Psychometric reliability, validity, and generalizability of 3MSE scores among American Indian adults: the Strong Heart Study

OBJECTIVE

Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians.

METHODS

We recruited 818 American Indians aged 65-95 for 3MSE examinations in 2010-2013; 403 returned for a repeat examination in 2017-2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models.

RESULTS

This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small.

CONCLUSION

These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist.

Psychometric Properties of Controlled Oral Word Association (COWA) Test and Associations With Education and Bilingualism in American Indian Adults: The Strong Heart Study

The Controlled Oral Word Association (COWA) test is used to assess phonemic fluency and executive function. Formal validation of test scores is important for accurate cognitive evaluation. However, there is a dearth of psychometric validation among American Indian adults. Given high burden of dementia risk and key contextual factors associated with cognitive assessments, this represents a critical oversight. In a large, longitudinal population-based cohort study of adult American Indians, we examined several validity inferences for COWA, including scoring, generalization, and extrapolation inferences, by investigation of factor structure, internal consistency, test-retest reliability, and differential test functioning. We found adequate unidimensional model fit, with high factor loadings. Internal consistency reliability and test-retest reliability were 0.88 and 0.77, respectively, for the full group. COWA scores were lowest among the oldest, lowest education, bilingual speakers; group effects for sex and bilingual status were small; age effect was medium; and education effect was largest. However, Wide Range Achievement Test (WRAT) score effect was stronger than education effect, suggesting better contextualization may be needed. These results support interpretation of total COWA score, including across sex, age, or language use strata.

Latent profile similarity of middle and high school youth risk and needs

Research concerning school success and completion has grown increasingly complex with the number of proposed associated risk and needs domains. As the number of domains expands, various data analytical techniques have been employed to understand them, including the modeling of latent profiles, to better understand how risks and needs aggregate at the level of individual persons. Latent profile analysis helps identify individuals' subgroups based on salient combinations of characteristics. The present study used latent profile analysis and a systematic profile similarity approach to examine the profiles across middle and high school student cohorts. The study replicates the profiles of previous work with high school students and extends this to middle school students. We used two independent cohorts to replicate a 3-profile solution for middle and high school samples. Results supported a similar 3-profile solution for both samples, with minor discrepancies. Results are discussed with respect to the replication and extension of the 3-profile model and its application to efforts to improve outcomes for youth in both grade level cohorts.

Characterization of a novel mouse model for deletion of a floxed gene in alternatively activated macrophages

V-maf musculoaponeurotic fibrosarcoma oncogene family, protein B (MafB) promoter has been identified as macrophage-specific promoter, but it has never been characterized for pulmonary macrophages. Therefore, we hypothesized that MafB-driven Cre Recombinase expression will allow recombination in alveolar macrophages that contain floxed alleles. MafB-Cre+/− \Rosa-mTOMFlox/Flox/mEGFP (MafB-EGFP) mice was generated by crossbreeding MafB-Cre+/+ and Rosa-mTOMFlox/Flox/mEGFP parents. To determine the extent of macrophage-specific gene recombination, we performed bronchoalveolar lavage, fluorescent microscopy, and flow cytometry on BALF and lung digest of 42 days old MafB-EGFP mice. In addition, we assess the beneficial effect of in vitro and in vivo macrophage activation on recombination efficiency. Flow cytometry analyses on macrophages from MafB-EGFP offspring revealed that: 1) only 30–40% of the alveolar macrophages are amenable to the Cre-Lox mediated recombination, 2) majority of bone marrow-derived macrophages are amenable to the Cre-Lox mediated recombination, 3) Classical activation status did not affect the Cre-Lox recombination efficiency in freshly cultured alveolar macrophages. However, the alternative activation increased the recombination efficiency to ~80–90% in cultured alveolar macrophages. Intratracheal IL-33 treatment of MafB-EGFP mice also increased Cre-Lox mediated recombination of alveolar macrophages to ~80%. Our data suggest that while MafB-EGFP mice do not allow Cre-Lox recombination in the homeostatic lung and inflamed lungs with classically activated macrophages, these mice allow significant recombination in alternatively activated macrophages.

Supported by NIEHS (R01, ES030125)

Real-world outcomes of systemic therapy in locally advanced, recurrent or metastatic cutaneous squamous cell carcinoma

Aim: Real-world treatment patterns and clinical outcomes in advanced cutaneous squamous cell carcinoma were evaluated. Methods: Adults receiving their first systemic therapy for unresectable, locally advanced or recurrent/metastatic cutaneous squamous cell carcinoma from 4 September 2014, to 30 June 2017, were evaluated. The primary end point was real-world overall response rate per Response Evaluation Criteria in Solid Tumors or physician assessment. Time-to-event outcomes were assessed using the Kaplan-Meier method. Results: Of 51 eligible patients, the median age was 76 years, 80% were male and 65% had an Eastern Cooperative Oncology Group score of 0-1. The most common regimens were cetuximab (51%) and carboplatin + paclitaxel (22%). Median real-world overall response rate ranged from 9.8% per Response Evaluation Criteria in Solid Tumors to 43.1% when supplemented by physician assessment. Median overall survival was 10.7 months, and median time to next treatment was 7.5 months. Conclusion: Survival in advanced cutaneous squamous cell carcinoma was short. Real-world overall response rate was lower with Response Evaluation Criteria in Solid Tumors than physician assessment.

Psychometric Properties of the Academic Intrinsic Motivation Scale in a High School Context

The Academic Intrinsic Motivation Scale (AIMS) measures key components of student intrinsic motivation (IM). We investigate score validity and reliability of a downward extension of the AIMS developed for students in the high school context using a sample of students from the Pacific Northwest region of the United States. Through classical test theory, this study documents the scale’s (1) item difficulty and discrimination, (2) underlying factor structure and score reliability via confirmatory factor analysis and omega coefficients, and (3) relationship with the theoretically related variables student retention, achievement, and teamwork ability. Findings support scoring, generalizability, and extrapolation inferences for the downward extension of the AIMS in a high school sample. Implications for additional psychometric validity evidence are discussed.

Equivalence Testing of a Youth Risk and Needs Assessment

Truancy can have a detrimental impact on student outcomes. Risk assessments are used to identify behavioral and emotional problems associated with school truancy. Although imperative for informing decisions about student’s welfare, risk assessments generally lack substantial validity evidence. Specifically, supporting score interpretation across cultural groups through measurement invariance (MI) is needed for such assessments. This study examined MI, specifically factor invariance (FI), of the Washington Assessment of the Risks and Needs of Students (WARNS) across African American, Latinx, and Caucasian students using confirmatory factor analysis with traditional FI criteria and the equivalence testing (ET) procedure. Results from traditional criteria suggested that the factor structure is similar across groups. The ET procedure demonstrated minor model misspecifications.

Prognostic impact of PD-L1 in oropharyngeal cancer after primary curative radiotherapy and relation to HPV and tobacco smoking

Background: Incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rising rapidly in many western countries due to Human papillomavirus (HPV) and tobacco smoking, with a considerable overlap. Immunotherapy directed at the PD1/PD-L1 axis have shown promise in head and neck cancer and other cancer types. PD-L1 expression may indicate a poorer prognosis, and at the same time indicate a possible benefit of anti-PD-L1 immunotherapeutic agents. The primary aim of this study was to establish the prognostic effect of PD-L1 expression after primary curative radiotherapy alone.Material and methods: A cohort of 303 OPSCC patients treated with primary, curative intended radiotherapy was established. PD-L1 expression was evaluated by immunohistochemistry on formalin fixed, paraffin embedded tissue sections. PD-L1 positivity was defined as a Combined Positive Score (CPS) ≥1, indicating staining of either tumor cells, lymphocytes or macrophages.Results: Median follow-up was 5.3 years. With 199 deaths, there was no difference in overall survival between patients with PD-L1+ and PD-L1- tumors (adjusted hazard ratio [aHR] and 95% confidence interval [CI]: 1.0 [0.71-1.4]). Also, locoregional failure was similar between the two groups (aHR 1.1 [CI: 0.68 - 1.7]). Tumors were PD-L1+ in 76% of cases, significantly more among HPV p16+ tumors (82% vs. 70%, p = .01). Interestingly, higher prevalence of PD-L1+ expression was seen in HPV p16+ patients with <10 pack-years of tobacco-smoking (93%) compared to HPV p16+ smokers (76%) or HPV p16-negative patients (70%) (p = .003).Conclusion: PD-L1 expression had no prognostic significance in OPSCC patients treated with primary radiotherapy alone. A substantial proportion of OPSCC tumors show PD-L1 overexpression, especially in HPV p16+ tumors in patients with little or no smoking history.

Differential Item Functioning of a Truancy Assessment

The Washington Assessment of Risk and Needs of Students (WARNS) is a brief self-report measure designed for schools, courts, and youth service providers to identify student behaviors and contexts related to school truancy. Empirical support for WARNS item invariance between ethnic groups is lacking. This study examined differential item functioning (DIF) to ensure that items on the WARNS function similarly across groups, especially for groups where truancy rates are highest. The item response theory graded response model was used to examine DIF between Caucasian, African American, and Latinx students. DIF was identified in six items across WARNS domains. The DIF amount and magnitude likely will not influence decisions based on total scores. Implications for practice and suggestions for an ecological framework to explain the DIF results are discussed.

Medication Management Performance and Associated Cognitive Correlates in Healthy Older Adults and Older Adults with aMCI

OBJECTIVE

Difficulties managing medications, particularly among older adults experiencing cognitive deficits, is an important contributing factor to medication nonadherence that may have significant negative financial and health outcomes. The current study examined the performance of healthy older adults' (HOA) and individuals with amnestic mild cognitive impairment (aMCI) on the medication management abilities assessment's (MMAA, a performance-based measure of medication management) original scoring criteria and derived error process measures, assessing medication overtaking and undertaking magnitude. Exploratory correlations between performances on the MMAA and self-reported confidence in medication management skills and cognitive abilities were also examined.

METHOD

A sample of 25 HOAs with aMCI and 25 age- and education-matched HOAs completed the MMAA, a self-reported medication management confidence rating and a battery of neuropsychological tests.

RESULTS

HOAs performed significantly better on the MMAA score and committed significantly less process errors than individuals with aMCI. Despite these differences in MMAA performance, the HOA and aMCI groups rated similar high levels of confidence in their ability to manage a new medication routine. Notably, while the HOA group's performance on all of the MMAA measures did not relate to cognitive measures, the aMCI group's performance on the MMAA score was significantly related to memory and executive functioning and a new process error score for overtaking was related to processing speed.

CONCLUSIONS

Although these results present promising potential for the MMAA as a measure of medication management in a clinical setting, further studies need to examine the validity of the MMAA against real-world adherence measures.

Patient-reported outcomes in KEYNOTE-087, a phase 2 study of pembrolizumab in patients with classical Hodgkin lymphoma

In KEYNOTE-087, pembrolizumab had a 69% overall response rate and acceptable safety in patients with relapsed/refractory classical Hodgkin lymphoma (rrHL). We assessed health-related quality of life (HRQoL) in KEYNOTE-087. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and the EuroQoL Five Dimensions Questionnaire 3-level version (EQ-5D) were administered to 206 patients across three cohorts defined by lymphoma progression after: (1) autologous stem cell transplantation (ASCT) and subsequent brentuximab vedotin (BV) (n = 69); (2) salvage chemotherapy and BV (n = 79); and (3) ASCT without post-transplantation BV (n = 58). Compliance/completion rates were ≥90% at week 12 and ≥70% at week 24. QLQ-C30 global health status/QoL and EQ-5D visual analog scale scores showed mean increases from baseline in overall health at all assessed timepoints. With few exceptions, mean improvements from baseline to weeks 12 and 24 in QLQ-C30 functional and symptom scores occurred in all cohorts.Clinicaltrials.gov identifier: NCT02453594.

Cardiac dysfunction among soft tissue sarcoma patients in Denmark

Purpose

Soft tissue sarcoma (STS) patients may experience post-treatment cardiotoxicity, yet no population-based data exist. We examined the incidence of left ventricular ejection fraction (LVEF) decline, heart failure, and cardiac death following STS diagnosis among adults, using Danish patient registries and medical record review.

Patients and methods

LVEF decline was examined in a regional cohort of STS patients diagnosed during 1997–2011 in Western Denmark for whom cardiac imaging data were available. LVEF decline was defined as an absolute decline from baseline to follow-up of 10% or more, or, where baseline imaging was not available, a decline below the lower limit of normal (or 40%) for a follow-up LVEF. Heart failure and cardiac death were investigated in a national Danish cohort of all STS patients diagnosed from 2000 to 2009. We followed patients from STS diagnosis until heart failure, cardiac death, emigration or December 31, 2012 (whichever occurred first).

Results

The incidence rate of LVEF decline for the regional cohort with follow-up data (N=100, five events) or baseline and follow-up measurements (N=75, 19 events) was 16.8 (95% confidence interval [CI]: 7.0–40.3) and 108 (95% CI: 69–170), respectively, per 1,000 person-years. In the national cohort (N=1,187), the incidence of heart failure (40 events) and cardiac death (15 events) was 7.3 (95% CI: 5.4–10.0) and 2.7 (95% CI: 1.6–4.5), respectively, per 1,000 person-years. The strongest predictors of heart failure were doxorubicin treatment (hazard ratio [HR] =2.2, 95% CI: 0.5–10.2) and pre-existing cardiovascular disease (HR=6.3, 95% CI: 0.98–40.6).

Conclusion

LVEF decline occurred more frequently compared to heart failure or cardiac death in a nationally representative cohort of Danish STS patients.

Tetranitroacetimidic acid: a high oxygen oxidizer and potential replacement for ammonium perchlorate

Considerable work has been focused on developing replacements for ammonium perchlorate (AP), a primary choice for solid rocket and missile propellants, due to environmental concerns resulting from the release of perchlorate into groundwater systems [corrected]. Additionally, the generation of hydrochloric acid contributes to high concentrations of acid rain and to ozone layer depletion. En route to synthesizing salts that contain cationic FOX-7, a novel, high oxygen-containing oxidizer, tetranitroacetimidic acid (TNAA), has been synthesized and fully characterized. The properties of TNAA were found to be exceptional, with a calculated specific impulse exceeding that of AP, leading to its high potential as a replacement for AP. TNAA can be synthesized easily in a one-step process by the nitration of FOX-7 in high yield (>93%). The synthesis, properties, and chemical reactivity of TNAA have been examined.

Additional effects of bisphenol A and paraben on the induction of calbindin-D(9K) and progesterone receptor via an estrogen receptor pathway in rat pituitary GH3 cells

There are concerns about the combined estrogenic effects of chemicals since mixtures of these chemicals exist in our environment. This study investigated potential additional interactions between bisphenol A (BPA) and isobutylparaben (IBP), which are major xenoestrogens used in the manufacture of plastics, cosmetics, drugs, and other products. The combined effects of these two chemicals were analyzed by measuring the expression of calbindin-D(9k) (CaBP-9k) in rat pituitary cancer GH3 cells. GH3 cells were treated with single and combination doses of both chemicals (BPA single doses: 10(-7), 10(-6) and 10(-5) M; IBP single doses: 10(-7), 10(-6) and 10(-5) M, and each of the BPA and IBP doses combined). Prior to treatment, cells were temporarily transfected with a plasmid containing an ERE-luciferase reporter gene. Luciferase activity was measured as an indicator of ER activation by 17β-estradiol (E2), BPA, and IBP. BPA (10(-5) M) combined with IBP (10(-7) M and 10(-6) M) induced a significant increase in the luciferase activity. Twenty-four hours after treatment, dose-dependent effects were observed in both single and combined dose groups, and several combination doses induced significant increases in the expression of CaBP-9k and progesterone receptor (PR) at both transcriptional and translational levels. Pre-treatment with ICI 182,780, a pure estrogen antagonist, significantly reversed BPA- and IBP-induced CaBP-9k and PR upregulation in GH3 cells. Taken together, these results indicate that BPA and IBP may have additionally increased estrogenic potency via an estrogen receptor-mediated pathway.

Curcumin inhibits COPD-like airway inflammation and lung cancer progression in mice

Recent studies have demonstrated that K-ras mutations in lung epithelial cells elicit inflammation that promotes carcinogenesis in mice (intrinsic inflammation). The finding that patients with chronic obstructive pulmonary disease (COPD), an inflammatory disease of the lung, have an increased risk of lung cancer after controlling for smoking suggests a further link between lung cancer and extrinsic inflammation. Besides exposure to cigarette smoke, it is thought that airway inflammation in COPD is caused by bacterial colonization, particularly with non-typeable Hemophilus influenzae (NTHi). Previously, we have shown that NTHi-induced COPD-like airway inflammation promotes lung cancer in an airway conditional K-ras-induced mouse model. To further test the role of inflammation in cancer promotion, we administered the natural anti-inflammatory agent, curcumin, 1% in diet before and during weekly NTHi exposure. This significantly reduced the number of visible lung tumors in the absence of NTHi exposure by 85% and in the presence of NTHi exposures by 53%. Mechanistically, curcumin markedly suppressed NTHi-induced increased levels of the neutrophil chemoattractant keratinocyte-derived chemokine by 80% and neutrophils by 87% in bronchoalveolar lavage fluid. In vitro studies of murine K-ras-induced lung adenocarcinoma cell lines (LKR-10 and LKR-13) indicated direct anti-tumoral effects of curcumin by reducing cell viability, colony formation and inducing apoptosis. We conclude that curcumin suppresses the progression of K-ras-induced lung cancer in mice by inhibiting intrinsic and extrinsic inflammation and by direct anti-tumoral effects. These findings suggest that curcumin could be used to protract the premalignant phase and inhibit lung cancer progression in high-risk COPD patients.

Dichlorodiphenyldichloroethane and polychlorinated biphenyls: intraindividual changes, correlations, and predictors in healthy women from the southeastern United States

Dichlorodiphenyldichloroethane (DDE) and polychlorinated biphenyls (PCB) are widespread environmental contaminants that have been postulated to increase the risk of diseases such as non-Hodgkin's lymphoma, breast cancer, as well as lead to early menopause. Studies assessing the effect of organochlorine exposure often can only measure organochlorine levels once, such as at study enrollment, which may not be an etiologically relevant time period. We assessed the temporal changes in DDE and PCBs and the predictors of those changes using interview data and DDE and PCB measures collected from 123 women who were enrolled in a baseline study from 1978 to 1982 and followed up in 2003 to 2004. Baseline and follow-up organochlorine levels were compared using Spearman correlations (r(s)), and predictors of the rate of change in log concentration were evaluated using linear regression models. Although serum concentrations dramatically declined (median follow-up to baseline concentration ratio was 16% for DDE and 45% for PCB), baseline and follow-up measures were strongly correlated for DDE (r(s)=0.72) and moderately correlated for PCBs (r(s)=0.43). Prediction of follow-up PCB levels was substantially improved (r(s)=0.75) with data on initial concentration, length of lactation, baseline body mass index, and percent change in body fat, whereas DDE prediction improved slightly (r(s)=0.83) with data on lactation and baseline body mass index. These findings suggest that a single organochlorine measure provides considerable information on relative ranking at distant times and that the predictive power can be improved, particularly for PCBs, with information on a few predictors.

Negative predictive value of sonography with mammography in patients with palpable breast lesions

OBJECTIVE

This study was performed to determine the negative predictive value of sonography with mammography in evaluating palpable breast lesions.

MATERIALS AND METHODS

Four hundred twenty patients with 455 palpable breast lesions were retrospectively identified from our mammography database as having negative mammographic and sonographic results. For patients diagnosed with breast cancer, images and medical records were reviewed to determine whether the palpable lesion evaluated on sonography and mammography corresponded to the patient's breast cancer. On the basis of the number of breast cancers that correlated to the palpable areas imaged, the negative predictive value of sonography with mammography was determined.

RESULTS

Sixty-two of the 420 patients in the study group were already diagnosed with breast carcinoma, and eight new carcinomas were diagnosed during the study period. Only one of six ipsilateral cancers corresponded to a palpable lesion that had a negative imaging evaluation. This lesion was diagnosed as an invasive lobular cancer, hard and fixed at physical examination. Imaging and clinical follow-up of the remaining patients showed no abnormality at the sites of previously investigated palpable abnormalities. The mean imaging follow-up was 25 months. The negative predictive value of sonography and mammography in the setting of a palpable lesion was 99.8%.

CONCLUSION

The negative predictive value of sonography with mammography is high, and together these imaging modalities can be reassuring if follow-up is planned when the physical examination is not highly suspicious. However, if the physical examination is suspicious, biopsy should not be delayed.

Metallic clip deployment during stereotactic breast biopsy: retrospective analysis

PURPOSE

To determine the visibility of presumably excised lesions on screen-film mammograms obtained after biopsy and to determine the accuracy of clip deployment on the basis of measurements obtained on routine pre- and postbiopsy mammograms.

MATERIALS AND METHODS

One hundred eleven cases of core-needle biopsy with clip deployment were reviewed. In each, the type of lesion, lesion location, and biopsy approach were recorded. Pre- and postbiopsy images were reviewed, and the distance between the clip and biopsy site was measured. Postbiopsy images were reviewed to determine whether the targeted lesion remained visible.

RESULTS

In 62 (56%) cases, the clip was located within 5 mm of the target on postbiopsy images (craniocaudal and mediolateral), while in 18 (16%), the clip was within 6-10 mm on one projection. However, 31 (28%) clips were more than 1 cm from the target on at least one postbiopsy image. Of the 111 cases, 39 (35%) were malignant or atypical and required excision. Of these, 18 (46%) had clips at least 1 cm from the targeted lesion on at least one projection.

CONCLUSION

Metallic clips placed during core-needle breast biopsy are intended to mark the biopsy site when the visible lesion is excised, in case additional biopsy is required. The data suggest that the position of metallic clips placed during stereotactic core-needle biopsy may differ substantially from the location of the biopsy site. Postbiopsy mammography should be performed in two orthogonal planes to document clip position relative to the biopsy site.

A waterborne outbreak of hepatitis E virus transmission in southwestern Vietnam

A hepatitis outbreak affecting primarily adults occurred in southwestern Vietnam, along the Hau river bordering Cambodia, in June and July 1994. One month after the outbreak, sera and epidemiologic information were collected from 150 subjects: 50 patient cases, 50 matched, healthy community controls, and 50 geographic controls living 50 km upriver. The prevalence of immunoglobulin G (IgG) to hepatitis E virus (HEV) was significantly (P < 0.001) higher (76%) among cases than among the matched (38%) and geographic (38%) control populations. Immunoglobulin M to HEV was detected by enzyme-linked immunosorbent assay and Western blot in 16% of sera collected from patients one month after the outbreak. Hepatitis E virus RNA was detected with the polymerase chain reaction in 6% of sera from patients; RNA was not detected in either control group. These results indicate that HEV was the etiologic agent responsible for the outbreak. Children were under-represented among clinical cases. River water served as the principal source for drinking and bathing among most (96%) of the case and control study populations. Boiling of drinking water was negatively associated (P < 0.05) with IgG anti-HEV seropositivity. Unusually heavy rainfall likely contributed to conditions that favored the outbreak. This is the first recognized outbreak of epidemic HEV transmission in Indo-China.