Using adaptive behavior scores to convey level of functioning in children with autism spectrum disorder: Evidence from the Study to Explore Early Development

LAY ABSTRACT

Autistic people are often described as "low-" or "high-functioning" based on their scores on cognitive tests. These terms are common in publications and in everyday communication. However, recent research and feedback from the autistic community suggests that relying on cognitive ability alone to describe functioning may miss meaningful differences in the abilities of autistic children and adults and in the kinds of support they may need. Additional methods are needed to describe "functioning" in autistic children. We examined whether scores from a test measuring adaptive behaviors would provide information on the functional abilities of children with autism that is different from cognitive ability and autism symptom severity. Adaptive behaviors include age-appropriate skills that allow people to function in their everyday lives and social interactions. We found that a large amount of the variation in adaptive behavior scores was not explained by cognitive development, autism symptom severity, and behavioral and emotional problems. In addition, there was a wide range of adaptive ability levels in children with autism in our study, including in those with low, average, or high cognitive scores. Our results suggest that adaptive behavior scores could provide useful information about the strengths and support needs of autistic children above and beyond measures of cognitive ability and autism symptom severity. Adaptive behavior scores provide important information on the needs of autistic people.

Getting Rides from Others as a Coping Mechanism in the Transition to Non-Driving

OBJECTIVES

To characterize the effect of the actual and potential ability to get rides from others on older adults' driving reduction at three-year follow up in the United States.

METHODS

We analyzed National Health and Aging Trends Study data from community-dwelling drivers in 2015 (unweighted n = 5,102). We used weighted logistic regression models to estimate whether getting rides from others in 2015 was associated with older adults increasing the number of driving behaviors they avoided, decreasing the frequency with which they drove, or not driving at three-year follow up after adjusting for biopsychosocial variables. We also measured presence of social network members living nearby including household and non-household members and estimated associated odds of driving reduction at three-year follow up.

RESULTS

Older adults who got rides from others in 2015 had greater odds of reporting no longer driving at three-year follow up compared to those who did not get rides (adjusted Odds Ratio [aOR] = 1.53, 95% Confidence Interval [CI]: 1.11-2.11). We found no statistically significant association between older adults living with others or having more nearby confidantes outside their household and their odds of reducing driving at three-year follow up.

DISCUSSION

These findings suggest that getting rides from others plays an important role in the transition to non-driving for older adults. Future research should examine whether other aspects of social networks (e.g., type, quality, closer proximity) might also be key modifiable coping factors for older adults transitioning to non-driving.

"There is no expiration date": a qualitative analysis using the Social Cognitive Theory to identify factors influencing physical activity among adults living with advanced cancer

PURPOSE

To identify cognitive, behavioral, environmental, and other factors that influence physical activity in adults with advanced cancer using qualitative, semi-structured interviews.

METHODS

Eighteen semi-structured interviews were conducted with adults living with stage IV breast, prostate, or colorectal cancer; or multiple myeloma recruited from the University of Wisconsin Carbone Cancer Center. We used the Social Cognitive Theory to design the interview guide and a reflexive thematic approach for analysis.

RESULTS

Participants were 62 years old on average and currently receiving treatment. Despite reporting numerous barriers to physical activity, most participants discussed engaging in some physical activity. Participants reported difficulties coping with changes in physical functioning especially due to fatigue, weakness, neuropathy, and pain. While cold weather was seen as a deterrent for activity, access to sidewalks was a commonly reported feature of neighborhood conduciveness for physical activity. Regardless of current activity levels, adults with advanced cancer were interested in engaging in activities to meet their goals of gaining strength and maintaining independence. Having a conversation with a provider from their cancer care team about physical activity was seen as encouraging for pursuing some activity.

CONCLUSIONS

Adults living with advanced cancer are interested in pursuing activity to gain strength and maintain independence despite reported barriers to physical activity. To ensure patients are encouraged to be active, accessible resources, targeted referrals, and interventions designed to address their goals are critical next steps.

RELEVANCE

Integrating conversations about physical activity into oncology care for adults living with advanced cancer is an important next step to encourage patients to remain active and help them improve strength and maintain quality of life and independence.

Atopic dermatitis phenotype affects expression of atopic diseases despite similar mononuclear cell cytokine response

BACKGROUND

The atopic march refers to the coexpression and progression of atopic diseases in childhood, often beginning with atopic dermatitis (AD), although children may not progress through each atopic disease.

OBJECTIVE

We hypothesized that future atopic disease expression is modified by AD phenotype and that these differences result from underlying dysregulation of cytokine signaling.

METHODS

Children (n = 285) were enrolled into the Childhood Origins of Asthma (COAST) birth cohort and followed prospectively. Rates of AD, food allergy, allergic rhinitis, and asthma were assessed longitudinally from birth to 18 years of age. Associations between AD phenotype and food allergy, allergic rhinitis, asthma, allergic sensitization, exhaled nitric oxide, and lung function were determined. Peripheral blood mononuclear cell responses (IL-5, IL-10, IL-13, IFN-γ) to dust mite, phytohemagglutinin, Staphylococcus aureus Cowan I, and tetanus toxoid were compared among AD phenotypes.

RESULTS

AD at year 1 was associated with an increased risk of food allergy (P = .004). Both persistent and late-onset AD were associated with an increased risk of asthma (P < .001), rhinitis (P < .001), elevated total IgE (P < .001), percentage of aeroallergens with detectable IgE (P < .001), and elevated exhaled nitric oxide (P = .002). Longitudinal analyses did not reveal consistent differences in peripheral blood mononuclear cell responses among dermatitis phenotypes.

CONCLUSION

AD phenotype is associated with differential expression of other atopic diseases. Our findings suggest that peripheral blood cytokine dysregulation is not a mechanism underlying this process, and immune dysregulation may be mediated at mucosal surfaces or in secondary lymphoid organs.

Racial and ethnic disparities in the co-occurrence of intellectual disability and autism: Impact of incorporating measures of adaptive functioning

Intellectual disability (ID) commonly co-occurs in children with autism. Although diagnostic criteria for ID require impairments in both cognitive and adaptive functioning, most population-based estimates of the frequency of co-occurring ID in children with autism-including studies of racial and ethnic disparities in co-occurring autism and ID-base the definition of ID solely on cognitive scores. The goal of this analysis was to examine the effect of including both cognitive and adaptive behavior criteria on estimates of co-occurring ID in a well-characterized sample of 2- to 5-year-old children with autism. Participants included 3264 children with research or community diagnoses of autism enrolled in the population-based Study to Explore Early Development (SEED) phases 1-3. Based only on Mullen Scales of Early Learning (MSEL) composite cognitive scores, 62.9% (95% confidence interval [CI]: 61.1, 64.7%) of children with autism were estimated to have co-occurring ID. After incorporating Vineland Adaptive Behavior Scales, Second Edition (VABS-II) composite or domains criteria, co-occurring ID estimates were reduced to 38.0% (95% CI: 36.2, 39.8%) and 45.0% (95% CI: 43.1, 46.9%), respectively. The increased odds of meeting ID criteria observed for non-Hispanic (NH) Black and Hispanic children relative to NH White children when only MSEL criteria were used were substantially reduced, though not eliminated, after incorporating VABS-II criteria and adjusting for selected socioeconomic variables. This study provides evidence for the importance of considering adaptive behavior as well as socioeconomic disadvantage when describing racial and ethnic disparities in co-occurring ID in epidemiologic studies of autism.

Farm animal exposure, respiratory illnesses, and nasal cell gene expression

BACKGROUND

Farm exposures in early life reduce the risks for childhood allergic diseases and asthma. There is less information about how farm exposures relate to respiratory illnesses and mucosal immune development.

OBJECTIVE

We hypothesized that children raised in farm environments have a lower incidence of respiratory illnesses over the first 2 years of life than nonfarm children. We also analyzed whether farm exposures or respiratory illnesses were related to patterns of nasal cell gene expression.

METHODS

The Wisconsin Infant Study Cohort included farm (n = 156) and nonfarm (n = 155) families with children followed to age 2 years. Parents reported prenatal farm and other environmental exposures. Illness frequency and severity were assessed using illness diaries and periodic surveys. Nasopharyngeal cell gene expression in a subset of 64 children at age 2 years was compared to farm exposure and respiratory illness history.

RESULTS

Farm versus nonfarm children had nominally lower rates of respiratory illnesses (rate ratio 0.82 [95% CI, 0.69, 0.97]) with a stepwise reduction in illness rates in children exposed to 0, 1, or ≥2 animal species, but these trends were nonsignificant in a multivariable model. Farm exposures and preceding respiratory illnesses were positively related to nasal cell gene signatures for mononuclear cells and innate and antimicrobial responses.

CONCLUSIONS

Maternal and infant exposure to farms and farm animals was associated with nonsignificant trends for reduced respiratory illnesses. Nasal cell gene expression in a subset of children suggests that farm exposures and respiratory illnesses in early life are associated with distinct patterns of mucosal immune expression.

Rhinoviruses A and C elicit long-lasting antibody responses with limited cross-neutralization

Rhinoviruses (RVs) can cause severe wheezing illnesses in young children and patients with asthma. Vaccine development has been hampered by the multitude of RV types with little information about cross-neutralization. We previously showed that neutralizing antibody (nAb) responses to RV-C are detected twofold to threefold more often than those to RV-A throughout childhood. Based on those findings, we hypothesized that RV-C infections are more likely to induce either cross-neutralizing or longer-lasting antibody responses compared with RV-A infections. We pooled RV diagnostic data from multiple studies of children with respiratory illnesses and compared the expected versus observed frequencies of sequential infections with RV-A or RV-C types using log-linear regression models. We tested longitudinally collected plasma samples from children to compare the duration of RV-A versus RV-C nAb responses. Our models identified limited reciprocal cross-neutralizing relationships for RV-A (A12-A75, A12-A78, A20-A78, and A75-A78) and only one for RV-C (C2-C40). Serologic analysis using reference mouse sera and banked human plasma samples confirmed that C40 infections induced nAb responses with modest heterotypic activity against RV-C2. Mixed-effects regression modeling of longitudinal human plasma samples collected from ages 2 to 18 years demonstrated that RV-A and RV-C illnesses induced nAb responses of similar duration. These results indicate that both RV-A and RV-C nAb responses have only modest cross-reactivity that is limited to genetically similar types. Contrary to our initial hypothesis, RV-C species may include even fewer cross-neutralizing types than RV-A, whereas the duration of nAb responses during childhood is similar between the two species. The modest heterotypic responses suggest that RV vaccines must have a broad representation of prevalent types.

A multi-site trial of an electronic health integrated physical activity promotion intervention in breast and endometrial cancers survivors: MyActivity study protocol

Despite the known benefits of moderate-to-vigorous physical activity (MVPA) for breast and endometrial cancer survivors, most are insufficiently active, interventions response is heterogeneous, and MVPA programming integration into cancer care is limited. A stepped care approach, in which the least resource-intensive intervention is delivered first and additional components are added based on individual response, is one strategy to enhance uptake of physical activity programming. However, the most effective intervention augmentation strategies are unknown. In this singly randomized trial of post-treatment, inactive breast and endometrial cancer survivors (n = 323), participants receive a minimal intervention including a Fitbit linked with their clinic's patient portal and, in turn, the electronic health record (EHR) with weekly feedback delivered via the portal. MVPA progress summaries are sent to participants' oncology team via the EHR. MVPA adherence is evaluated at 4, 8, 12, 16 and 20 weeks; non-responders (those meeting ≤80% of the MVPA goal over previous 4 weeks) at each timepoint are randomized once for the remainder of the 24-week intervention to one of two "step-up" conditions: (1) online gym or (2) coaching calls, while responders continue with the minimal Fitbit+EHR intervention. The primary outcome is ActiGraph-measured MVPA at 24 and 48 weeks. Secondary outcomes include symptom burden and functional performance at 24 and 48 weeks. This trial will inform development of an effective, scalable, and tailored intervention for survivors by identifying non-responders and providing them with the intervention augmentations necessary to increase MVPA and improve health outcomes. Clinical Trials Registration # NCT04262180.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

1659. Association of Rurality and Identifying as Black with Receipt of Specialty Care among Patients Hospitalized with Diabetic Foot Ulcers: a Medicare cohort study

Background

Among those with diabetic foot ulcers, rural patients identifying as Black face at least 10% greater risk of major amputation or death compared to the US as a whole. As specialty care is associated with lower risk of major amputation, this difference could be driven by specialty care access. We hypothesize that rural patients and, particularly, rural patients identifying as Black, receive less inpatient specialty care compared to the overall cohort.

Methods

We built a cohort of all Medicare patients hospitalized with diabetic foot ulcers (2013–2014). Rurality was measured using Rural Urban Commuting Area codes. Race was categorized using the Research Triangle Institute algorithm. Specialty care was defined as receiving inpatient care from at least 1 of 6 relevant specialties to address diabetes, infection, biomechanics or vascular disease, per National Provider Taxonomy codes: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. We reported observed differences in specialty care, overall and stratified by rurality, identifying as Black, and ulcer severity. Pearson X² tests were performed on observed frequencies.

Results

Overall, 32.2% of the cohort received inpatient specialty care. This proportion decreased to 29.6% for rural patients (X² = 36.2, p ≤ 0.001) and 26.2% for rural patients identifying as Black (X² = 19.5, p ≤ 0.001). Among those with osteomyelitis, 54.3% of the cohort received specialty care, while only 49.5% of rural patients, 50.8% of patients identifying as Black, and 37.6% of rural patients identifying as Black received specialty care; the disparity for rural patients identifying as Black was greater than the sum of rural and racial disparities (4.8% for rural + 3.5% for Blacks = 8.3% versus a 16.7% observed difference for rural Blacks; Figure 1). Notably, only 2.7% of patients presenting with osteomyelitis were seen by an infectious disease specialist. This proportion decreased to 2.5% for rural patients.

Observed Proportions of Patients Receiving Specialty Care Stratified by Rurality, Identifying as Black, and Ulcer Severity

Conclusion

A smaller proportion of rural patients received specialty care, and rural patients identifying as Black were half as likely to receive specialty care than the overall cohort. Improving specialty access for these high-risk patients may reduce disparities in major amputations.

Disclosures

All Authors: No reported disclosures.

School District Prevention Policies and Risk of COVID-19 Among In-Person K-12 Educators, Wisconsin, 2021

Objectives. To assess the rate of COVID-19 among in-person K-12 educators and the rate's association with various COVID-19 prevention policies in school districts. Methods. We linked actively working, in-person K-12 educators in Wisconsin to COVID-19 cases with onset from September 2 to November 24, 2021. A mixed-effects Cox proportional hazards model, adjusted for pertinent person- and community-level confounders, compared the hazard rate of COVID-19 among educators working in districts with and without specific COVID-19 prevention policies. Results. In-person educators working in school districts that required masking for students and staff experienced 19% lower hazards of COVID-19 than did those in districts without any masking policy (hazard ratio = 0.81; 95% confidence interval = 0.72, 0.92). Reduced COVID-19 hazards were consistent and remained statistically significant when educators were stratified by elementary, middle, and high school environments. Conclusions. In Wisconsin's K-12 school districts, during the fall 2021 academic semester, a policy that required both students and staff to mask was associated with significantly reduced risk of COVID-19 among in-person educators across all grade levels. (Am J Public Health. 2022;112(12):1791-1799. https://doi.org/10.2105/AJPH.2022.307095).

Assessing the relationship between physical activity and the gut microbiome in a large, population-based sample of Wisconsin adults

The gut microbiome is an important factor in human health and disease. While preliminary studies have found some evidence that physical activity is associated with gut microbiome richness, diversity, and composition, this relationship is not fully understood and has not been previously characterized in a large, population-based cohort. In this study, we estimated the association between several measures of physical activity and the gut microbiota in a cohort of 720 Wisconsin residents. Our sample had a mean age of 55 years (range: 18, 94), was 42% male, and 83% of participants self-identified as White. Gut microbial composition was assessed using gene sequencing of the V3-V4 region of 16S rRNA extracted from stool. We found that an increase of one standard deviation in weekly minutes spent in active transportation was associated with an increase in alpha diversity, particularly in Chao1's richness (7.57, 95% CI: 2.55, 12.59) and Shannon's diversity (0.04, 95% CI: 0.0008, 0.09). We identified interactions in the association between Inverse Simpson's diversity and physical activity, wherein active transportation for individuals living in a rural environment was associated with additional increases in diversity (4.69, 95% CI: 1.64, 7.73). We also conducted several permutational ANOVAs (PERMANOVA) and negative binomial regression analyses to estimate the relationship between physical activity and microbiome composition. We found that being physically active and increased physical activity time were associated with increased abundance of bacteria in the family Erysipelotrichaceae. Active transportation was associated with increased abundance of bacteria in the genus Phascolarctobacterium, and decreased abundance of Clostridium. Minutes in active transportation was associated with a decreased abundance of the family Clostridiaceae.

Examining the association between the gastrointestinal microbiota and Gulf War illness: A prospective cohort study

Gulf War Illness (GWI) affects 25–35% of the 1991 Gulf War Veteran (GWV) population. Patients with GWI experience pain, fatigue, cognitive impairments, gastrointestinal dysfunction, skin disorders, and respiratory issues. In longitudinal studies, many patients with GWI have shown little to no improvement in symptoms since diagnosis. The gut microbiome and diet play an important role in human health and disease, and preliminary studies suggest it may play a role in GWI. To examine the relationship between the gut microbiota, diet, and GWI, we conducted an eight-week prospective cohort study collecting stool samples, medications, health history, and dietary data. Sixty-nine participants were enrolled into the study, 36 of which met the case definition for GWI. The gut microbiota of participants, determined by 16S rRNA sequencing of stool samples, was stable over the duration of the study and showed no within person (alpha diversity) differences. Between group analyses (beta diversity) identified statistically significant different between those with and without GWI. Several taxonomic lineages were identified as differentially abundant between those with and without GWI (n = 9) including a greater abundance of Lachnospiraceae and Ruminococcaceae in those without GWI. Additionally, there were taxonomic differences between those with high and low healthy eating index (HEI) scores including a greater abundance of Ruminococcaceae in those with higher HEI scores. This longitudinal cohort study of GWVs found that participants with GWI had significantly different microbiomes from those without GWI. Further studies are needed to determine the role these differences may play in the development and treatment of GWI.

Cause-specific student absenteeism monitoring in K-12 schools for detection of increased influenza activity in the surrounding community—Dane County, Wisconsin, 2014–2020

Background

Schools are primary venues of influenza amplification with secondary spread to communities. We assessed K-12 student absenteeism monitoring as a means for early detection of influenza activity in the community.

Materials and methods

Between September 2014 and March 2020, we conducted a prospective observational study of all-cause (a-TOT), illness-associated (a-I), and influenza-like illness–associated (a-ILI) absenteeism within the Oregon School District (OSD), Dane County, Wisconsin. Absenteeism was reported through the electronic student information system. Students were visited at home where pharyngeal specimens were collected for influenza RT-PCR testing. Surveillance of medically-attended laboratory-confirmed influenza (MAI) occurred in five primary care clinics in and adjoining the OSD. Poisson general additive log linear regression models of daily counts of absenteeism and MAI were compared using correlation analysis.

Findings

Influenza was detected in 723 of 2,378 visited students, and in 1,327 of 4,903 MAI patients. Over six influenza seasons, a-ILI was significantly correlated with MAI in the community (r = 0.57; 95% CI: 0.53–0.63) with a one-day lead time and a-I was significantly correlated with MAI in the community (r = 0.49; 0.44–0.54) with a 10-day lead time, while a-TOT performed poorly (r = 0.27; 0.21–0.33), following MAI by six days.

Discussion

Surveillance using cause-specific absenteeism was feasible and performed well over a study period marked by diverse presentations of seasonal influenza. Monitoring a-I and a-ILI can provide early warning of seasonal influenza in time for community mitigation efforts.

Effect of semi-recumbent vibration exercise on muscle outcomes in older adults: a pilot randomized controlled clinical trial

Background

Many older adults with physical limitations living in residential care apartments are unable to exercise in a standing position and are at risk for declining in muscle function leading to falls and injury. Novel approaches to achieve exercise benefits are needed. The purpose of this study was to test the effect of semi-recumbent vibration exercise on muscle outcomes in older adults living in residential care apartment complexes (RCACs).

Methods

A randomized, crossover design was used to examine the effect of semi-recumbent vibration exercise on muscle function and mass among 32 RCAC residents (mean age 87.5 years) with physical limitations. Participants received a randomized sequence of two study conditions: sham or vibration for 8 weeks each separated by a 4-week washout. Before and after the 8 weeks of vibration treatment and sham treatment, muscle mechanography was used to assess muscle function including jump power, weight-corrected jump power, and jump height. Short physical performance battery (SPPB) and handgrip strength were also used to measure muscle function. Bioelectrical impedance spectroscopy was used to estimate skeletal muscle mass. The effect of the vibration treatment on muscle outcomes was analyzed through mixed effects linear regression models.

Results

Vibration exercise leads to better jump height (p < .05) compared to sham exercise but also poorer chair rise performance (p = 0.012). Other muscle functions tests and muscle mass parameters showed non-significant changes.

Conclusion

This small pilot study showed no conclusive results on the effect of semi-recumbent vibration exercise on muscle function and mass in older adults living in RCAC. However, the promising signals of improved jump performance could be used to power larger studies of longer duration with various vibration doses to determine the benefit of vibration exercise in this physically impaired, high-risk population with few exercise capabilities.

Trial registration

The study is registered at clinicaltrials.gov (NCT02533063; date of first registration 26/08/2015).

Improvements in strength and agility measures of functional fitness following a telehealth-delivered home-based exercise intervention in endometrial cancer survivors

PURPOSE

Endometrial cancer is strongly linked to obesity and inactivity; however, increased physical activity has important benefits even in the absence of weight loss. Resistance (strength) training can deliver these benefits; yet few women participate in resistance exercise. The purpose of this study was to describe both physiological and functional changes following a home-based strength training intervention.

METHODS

Forty post-treatment endometrial cancer survivors within 5 years of diagnosis were enrolled in a pilot randomized trial, comparing twice-weekly home-based strength exercise to wait list control. Participants conducted the exercises twice per week for 10 supervised weeks with 5 weeks of follow-up. Measures included DXA-measured lean mass, functional fitness assessments, blood biomarkers, and quality of life outcomes.

RESULTS

On average, participants were 60.9 years old (SD = 8.7) with BMI of 39.9 kg/m2 (SD = 15.2). At baseline, participants had 51.2% (SD = 6.0) body fat, which was not different between groups. Improvements were seen in the 30-s chair sit to stand (d = .99), the 30-s arm curl (d = .91), and the 8-ft up-and-go test (d = .63). No changes were measured for HbA1c or C-reactive protein. No changes were observed for flexibility (chair sit and reach, back scratch tests), 6-min walk test, maximum handgrip test, anxiety, depression, fatigue, or self-efficacy for exercise.

CONCLUSIONS

Home-based muscle-strengthening exercise led to favorable and clinically relevant improvements in 3 of 7 physical function assessments. Physical function, body composition, blood biomarkers, and patient-reported outcomes were feasible to measure. These fitness improvements were observed over a relatively short time frame of 10 weeks.

The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS): Rationale, objectives, and design

BACKGROUND

Influenza viruses pose significant disease burdens through seasonal outbreaks and unpredictable pandemics. Existing surveillance programs rely heavily on reporting of medically attended influenza (MAI). Continuously monitoring cause-specific school absenteeism may identify local acceleration of seasonal influenza activity. The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS; Oregon, WI) implements daily school-based monitoring of influenza-like illness-specific student absenteeism (a-ILI) in kindergarten through Grade 12 schools and assesses this approach for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

METHODS

Starting in September 2014, ORCHARDS combines automated reporting of daily absenteeism within six schools and home visits to school children with acute respiratory infection (ARI). Demographic, epidemiological, and symptom data are collected along with respiratory specimens. Specimens are tested for influenza and other respiratory viruses. Household members can opt into a supplementary household transmission study. Community comparisons are possible using a pre-existing and highly effective influenza surveillance program, based on MAI at five family medicine clinics in the same geographical area.

RESULTS

Over the first 5 years, a-ILI occurred on 6634 (0.20%) of 3,260,461 student school days. Viral pathogens were detected in 64.5% of 1728 children with ARI who received a home visit. Influenza was the most commonly detected virus, noted in 23.3% of ill students.

CONCLUSION

ORCHARDS uses a community-based design to detect influenza trends over multiple seasons and to evaluate the utility of absenteeism for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

Association of Macular Thickness With Age and Age-Related Macular Degeneration in the Carotenoids in Age-Related Eye Disease Study 2 (CAREDS2), An Ancillary Study of the Women's Health Initiative

Purpose

To evaluate the relationship of retinal layer thickness with age and age-related macular degeneration (AMD) in the Carotenoids in Age-Related Eye Disease Study 2.

Methods

Total retinal thickness within the macular area, and individual layer thickness was determined for CAREDS2 participants (n = 906 eyes, 473 women) from the Women's Health Initiative using Heidelberg optical coherence tomography (OCT). Mean measurements within the OCT grid were compared across age tertiles (69–78, 78–83, and 83–101 years) and AMD outcomes.

Results

Mean retinal thickness in the central circle, inner ring, and outer ring were 277 ± 34 µm, 326 ± 20 µm, and 282 ± 15 µm, respectively. Thickness did not vary by age in the central circle, but decreased with age in the inner and outer circles (P ≤ 0.004). Specifically, ganglion cell (GCL), inner plexiform, and outer nuclear (ONL) layer thickness decreased with age (P ≤ 0.003). Age-adjusted retinal thickness in all three circles did not vary by AMD outcomes (486 without AMD and 413 with AMD). However, individual layers showed changes with GCL and photoreceptor thinning and retinal pigment epithelial thicknening in eyes with late AMD. After controlling for age and AMD, higher ONL thickness was associated with better visual acuity.

Conclusions

In this cohort of older women, a decrease in perifoveal thickness was associated with increasing age, particularly in the inner retinal layers. Variabilty in thickness in AMD eyes was primarily due to outer retinal layers. Among all retinal layers, the ONL plays an important role in preserving visual acuity.

Translational Relevance

The study provides a deeper understanding of age related changes to the retinal layers and their effect on visual loss.

Enhanced Neutralizing Antibody Responses to Rhinovirus C and Age-Dependent Patterns of Infection

Rationale: Rhinovirus (RV) C can cause asymptomatic infection and respiratory illnesses ranging from the common cold to severe wheezing.Objectives: To identify how age and other individual-level factors are associated with susceptibility to RV-C illnesses.Methods: Longitudinal data from the COAST (Childhood Origins of Asthma) birth cohort study were analyzed to determine relationships between age and RV-C infections. Neutralizing antibodies specific for RV-A and RV-C (three types each) were determined using a novel PCR-based assay. Data were pooled from 14 study cohorts in the United States, Finland, and Australia, and mixed-effects logistic regression was used to identify factors related to the proportion of RV-C versus RV-A detection.Measurements and Main Results: In COAST, RV-A and RV-C infections were similarly common in infancy, whereas RV-C was detected much less often than RV-A during both respiratory illnesses and scheduled surveillance visits (P < 0.001, χ2) in older children. The prevalence of neutralizing antibodies to RV-A or RV-C types was low (5-27%) at the age of 2 years, but by the age of 16 years, RV-C seropositivity was more prevalent (78% vs. 18% for RV-A; P < 0.0001). In the pooled analysis, the RV-C to RV-A detection ratio during illnesses was significantly related to age (P < 0.0001), CDHR3 genotype (P < 0.05), and wheezing illnesses (P < 0.05). Furthermore, certain RV types (e.g., C2, C11, A78, and A12) were consistently more virulent and prevalent over time.Conclusions: Knowledge of prevalent RV types, antibody responses, and populations at risk based on age and genetics may guide the development of vaccines or other novel therapies against this important respiratory pathogen.

The Association Between Exposure to Maternal Depression During Year 2 of a Child's Life and Future Child Problem Behavior

INTRODUCTION

We examined the association of exposure to maternal depression during year 2 of a child's life with future child problem behavior. We conducted a secondary analysis to investigate whether race/ethnicity is a moderator of this relationship.

METHODS

We used Fragile Families and Child Well-Being Study data (age 3 N = 3288 and 49% Black, 26% Hispanic, 22% non-Hispanic White; age 5 N = 3001 and 51% Black, 25% Hispanic, 21% non-Hispanic White; age 9 N = 3630 and 50% Black, 25% Hispanic, 21% non-Hispanic White) and ordinal logistic regression to model problem behavior at ages 3, 5, and 9 on maternal depression status during year 2.

RESULTS

At age 9, children whose mother was depressed during year 2 were significantly more likely to have higher internalizing (AOR = 1.92, 95% CI: 1.42,2.61) and externalizing (AOR = 1.65, 95% CI: 1.10,2.48) problem behavior scores. In our secondary analysis, race/ethnicity did not have moderating effects, potentially due to a limitation of the data that required use of maternal self-reported race/ethnicity as a proxy for child race/ethnicity.

DISCUSSION

Exposure to maternal depression after the prenatal and perinatal periods may have a negative association with children's behavioral development through age 9. Interventions that directly target maternal depression during this time should be developed. Additional research is needed to further elucidate the role of race/ethnicity in the relationship between maternal depression and child problem behavior.

Disseminating Tai Chi in the Community: Promoting Home Practice and Improving Balance

BACKGROUND AND OBJECTIVES

Falls among older adults is a pressing public health challenge. Considerable research documents that longer tai chi courses can reduce falls and improve balance. However, longer courses can be challenging to implement. Our goal was to evaluate whether a short 6-week modified tai chi course could be effective at reducing falls risk if older adults designed a personal home practice plan to receive a greater tai chi "dose" during the 6 weeks.

DESIGN

A 3-city wait-listed randomized trial was conducted. Habituation Intention and Social Cognitive Theories framed the "coaching" strategy by which participants designed practice plans. RE-AIM and Treatment Fidelity Frameworks were used to evaluate implementation and dissemination issues. Three advisory groups advised the study on intervention planning, implementation, and evaluation. To measure effectiveness, we used Centers for Disease Control and Prevention recommended measures for falls risk including leg strength, balance, and mobility and gait. In addition, we measured balance confidence and executive function.

RESULTS

Program Implementation resulted in large class sizes, strong participant retention, high program fidelity and effectiveness. Participants reported practicing an average of 6 days a week and more than 25 min/day. Leg strength, tandem balance, mobility and gait, balance confidence, and executive function were significantly better for the experimental group than control group.

CONCLUSION

The tai chi short course resulted in substantial tai chi practice by older adults outside of class as well as better physical and executive function. The course reach, retention, fidelity, and implementation across 3 cities suggest strong potential for implementation and dissemination of the 6-week course.

Effect of a technology-supported physical activity intervention on health-related quality of life, sleep, and processes of behavior change in cancer survivors: A randomized controlled trial

OBJECTIVES

This pilot trial tested the effect of adding a multi-level, technology-based physical activity intervention module to a standard survivorship care plan for breast and colorectal cancer survivors. The objective of this analysis was to determine whether the physical activity module improved health-related quality of life, sleep, and factors key to lasting behavior change (eg, social support, self-efficacy).

METHODS

Breast and colorectal cancer survivors (n = 50) were enrolled alongside a support partner. Survivors were assigned to receive a standard survivorship care plan either alone or augmented by a 12-week multi-component physical activity module. The module included a Fitbit tracker (with the physical activity data integrated into the electronic health record for clinician review) and customized email feedback. Physical activity was measured using the ActiGraph GT3X+. Psychosocial outcomes included the SF-36, FACT, ISEL, PROMIS sleep measures, and physical activity beliefs. Data were analyzed using linear mixed modeling.

RESULTS

Cancer survivors were aged 54.4 ± 11.2 years and were 2.0 ± 1.5 years from diagnosis. Relative to comparison, the intervention was associated with moderate-to-large improvements in physical health (effect size: d = 0.39, 95% CI = 0.0, 0.78), mental health (d = 0.59, 95% CI = 0.19, 0.99), sleep impairment (d = 0.62, 95% CI = -1.02, -0.22), and exercise self-efficacy (d = 0.60, 95% CI = 0.20, 1.0).

CONCLUSIONS

The intervention delivered meaningful improvements in survivors' quality of life, social support, and sleep impairment. If replicated in a larger sample, adding a technology-supported physical activity module to survivorship care plans may be a practical strategy for supporting healthy survivorship.

TRIAL REGISTRATION

ClinicalTrials.gov#: NCT02677389.

Food Insecurity and Housing Instability Partially Mediate the Association Between Maternal Depression and Child Problem Behavior

Maternal depression is a risk factor for the development of problem behavior in children. Although food insecurity and housing instability are associated with adult depression and child behavior, how these economic factors mediate or moderate the relationship between maternal depression and child problem behavior is not understood. The purpose of this study was to determine whether food insecurity and housing instability are mediators and/or moderators of the relationship between maternal depression when children are age 3 and children's problem behaviors at age 9 and to determine whether these mechanisms differ by race/ethnicity. We used data from the Fragile Families and Child Wellbeing Study. Food insecurity and housing instability at age 5 were tested as potential mediators and moderators of the relationship between maternal depression status at age 3 and problem behavior at age 9. A path analysis confirmed our hypothesis that food insecurity and housing instability partially mediate the relationship between maternal depression when children are age 3 and problem behavior at age 9. However, housing instability was only a mediator for externalizing problem behavior and not internalizing problem behavior or overall problem behavior. Results of the moderation analysis suggest that neither food insecurity nor housing instability were moderators. None of the mechanisms explored differed by race/ethnicity. While our findings stress the continued need for interventions that address child food insecurity, they emphasize the importance of interventions that address maternal mental health throughout a child's life. Given the central role of maternal health in child development, additional efforts should be made to target maternal depression.

Development of a Rhinovirus Inoculum Using a Reverse Genetics Approach

Background

Experimental inoculation is an important tool for common cold and asthma research. Producing rhinovirus (RV) inocula from nasal secretions has required prolonged observation of the virus donor to exclude extraneous pathogens. We produced a RV-A16 inoculum using reverse genetics and determined the dose necessary to cause moderate colds in seronegative volunteers.

Methods

The consensus sequence of RV-A16 from a previous inoculum was cloned, and inoculum virus was produced using reverse genetics techniques. After safety testing, volunteers were inoculated with either RV-A16 (n = 26) or placebo (n = 10), Jackson cold scores were recorded, and nasal secretions were tested for shedding of RV-A16 ribonucleic acid.

Results

The reverse genetics process produced infectious virus that was neutralized by specific antisera and had a mutation rate similar to conventional virus growth techniques. The 1000 median tissue culture infectious dose (TCID₅₀) dose produced moderate colds in most individuals with effects similar to that of a previously tested conventional RV-A16 inoculum.

Conclusions

Reverse genetics techniques produced a RV-A16 inoculum that can cause clinical colds in seronegative volunteers, and they also serve as a stable source of virus for laboratory use. The recombinant production procedures eliminate the need to derive seed virus from nasal secretions, thus precluding introduction of extraneous pathogens through this route.

2582. The Association Between Dietary Fiber and Diet and Gut Colonization with Clostridium difficile

Background

There is little research on the relationship between diet and Clostridium difficile infection. Animal studies have shown potential benefits of dietary fiber in modulating C. difficile infection.

Methods

In 2016–2017, we carried out a microbiota study among adults in the Survey of the Health of Wisconsin, a population-based health survey collecting data on a wide range of health determinants and outcomes. We administered the Dietary History Questionnaire and asked about risk factors for C. difficile and collected fecal samples for 16S rRNA sequencing of gut microbiota and cultured for C. difficile. Dietary components were standardized to 1,000 kcal energy intake. Logistic regression was used to examine diet factors associated with C. difficile colonization. The quasi-conditional association test (QCAT) was performed to identify taxa that were significantly associated with fiber intake.

Results

In our general population sample of adults [(N = 238; 58% female; mean (range) age = 54 (18–94)], the prevalence of gut colonization with C. difficile was 9.2% (18 toxigenic/3 non-toxigenic). After adjusting for age, sex, and antibiotic use, C. difficile colonization was associated with usual daily fiber consumption over the last year. ORs (95% CI) in the highest vs. lowest quartile were 0.18 (0.03, 0.89) for total fiber, 0.09 (0.01, 0.77) for soluble fiber, and 0.10 (0.1, 0.80) for insoluble fiber. Lower odds of C. difficile colonization were associated with greater consumption of dark green vegetables and less consumption of solid fats, total saturated fats, and added sugar, but not significantly. Omega 3 fatty acids and fruit consumption were either non-monotonically or not associated with C. difficile colonization. Higher levels of total dietary fiber intake were also associated with increased colonization by bacteria within the order Clostridiales, the families Coriobacteriaceae, Lactobacillaceae, and Veillonellacea, and the genera Bifidobacterium, and Lactobacillus.

Conclusion

Higher average daily dietary fiber (total, soluble, and insoluble) appears to be associated with lower odds of gut colonization with C. difficile. Future research should examine the impact of dietary interventions on C. difficile colonization and infection.

Disclosures

All authors: No reported disclosures.

Characterising the gut microbiome in veterans with Gulf War Illness: a protocol for a longitudinal, prospective cohort study

INTRODUCTION

Approximately 25%-35% of the 1991 Gulf War Veteran population report symptoms consistent with Gulf War Illness (GWI), a chronic, multi-symptom illness characterised by fatigue, pain, irritable bowel syndrome and problems with cognitive function. GWI is a disabling problem for Gulf War Veterans, and there remains a critical need to identify innovative, novel therapies.Gut microbiota perturbation plays a key role in the symptomatology of other chronic multi-symptom illnesses, including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Given similarities between ME/CFS and GWI and the presence of gastrointestinal disorders in GWI patients, Veterans with GWI may also have gut abnormalities like those seen with ME/CFS. In this longitudinal cohort study, we are comparing the diversity (structure) and the metagenomes (function) of the gut microbiome between Gulf War Veterans with and without GWI. If we find differences in Veterans with GWI, the microbiome could be a target for therapeutic intervention to alleviate GWI symptoms.

METHODS AND ANALYSIS

Participants answer questions about diet, exercise and lifestyle factors. Participants also complete a questionnaire (based on the Kansas case definition of GWI) regarding their medical history and symptoms; we use this questionnaire to group participants into GWI versus healthy control cohorts. We plan to enrol 52 deployed Gulf War Veterans: 26 with GWI and 26 healthy controls. Participants provide stool and saliva samples weekly for an 8-week period for microbiome analyses. Participants also provide blood samples at the beginning and end of this period, which we will use to compare measures of inflammation markers between the groups.

ETHICS AND DISSEMINATION

The protocol was approved by the University of Wisconsin-Madison Health Sciences Institutional Review Board and the William S. Middleton Memorial Veterans Hospital Research and Development Committee. Results of this study will be submitted for publication in a peer-reviewed journal.

Automatic Identification of Physical Activity Type and Duration by Wearable Activity Trackers: A Validation Study

Background

Activity trackers are now ubiquitous in certain populations, with potential applications for health promotion and monitoring and chronic disease management. Understanding the accuracy of this technology is critical to the appropriate and productive use of wearables in health research. Although other peer-reviewed validations have examined other features (eg, steps and heart rate), no published studies to date have addressed the accuracy of automatic activity type detection and duration accuracy in wearable trackers.

Objective

The aim of this study was to examine the ability of 4 commercially available wearable activity trackers (Fitbits Flex 2, Fitbit Alta HR, Fitbit Charge 2, and Garmin Vívosmart HR), in a controlled setting, to correctly and automatically identify the type and duration of the physical activity being performed.

Methods

A total of 8 activity types, including walking and running (on both a treadmill and outdoors), a run embedded in walking bouts, elliptical use, outdoor biking, and pool lap swimming, were tested by 28 to 34 healthy adult participants (69 total participants who participated in some to all activity types). Actual activity type and duration were recorded by study personnel and compared with tracker data using descriptive statistics and mean absolute percent error (MAPE).

Results

The proportion of trials in which the activity type was correctly identified was 93% to 97% (depending on the tracker) for treadmill walking, 93% to 100% for treadmill running, 36% to 62% for treadmill running when preceded and followed by a walk, 97% to 100% for outdoor walking, 100% for outdoor running, 3% to 97% for using an elliptical, 44% to 97% for biking, and 87.5% for swimming. When activities were correctly identified, the MAPE of the detected duration versus the actual activity duration was between 7% and 7.9% for treadmill walking, 8.7% and 144.8% for treadmill running, 23.6% and 28.9% for treadmill running when preceded and followed by a walk, 4.9% and 11.8% for outdoor walking, 5.6% and 9.6% for outdoor running, 9.7% and 13% for using an elliptical, 9.5% and 17.7% for biking, and was 26.9% for swimming.

Conclusions

In a controlled setting, wearable activity trackers provide accurate recognition of the type of some common physical activities, especially outdoor walking and running and walking on a treadmill. The accuracy of measurement of activity duration varied considerably by activity type and tracker model and was poor for complex sets of activity, such as a run embedded within 2 walking segments.

686. Use of an Influenza-Like Illness School Absenteeism Monitoring System to Identify Seasonal Influenza Outbreaks in the Community: ORCHARDS (Wisconsin, September 2014–June 2017)

Background

Schools are purported to be primary venues of influenza transmission and amplification with secondary spread to communities. We assessed K—12 student absenteeism monitoring as a means for early detection of influenza activity in the community. Methods. We conducted a 3-year, prospective observational study of all-cause (a-TOT), illness-associated (a-I), and influenza-like illness-associated (a-ILI) absenteeism within the Oregon School District, Oregon, WI (OSD: enrollment = 3,900 students). Absenteeism reporting was facilitated by automated processes within OSD’s electronic student information system. Students were screened for ILI, and, if eligible, visited at home, where pharyngeal specimens were collected for influenza RT-PCR (IVD CDC Human Influenza Virus RT-PCR Diagnostic Panel) and multipathogen testing (Luminex NxTAG RPP). The study definition of a-ILI was validated for 700 children with acute respiratory infections using binomial logistic regression. Surveillance of medically attended laboratory-confirmed influenza (MAI) occurred in five primary care clinics in and adjoining OSD as part of the Wisconsin Influenza Incidence Surveillance Project using the same laboratory testing. Poisson general additive log linear regression models of daily counts of absenteeism and MAI were compared using correlation analysis. Results. Influenza A and B were detected in 54 and 51 of the 700 visited students, respectively. Influenza was significantly associated with a-ILI status (OR = 4.74; 95% CI: 2.78—8.18; P &lt; 0.001). Of MAI patients, 371 had influenza A and 143 had influenza B. a-I was significantly correlated with MAI in the community (r = 0.472; P &lt; 0.001) with a 15-day lead time. a-ILI was significantly correlated with MAI in the community (r = 0.480; P &lt; 0.001) with a 1-day lead time. a-TOT performed poorly (r = 0.278; P &lt; 0.001), following MAI by 9 days (Figure 1). Conclusion. Surveillance using cause-specific absenteeism was feasible to implement in OSD and performed well over a 3-year period marked by diverse presentations of seasonal influenza. Monitoring a-I and a-ILI can detect influenza outbreaks in the community, providing early warning in time for community mitigation efforts for seasonal and pandemic influenza.

Disclosures

All authors: No reported disclosures.

Common Model Inputs Used in CISNET Collaborative Breast Cancer Modeling

BACKGROUND

Since their inception in 2000, the Cancer Intervention and Surveillance Network (CISNET) breast cancer models have collaborated to use a nationally representative core of common input parameters to represent key components of breast cancer control in each model. Employment of common inputs permits greater ability to compare model output than when each model begins with different input parameters. The use of common inputs also enhances inferences about the results, and provides a range of reasonable results based on variations in model structure, assumptions, and methods of use of the input values. The common input data are updated for each analysis to ensure that they reflect the most current practice and knowledge about breast cancer. The common core of parameters includes population rates of births and deaths; age- and cohort-specific temporal rates of breast cancer incidence in the absence of screening and treatment; effects of risk factors on incidence trends; dissemination of plain film and digital mammography; screening test performance characteristics; stage or size distribution of screen-, interval-, and clinically- detected tumors by age; the joint distribution of ER/HER2 by age and stage; survival in the absence of screening and treatment by stage and molecular subtype; age-, stage-, and molecular subtype-specific therapy; dissemination and effectiveness of therapies over time; and competing non-breast cancer mortality.

METHOD AND RESULTS

In this paper, we summarize the methods and results for the common input values presently used in the CISNET breast cancer models, note assumptions made because of unobservable phenomena and/or unavailable data, and highlight plans for the development of future parameters.

CONCLUSION

These data are intended to enhance the transparency of the breast CISNET models.

Wisconsin microbiome study, a cross-sectional investigation of dietary fibre, microbiome composition and antibiotic-resistant organisms: rationale and methods

INTRODUCTION

Prevention of multidrug-resistant organism (MDRO) infections, such as those caused by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, fluoroquinolone-resistant Gram-negative bacteria and Clostridium difficile is crucial. Evidence suggests that dietary fibre increases gut microbial diversity, which may help prevent colonisation and subsequent infection by MDROs. The aim of the Winning the War on Antibiotic Resistance (WARRIOR) project is to examine associations of dietary fibre consumption with the composition of the gut microbiota and gut colonisation by MDROs. The secondary purpose of the study is to create a biorepository of multiple body site specimens for future microbiota research.

METHODS AND ANALYSIS

The WARRIOR project collects biological specimens, including nasal, oral and skin swabs and saliva and stool samples, along with extensive data on diet and MDRO risk factors, as an ancillary study of the Survey of the Health of Wisconsin (SHOW). The SHOW is a population-based health survey collecting data on several different health determinants and outcomes, as well as objective body measurements and biological specimens. WARRIOR participants include 600 randomly selected Wisconsin residents age 18 and over. Specimens are screened for MDRO colonisation and DNA is extracted for 16S ribosomal RNA-based microbiota sequencing. Data will be analysed to assess the relationship between dietary fibre, the gut microbiota composition and gut MDRO colonisation.

ETHICS AND DISSEMINATION

The WARRIOR project is approved by the University of Wisconsin Institutional Review Board. The main results of this study will be published in a peer-reviewed scientific journal.

Association of Screening and Treatment With Breast Cancer Mortality by Molecular Subtype in US Women, 2000-2012

IMPORTANCE

Given recent advances in screening mammography and adjuvant therapy (treatment), quantifying their separate and combined effects on US breast cancer mortality reductions by molecular subtype could guide future decisions to reduce disease burden.

OBJECTIVE

To evaluate the contributions associated with screening and treatment to breast cancer mortality reductions by molecular subtype based on estrogen-receptor (ER) and human epidermal growth factor receptor 2 (ERBB2, formerly HER2 or HER2/neu).

DESIGN, SETTING, AND PARTICIPANTS

Six Cancer Intervention and Surveillance Network (CISNET) models simulated US breast cancer mortality from 2000 to 2012 using national data on plain-film and digital mammography patterns and performance, dissemination and efficacy of ER/ERBB2-specific treatment, and competing mortality. Multiple US birth cohorts were simulated.

EXPOSURES

Screening mammography and treatment.

MAIN OUTCOMES AND MEASURES

The models compared age-adjusted, overall, and ER/ERBB2-specific breast cancer mortality rates from 2000 to 2012 for women aged 30 to 79 years relative to the estimated mortality rate in the absence of screening and treatment (baseline rate); mortality reductions were apportioned to screening and treatment.

RESULTS

In 2000, the estimated reduction in overall breast cancer mortality rate was 37% (model range, 27%-42%) relative to the estimated baseline rate in 2000 of 64 deaths (model range, 56-73) per 100 000 women: 44% (model range, 35%-60%) of this reduction was associated with screening and 56% (model range, 40%-65%) with treatment. In 2012, the estimated reduction in overall breast cancer mortality rate was 49% (model range, 39%-58%) relative to the estimated baseline rate in 2012 of 63 deaths (model range, 54-73) per 100 000 women: 37% (model range, 26%-51%) of this reduction was associated with screening and 63% (model range, 49%-74%) with treatment. Of the 63% associated with treatment, 31% (model range, 22%-37%) was associated with chemotherapy, 27% (model range, 18%-36%) with hormone therapy, and 4% (model range, 1%-6%) with trastuzumab. The estimated relative contributions associated with screening vs treatment varied by molecular subtype: for ER+/ERBB2-, 36% (model range, 24%-50%) vs 64% (model range, 50%-76%); for ER+/ERBB2+, 31% (model range, 23%-41%) vs 69% (model range, 59%-77%); for ER-/ERBB2+, 40% (model range, 34%-47%) vs 60% (model range, 53%-66%); and for ER-/ERBB2-, 48% (model range, 38%-57%) vs 52% (model range, 44%-62%).

CONCLUSIONS AND RELEVANCE

In this simulation modeling study that projected trends in breast cancer mortality rates among US women, decreases in overall breast cancer mortality from 2000 to 2012 were associated with advances in screening and in adjuvant therapy, although the associations varied by breast cancer molecular subtype.

A Pilot Study of Perceived Mouth Dryness, Perceived Swallowing Effort, and Saliva Substitute Effects in Healthy Adults Across the Age Range

Xerostomia, or perceived mouth dryness, increases with advancing age, but its influence on swallowing effort is unknown. This study: (1) quantified relationships among age, perceived sense of swallowing effort, and ratings of perceived mouth dryness, and (2) examined changes in swallowing effort following application of a gel-based saliva substitute in healthy participants. This was a cross-sectional observational study and data were collected from attendees of a community healthy aging fair. Forty-two healthy participants (mean age = 65 years; 20 female) were enrolled. Each participant rated perceived effort with swallowing and perceived mouth dryness on a 10-cm horizontal, undifferentiated line. After participants applied a gel-based saliva substitute (Biotene^® Oral Balance) to their tongue and oral mucosa, they rated perceived effort with swallowing again. Age was associated with greater perceived mouth dryness (r = 0.37, p < 0.03) but not with perceived swallowing effort (r = 0.16, p = 0.32). Perceived mouth dryness was associated with greater perceived swallowing effort (r = 0.62, p < 0.001). Perceived swallowing effort declined following application of the salivary substitute (mean difference = 9.39 mm, p < 0.002). Age was found to be a significant predictor of perceived mouth dryness (p < .02); and perceived mouth dryness was found to significantly predict perceived swallow effort (p < .001). Perceived mouth dryness increased with advancing age, but perceived swallowing effort did not. Regardless of age, participants with higher levels of perceived mouth dryness also reported more perceived effort with swallowing suggesting a role for adequate oral lubrication in this perception. Even in healthy participants, use of a gel-based saliva substitute lowered perceived swallowing effort.

Collaborative Modeling of the Benefits and Harms Associated With Different U.S. Breast Cancer Screening Strategies

BACKGROUND

Controversy persists about optimal mammography screening strategies.

OBJECTIVE

To evaluate screening outcomes, taking into account advances in mammography and treatment of breast cancer.

DESIGN

Collaboration of 6 simulation models using national data on incidence, digital mammography performance, treatment effects, and other-cause mortality.

SETTING

United States.

PATIENTS

Average-risk U.S. female population and subgroups with varying risk, breast density, or comorbidity.

INTERVENTION

Eight strategies differing by age at which screening starts (40, 45, or 50 years) and screening interval (annual, biennial, and hybrid [annual for women in their 40s and biennial thereafter]). All strategies assumed 100% adherence and stopped at age 74 years.

MEASUREMENTS

Benefits (breast cancer-specific mortality reduction, breast cancer deaths averted, life-years, and quality-adjusted life-years); number of mammograms used; harms (false-positive results, benign biopsies, and overdiagnosis); and ratios of harms (or use) and benefits (efficiency) per 1000 screens.

RESULTS

Biennial strategies were consistently the most efficient for average-risk women. Biennial screening from age 50 to 74 years avoided a median of 7 breast cancer deaths versus no screening; annual screening from age 40 to 74 years avoided an additional 3 deaths, but yielded 1988 more false-positive results and 11 more overdiagnoses per 1000 women screened. Annual screening from age 50 to 74 years was inefficient (similar benefits, but more harms than other strategies). For groups with a 2- to 4-fold increased risk, annual screening from age 40 years had similar harms and benefits as screening average-risk women biennially from 50 to 74 years. For groups with moderate or severe comorbidity, screening could stop at age 66 to 68 years.

LIMITATION

Other imaging technologies, polygenic risk, and nonadherence were not considered.

CONCLUSION

Biennial screening for breast cancer is efficient for average-risk populations. Decisions about starting ages and intervals will depend on population characteristics and the decision makers' weight given to the harms and benefits of screening.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health-Related Outcomes in Older Adults with Dysphagia

Swallowing disorders (dysphagia) are associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multidisciplinary program that employs a specific approach to oropharyngeal strengthening-device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy-with the goal of reducing health-related sequelae in veterans with dysphagia. Participants completed 8 weeks of D-F I-PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, videofluoroscopic swallowing studies were performed. Dietary and swallowing-related quality of life questionnaires were administered. Long-term monitoring for 6-17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6-17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (N = 56; 55 male, 1 female; mean age 70) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, P < .001) and posterior locations (effect estimate = 85.4, P < .001) over 8 weeks. Statistically significant improvements occurred on eight of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL-QOL) Questionnaire (effect estimates = 6.5-19.5, P < .04) and in self-reported sense of effort (effect estimate = -18.1, P = .001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, P = .02) indicated that participants were able to eat less-restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; P = .009) from before to after enrollment. Findings suggest that the Swallow STRONG multidisciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia.

Reproducibility of jumping mechanography and traditional measures of physical and muscle function in older adults

SUMMARY

Improved approaches to assess functional change over time are needed to optimally reduce fall/fracture risk; jumping mechanography (JM) may be one such methodology. In this study, JM parameters were more reproducible than traditional functional tests. JM may be better able to demonstrate efficacy of interventions to mitigate sarcopenia.

INTRODUCTION

Jumping mechanography (JM), a tool using maximal countermovement jumps performed on a force plate, may more reliably assess muscle function than traditional methods. The purpose of this study was to examine JM retest reliability in older adults compared with commonly used muscle and physical function assessments.

METHODS

Community-dwelling individuals age≥70 years performed physical and muscle function assessments including the short physical performance battery (SPPB), grip strength, and JM on multiple occasions over 3 months. JM parameters included body weight-corrected peak power and jump height. Appendicular lean mass was measured by dual energy x-ray (DXA). Mixed effects linear regression models were used to estimate between- and within-person variability summarized as intra-class correlation coefficients (ICC).

RESULTS

Ninety-seven individuals (49 females, 48 males, mean age 80.7 years) participated. All testing was well tolerated; no participant sustained injury. Jump power, height, and grip strength were greater (p<0.0001) in men than women. Grip strength, jump power, and height had excellent ICCs (0.95, 0.93, and 0.88, respectively); chair rise, SPPB score, and gait speed had lower ICCs (0.81, 0.77, and 0.76, respectively).

CONCLUSION

In older adults, JM has excellent retest reliability, is stable over time, and can be performed safely. JM retest reliability was comparable to grip strength and possibly better than SPPB and gait speed. JM is a promising tool for muscle function assessment in older adults. Comparison of this approach with traditional assessment tools in longitudinal interventional studies is needed.

Development of a novel, objective measure of health care-related financial burden for U.S. families with children

OBJECTIVE

To develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children.

DATA SOURCES

The measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey.

STUDY DESIGN

We estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk.

PRINCIPAL FINDINGS

We successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent).

CONCLUSION

The newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation.