increment in ANP and the decrease in ET concentrations from admission to discharge was inversely correlated (r = -0.81, p < 0.005). ANP was inversely correlated to LVEF (r = -0.82, p < 0.001) and to the end-systolic volume index at discharge (r = -0.73, p < 0.003).

CONCLUSION

Dynamic and inverse fluctuations in ET and ANP occur within the 1st week of AMI. The magnitude of endocrine activation in the ANP-ET system seems to reflect an impairment in the left-ventricular systolic performance.

Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury

Although the Modified Ashworth Scale (MAS) is commonly used to assess the severity of muscle spasticity for ankle plantarflexors, its reliability has only been established for elbow muscles. Interrater reliability, intrarater reliability and temporal (between-days) reliability were examined in this study. Also, interrater reliability for use of the scale with plantarflexors was compared with reported results from the measurement of elbow flexors. Thirty adult volunteers with traumatic brain injuries participated. There were 20 men and 10 women; the mean age was 28.3 years (SD = 10.8). Two physical therapists used the MAS to score the subjects independently. Measurements were repeated to yield multiple scores for intrarater reliability assessment. Twenty-one of the subjects returned individually on separate days to be measured again, so that temporal reliability could be assessed. Spearman's correlation coefficients were 0.73 for interrater reliability 0.74 and 0.55 for intrarater reliability, and 0.82 for temporal reliability. Overall, reliability of the MAS for assessing plantarflexor spasticity in patients with traumatic brain injury was found to be minimally adequate to support its continued use. However, interrater reliability was less than that which has been reported for elbow flexors, and intrarater reliability findings were mixed.

[Embolic episodes after treatment of atrial fibrillation in a patient with thyrotoxicosis]

Thyrotoxic artrial fibrillation is well known and occurs in 10-30% of all patients with thyrotoxicosis. The risk of systemic embolism has been found to be 10-40% in patients with thyrotoxic atrial fibrillation. We present a case of 53 year-old man, a healthy and active athlete, with atrial fibrillation and thyrotoxicosis. He was treated with a beta-blocking agent (sotalol) and sent home. Seven days later, he suffered systemic arterial emboli, one in the right arm and one in the left leg. After embolectomy the patient started anticoagulation and no further complications occurred. Previous studies are discussed, and the following conclusions made. When taken together the data suggest that the rate of embolism in patients with thyrotoxic atrial fibrillation exceeds that of non-thyrotoxic atrial fibrillation unassociated with rheumatic heart disease. The majority of clinically evident embolic events that occur in patients with thyrotoxic atrial fibrillation involve the central nervous system. The rate of embolic events appears to be greatest early in the course of thyrotoxic atrial fibrillation, but may persist for some weeks after conversion and may be particularly high in patients with associated heart failure. It is suggested that anticoagulation therapy should be considered in these patients.

Beta 2-microglobulin expression of AIDS-related and classical Kaposi's sarcoma

The expression of beta 2-microglobulin, the invariable light chain of HLA class I molecules, of Kaposi's sarcoma from 11 AIDS patients and from 11 patients without known immunodeficiency was studied by immunohistochemistry using a polyclonal antibody to beta 2-microglobulin. The staining intensity of spindle cells in these lesions was scored in a semiquantitative system. We found that the spindle cells of Kaposi's sarcomas from AIDS patients showed significantly increased staining intensity for beta 2-microglobulin compared to those of Kaposi's sarcomas from non-AIDS patients. The results may indicate that Kaposi's sarcomas developing in immunocompromised individuals, such as AIDS patients, are not subject to immune selection by T cells eliminating HLA class I high-expressing tumor cells, while this may be the case in non-AIDS patients. Alternatively, the results may be caused by differences in the activity of cytokines, which upregulate the expression of HLA class I molecules on the cell surface.

Changes in left and right ventricular performance and volumes in seven-year survivors of acute myocardial infarction

We describe the spontaneous long-term changes in right (RV) and left (LV) ventricular performance during a 7-year period after acute myocardial infarction (AMI). Radionuclide ventriculography was performed in the second week after AMI in 201 patients. RV and LV ejection fractions, and LV end-diastolic and end-systolic volumes were determined. A follow-up after 7 years was performed in 55 survivors. Of these, 16 patients were also examined after 1 year. During the 7-year follow-up period, LV ejection fraction decreased from 0.49 to 0.45 (p < 0.01). LV end-diastolic volume increased from 161 to 210 ml (30%) (p < 0.01), and LV end-systolic volume from 83 to 123 ml (48%) (p < 0.01). In patients without recurrent AMI, coronary artery bypass grafting surgery, or angiotensin-converting enzyme inhibitor therapy (n = 37) during follow-up, no change in average LV ejection fraction was observed. Nevertheless, this subgroup had substantial increases in LV end-diastolic volume, from 157 to 190 ml (21%) (p = 0.002) and in LV end-systolic volume, from 80 to 105 ml (31%) (p < 0.001). In a subgroup of patients also reinvestigated after 1 year (n = 16), there was a 15% increase in LV end-diastolic volume the first year after AMI with an additional 10% increase in LV end-diastolic volume between years 1 and 7. Corresponding figures for LV end-systolic volume were 20% and 12%, respectively. Hardly any association was apparent between LV ejection fraction, LV end-diastolic volume, and LV stroke volume at discharge for subsequent LV dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)