ADVANCING HEARING HEALTH EQUITY FOR OLDER ADULTS: FINDINGS FROM THE HEARS RCT

Hearing loss is highly prevalent but disparities exist in hearing care. Delivering care in partnership with community health workers (CHWs) is an established approach to addressing disparities but has not been robustly studied in hearing care. We recruited older adults with hearing loss from community sites in Baltimore, MD. The 2-hour intervention consists of fitting a low-cost amplification device and counseling.151 participants were randomized. The primary outcome was change in communication function (Hearing Handicap Inventory for the Elderly-Screening [HHIE-S]; range 0-40; higher scores indicate poorer function). Communication function significantly improved in the intervention group, with an intention to treat estimated average treatment effect of a -12.98 point change (95% CI: -15.52, -10.42). In the first randomized control trial of a CHW-delivered hearing care intervention for older adults using low-cost amplification devices, participants receiving the intervention demonstrated a treatment effect comparable to prior studies of conventional hearing aids fit by audiologists.

CAPTURING OLDER ADULT PEER MENTORS' EXPERIENCE WITH COMMUNITY-DELIVERED HEARING CARE THROUGH PHOTOVOICE

While age-related hearing loss is common, disparities in care exist by race, ethnicity, and socioeconomic position. HEARS is a hearing care intervention that incorporates over-the-counter hearing technology, partnering older adults with peer mentors via a community health worker (CHW) model to address disparities. Through a randomized controlled trial, 8 older adult peer mentors delivered the HEARS intervention. We aimed to understand the CHWs’ perspectives on their role through photovoice. Participants took photos illustrating the intervention, their role, and hearing health. Semi-structured interviews (n=4) and a focus group were conducted. CHWs responded positively to the intervention and were satisfied with their role. A notable theme was the value of serving as a peer mentor. Participants valued the opportunity for generativity, learning as older adults, and associated social benefits. Our findings demonstrate an opportunity to engage older adults in the evaluation process, expanding access to hearing care, and in peer mentorship.

FUNCTIONAL HEARING AND VISION IMPAIRMENT AND SOCIAL ISOLATION OVER 8 YEARS IN COMMUNITY-DWELLING OLDER ADULTS

One in four older adults experience social isolation. Sensory impairment is a potentially modifiable risk factor for social isolation. Little is known about the long-term impact of sensory impairment on social well-being. This study quantifies the longitudinal associations between hearing, vision, and concurrent hearing and vision impairment (dual sensory impairment) and social isolation over 8 years among older adults. Data were from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study (2011- 2019) of U.S. Medicare beneficiaries. Social isolation was measured by a composite that incorporated four domains: living arrangement, core discussion network size, religious services attendance, and social participation. Baseline hearing and vision were measured by self-report. Associations between sensory impairments and odds of overall social isolation over 8 years were assessed using multivariate generalized logistic mixed models adjusted for demographic and health characteristics. Among 5,552 participants, 18.9% reported hearing impairment, 4.8% reported vision impairment, and 2.3% reported dual sensory impairment. Over 8 years, hearing impairment was associated with 28% greater odds of social isolation. Specifically, participants with hearing impairment were more likely to live alone and limit engagement in social activities. A similar pattern of association was observed for dual sensory impairment; however, estimates did not reach statistical significance. No association was observed between vision impairment and social isolation. Older adults with hearing impairment may be a clinically important subgroup to monitor for social isolation. Interventions for increasing social support and social participation may be especially valuable for older adults with hearing impairment.

Prognostic implication of the neoadjuvant rectal score and other biomarkers of clinical outcome in Hong Kong Chinese patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy

BACKGROUND

Neoadjuvant chemoradiotherapy is a standard treatment for locally advanced rectal cancer, for which pathological complete response is typically used as a surrogate survival endpoint. Neoadjuvant rectal score is a new biomarker that has been shown to correlate with survival. The main objectives of this study were to investigate factors contributing to pathological complete response, to validate the prognostic significance of neoadjuvant rectal score, and to investigate factors associated with a lower neoadjuvant rectal score in a cohort of Hong Kong Chinese.

METHODS

Data of patients with locally advanced rectal cancer who received neoadjuvant chemoradiotherapy from August 2006 to October 2018 were retrieved from hospital records and retrospectively analysed.

RESULTS

Of 193 patients who had optimal response to neoadjuvant chemoradiotherapy and surgery, tumour down-staging was the only independent prognostic factor that predicted pathological complete response (P<0.0001). Neoadjuvant rectal score was associated with overall survival (hazard ratio [HR]=1.042, 95% confidence interval [CI]=1.021-1.064; P<0.0001), disease-free survival (HR=1.042, 95% CI=1.022-1.062; P<0.0001), locoregional recurrence-free survival (HR=1.070, 95% CI=1.039-1.102; P<0.0001) and distant recurrence-free survival (HR=1.034, 95% CI=1.012-1.056; P=0.002). Patients who had pathological complete response were associated with a lower neoadjuvant rectal score (P<0.0001), but pathological complete response was not associated with survival. For patients with intermediate neoadjuvant rectal scores, late recurrences beyond 72 months from diagnosis were observed.

CONCLUSION

Neoadjuvant rectal score is an independent prognostic marker of survival and disease recurrence in a cohort of Hong Kong Chinese patients who received neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

Community Engagement and Human-Centered Design: Lessons From HEARS in Inclusive Recruitment of Older Adults

Within hearing care, significant disparities persist despite the highly prevalent nature of age-related hearing loss and relatively few trials include representation of racial/ethnic minorities. HEARS is an affordable, accessible hearing care intervention delivered by older adult peer mentors. The HEARS randomized controlled trial (NCT03442296) is a community-engaged RCT with an embedded human-centered design practitioner. Recruitment efforts occurred over 18 months in partnership with 13 affordable housing and social centers. The cohort (n=151) includes 43% (n=65) who self-identify as African American and 63.6% (n=96) with <$25,000 annual household income. The cohort represents the largest to-date of African American and low-income older adults with hearing loss. Recruitment efforts entailed 470.5 staff hours and $4,917.26 in supplies, equating to 1.4 hours and $14.13 per 1 individual screened and 3.1 hours and $32.56 for 1 participant randomized. Community-engaged research, partnered with human-centered design, may offer critical approaches to increasing representation within behavioral intervention trials.

Associations Between Hearing Loss, Loneliness, and Social Isolation: A Systematic Review

Hearing loss is highly prevalent among older adults, as is occurrences of loneliness and social isolation. Both loneliness and social isolation are also associated with insidious outcomes such as earlier mortality from all-causes and higher prevalence of chronic comorbidities. The purpose of this review is to synthesize published investigations that report on the associations between hearing loss with loneliness and social isolation. A systematic search through PubMed, Embase, CINAHL Plus, PsycINFO, and the Cochrane Library identified an initial total of 2495 references. Two independent reviewers screened articles for inclusion, with a third reviewer adjudicating. Studies published in English of older adults with hearing loss that also assessed loneliness and/or social isolation using a validated measure were included. Investigators used a modified Newcastle-Ottawa Scale (NOS) to appraise study quality. A final total of 14 articles were included in the review. The majority (12/14) were cross-sectional in design. Assessment methods were varied across hearing status, loneliness, and social isolation. Despite this heterogeneity, most multivariable adjusted investigations revealed that hearing loss was significantly associated with higher risks for both phenomena. Several studies also revealed this association to vary across gender, with women showing a stronger association than men. Our findings indicate that hearing loss is associated with both loneliness and social isolation, which have important implications for the cognitive and psychosocial health of older adults. Future investigations should examine possible underlying mechanisms of these relationships, as well as the efficacy of interventions through aural rehabilitation programs in addressing loneliness and social isolation.

Graphene metamaterial modulator for free-space thermal radiation

We proposed and demonstrated a new metamaterial architecture capable of high speed modulation of free-space space thermal infrared radiation using graphene. Our design completely eliminates channel resistance, thereby maximizing the electrostatic modulation speed, while at the same time effectively modulating infrared radiation. Experiment results verify that our device with area of 100 × 120 µm² can achieve a modulation speed as high as 2.6 GHz. We further highlight the utility of our graphene metamaterial modulator by reconstructing a fast infrared signal using an equivalent time sampling technique. The graphene metamaterial modulator demonstrated here is not only limited to the thermal infrared, but may be scaled to longer infrared and terahertz wavelengths. Our work provides a path forward for realization of frequency selective and all-electronic high speed devices for infrared applications.

Carotid artery resection and reconstruction: clinical experience of 28 consecutive cases

The aim of this study was to analyse the experience at a single institution in carotid artery resection with or without reconstruction performed as part of an oncological procedure or emergency haemostasis. A total of 28 patients were included in this retrospective study; 17 underwent ligation or resection of the carotid artery, and 11 underwent reconstruction of the carotid artery. The perioperative complications and surgical outcomes were recorded and analysed. Of the 17 patients with ligation or resection of the carotid artery, 4 developed neurologic deficit within 2 weeks postoperatively. Three patients with malignant tumours died 1 month (1) and 4 months (2) postoperatively. Of the 11 patients undergoing carotid reconstruction, no major cerebral complications were noted after operation. Colour Doppler showed patent vascular graft 1 year postoperatively in nine patients. Due to the higher complication rates both in short and long term with ligation or resection of the carotid artery, resection and revascularization of the carotid artery is advocated for patients with carotid artery involvement when possible.

Preferential expression of hPGFS in primary SCCHN and tumour cell lines derived from respiratory and digestive organs

Identifying overexpressed genes in tumours is a critical step for tumour diagnosis, prognosis, and treatment. Using differential display polymerase chain reaction, sequence analysis, and gene Blast searches, we discovered that human prostaglandin F synthase (hPGFS) was upregulated in squamous cell carcinoma of the head and neck (SCCHN). Northern blot analysis indicated that up to a 16-fold increase in the level of hPGFS expression was detected in 40.5% (15 out of 37) of SCCHN primary tumours. The increased expression of hPGFS in SCCHN was primarily detected in SCC of larynx and hypopharynx (59%, P<0.05). Using the same primary tissue samples, increased levels of epidermal growth factor receptor (EGFR) expression were detected in only 32% of tumour tissues, suggesting hPGFS may have the potential to become a drug target or molecular marker for SCCHN. To determine if the increased level of hPGFS expression came from tumour cells, we determined the level of hPGFS expression in SCCHN tumour cell lines. A high level of hPGFS expression was detected in four out of five tumour SCCHN cell lines. To determine if upregulation of hPGFS is SCCHN-specific, hPGFS expression was analysed in 59 tumour cell lines derived from different types of tumours. The expression of hPGFS was increased from two- to 500-fold in a large portion of cell lines derived from lung (five out of nine), colon (five out of seven) as well as head and neck cancer (four out of five). These data link hPGFS expression to tumours located in the respiratory and digestive organs.

Regression of tumors by IFN-alpha electroporation gene therapy and analysis of the responsible genes by cDNA array

The key to success with nonviral gene therapy as a treatment for cancer is to discover effective therapeutic genes and gene delivery methods and to understand how tumors are eradicated. We discovered that electroporation of IFN-alpha DNA into tumors in the SCCVII tumor-bearing mice led to tumor eradication in 50% of the mice and a more than two-fold increase in survival time when compared with controls (P = 0.0012). Analyses using cDNA array and Northern blot indicated that the genes responsible for the therapeutic effect of electro-IFN-alpha gene therapy included IRF-7, Granzyme A, Granzyme C, Gjb2, Krt14, Mig, IP-10 and MCP3. Because most of these genes have been known to either inhibit angiogenesis (Mig, IP-10), inhibit tumor growth (Gjb2, MCP3), kill tumor cells (Granzyme A and C), or induce expression of antitumor gene (IRF-7), they may become promising therapeutic gene candidates for a combination gene therapy approach to cancer treatment.

A novel alternative approach for prediction of radiation response of squamous cell carcinoma of head and neck

Accurate prediction of human tumor response to radiation therapy and concomitant chemoradiation would be an important tool to assist the physician in making recommendations for tumor treatment. Most of the studies that define the molecular markers for prediction of radiation response are based on the observation of gene expression using immunostaining, Northern blot, or Western blot analysis of a single or several genes. The results vary among different studies, and some results are contradictory. However, the studies agree that the change in expression of the tumor-related gene affects the radiation response. In this study, we explored a novel approach to predict the radiation response of human tumor using Atlas human cancer 1.2 cDNA array to analyze the expression profile of 1187 tumor-related genes in radiation-resistant and radiation-sensitive tissues. Sixty tumor-related genes were selected as predictors of radiation response of squamous cell carcinoma of the head and neck. Using the expression intensity of these 60 tumor-related genes, in combination with cluster analysis, we successfully predicted the radiation identity of two tumor samples.

Intramuscular electroporation delivery of IL-12 gene for treatment of squamous cell carcinoma located at distant site

Gene therapy with IL-12 has been shown to elicit potent systemic antitumor response in a variety of tumors. Although direct intratumoral injection is the most commonly used delivery route for gene therapy of solid tumors, the skeletal muscle has been shown to be an ideal tissue for gene delivery to produce systemic gene expression. We have previously demonstrated that electroporation delivery of a reporter gene to muscle enhances the transfection efficiency and the level of gene expression by two to three logs. We report here that intramuscular (i.m.) injection of as little as 10 microg of the IL-12 DNA plasmid followed by electroporation prevents squamous cell carcinoma (SCCVII) tumor establishment in up to 40% of experimental animals and reduces the volume of established tumors by 75% compared to controls (P<.05). By comparison, there was no difference in tumor growth observed between IL-12 injection alone and injection of empty vector with or without electroporation. The induction of antitumor activity by i.m. electroporation delivery of the IL-12 gene is associated with an increase in IL-12 expression in muscle and serum. The level of IL-12 expression in muscle and serum was 1500 pg/tibialias muscle and 170 pg/mL serum, respectively, at day 6, after the gene was delivered by electroporation. In contrast, the level of IL-12 when the gene was injected without electroporation was hardly detectable after subtracting the background level of IL-12 detected in naïve mice. The high level of IL-12 expression led to a 170-fold induction of IFN-gamma expression in serum at day 6 after i.m. electroporation delivery of IL-12 DNA plasmid, which was equal to 1450 pg/mL in the serum. The induction of antitumor activity by i.m. electroporation delivery of the IL-12 gene also correlates with increased CD8+ T-cell population in peripheral blood but not in spleen. Our findings suggest that i.m. delivery of IL-12 gene using electroporation is an effective method of inducing a systemic antitumor response against SCC.

Intramuscular electroporation delivery of IFN-alpha gene therapy for inhibition of tumor growth located at a distant site

Although electroporation has been shown in recent years to be a powerful method for delivering genes to muscle, no gene therapy via electro-injection has been studied for the treatment of tumors. In an immunocompetent tumor-bearing murine model, we have found that delivery of a low dose of reporter gene DNA (10 microg) to muscle via electroporation under specific pulse conditions (two 25-ms pulses of 375 V/cm) increased the level of gene expression by two logs of magnitude. Moreover, administration of 10 microg of interferon (IFN)-alpha DNA plasmid using these parameters once a week for 3 weeks increased the survival time and reduced squamous cell carcinoma (SCC) growth at a distant site in the C3H/HeJ-immunocompetent mouse. IFN-alpha gene therapy delivered to muscle using electroporation demonstrated statistically significant (P < 0.05) therapeutic efficacy for treating SCC located at a distant site, compared with interleukin (IL)-2 or endostatin gene, also delivered by electro-injection. The increased therapeutic efficacy was associated with a high level and extended duration of IFN-alpha expression in muscle and serum. We also discovered that the high level of IFN-alpha expression correlated with increased expression levels of the antiangiogenic genes IP-10 and Mig in local tumor tissue, which may have led to the reduction of blood vessels observed at the local tumor site. Delivery of increasing doses (10-100 microg) of IFN-alpha plasmid DNA by injection alone did not increase antitumor activity, whereas electroporation delivery of increasing doses (10-40 microg) of IFN-alpha plasmid DNA did increase the survival time. Our data clearly demonstrate the potential utility of electroporation for delivery of gene therapy to muscle for the treatment of residual or disseminated tumors.

Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care

BACKGROUND

The current health care climate demands the provision of quality patient care in a cost-effective manner. Clinical pathways define the essential components of care that are provided to patients with a specific diagnosis to achieve a desired outcome within a predetermined period. Development and implementation of clinical pathways streamline the provision of quality care in the most cost-effective manner.

OBJECTIVES

To develop a clinical pathway for patients undergoing total laryngectomy and to evaluate its impact on the cost and quality of care provided to these patients.

SETTING

A tertiary care academic medical center.

PATIENTS AND METHODS

A total of 45 patients were included in the study. The clinical pathway was implemented for 15 patients, while the other 30 patients were treated without the implementation of the pathway guidelines.

MAIN OUTCOME MEASURES

Length of hospital stay, readmission rate, and hospital variable costs.

RESULTS

The clinical pathway affected all cost outcome measures. Length of stay decreased by 2.4 days (29%; P=.001), and the average hospital variable cost decreased from $3992 to $3419 per case. This represents a 14.4% reduction in cost associated with pathway implementation (P=.02). The standardization of care eliminated unnecessary variation and repetition in resource usage, resulting in overall cost reduction. Pathway implementation resulted in a lower readmission rate (7% [1/15]) than that of patients treated prior to protocol implementation (23% [7/30]).

CONCLUSION

Implementing a carefully developed clinical pathway may reduce cost without compromising the quality of care for patients undergoing total laryngectomy.

Characterization of Varicella-Zoster virus glycoprotein K (open reading frame 5) and its role in virus growth

Varicella-zoster virus (VZV) is an alphaherpesvirus that is the causative agent of chickenpox and herpes zoster. VZV open reading frame 5 (ORF5) encodes glycoprotein K (gK), which is conserved among alphaherpesviruses. While VZV gK has not been characterized, and its role in viral replication is unknown, homologs of VZV gK in herpes simplex virus type 1 (HSV-1) and pseudorabies virus (PRV) have been well studied. To identify the VZV ORF5 gene product, we raised a polyclonal antibody against a fusion protein of ORF5 codons 25 to 122 with glutathione S-transferase and used it to study the protein in infected cells. A 40,000-molecular-weight protein was detected in cell-free virus by Western blotting. In immunogold electron microscopic studies, VZV gK was in enveloped virions and was evenly distributed in the cytoplasm in infected cells. To determine the function of VZV gK in virus growth, a series of gK deletion mutants were constructed with VZV cosmid DNA derived from the Oka strain. Full and partial deletions in gK prevented viral replication when the gK mutant cosmids were transfected into melanoma cells. Insertion of the HSV-1 (KOS) gK gene into the endogenous VZV gK site did not compensate for the deletion of VZV gK. The replacement of VZV gK at a nonnative AvrII site in the VZV genome restored the phenotypic characteristics of intact recombinant Oka (rOka) virus. Moreover, gK complementing cells transfected with a full gK deletion mutant exhibited viral plaques indistinguishable from those of rOka. Our results are consistent with the studies of gK proteins of HSV-1 and PRV showing that gK is indispensable for viral replication.

Cranial chordomas in children and adolescents

Chordomas are rare tumors that usually occur in adults. This report describes four cases of intracranial chordomas treated in patients 20 years of age or younger by the senior author (O.A.M.) during a 4-year period. The authors also reviewed the literature on pediatric patients, which revealed that the clinical presentations, histological patterns, and behaviors of these tumors differ considerably depending on whether the patient is younger or older than 5 years of age. The younger population had a wider range of presenting symptoms, a greater prevalence of atypical histological findings with aggressive behavior, a greater range of cellularity than the classic chordomas, and a higher instance of metastasis; it showed no chondroid component compared to a 17.1% instance in the older patients. The prognosis for patients with a chordoma is related directly to the histological pattern of the tumor; the atypical chordoma carries a poor prognosis. The prognoses for children older than 5 years of age with a classic or chondroid tumor were not significantly different (p=0.788). At follow up, the difference in survival rates between patients undergoing surgery plus radiation therapy and those who had surgery alone was statistically significant (p=0.00446). No correlation was found between radical resection or radiation therapy and an improved prognosis for patients younger than 5 years of age who had a tumor with an atypical histological pattern. This study identifies and delineates the distinction between these age groups and provides a review of the potential prognostic factors.

Descriptive epidemiology of local public health systems

This article, presented at the Research and Measurement of Public Health Core Functions Science Symposium sponsored by the Centers for Disease Control and Prevention (CDC) in June 1994, provides selected data from the 1992-1993 National Profile of Local Health Departments. The National Association of County and City Health Officials (NACCHO), in cooperation with the CDC Public Health Practice Program Office, recently completed the 1992-1993 National Profile of Local Health Departments. This study describes public health at the local level and updates the first Profile study, conducted in 1989. The study population included 2,888 local health departments (LHDs) in the United States. Responses were received from 72% of LHDs. Comparisons are made with the 1990 Profile where available. This article provides a selected overview of the information contained in the 1992-1993 Profile and includes structure of LHDs, top agency executive, staffing, expenditures, and planning. The findings have important ramifications for community health planners and policy makers at all levels. With the ongoing potential for change in the U.S. health care system, reliable data establishing baselines and monitoring trends in public health at the local level are important. The information in this report, and the 1992-1993 National Profile of Local Health Departments, updates and expands the available knowledge of LHD structures and activities.

Analysis of the current status of public health practice in local health departments

This article describes the performance by local health departments of core public health functions. A post hoc analysis based on these essential functions was implemented using the 1994 dataset from a cooperative project with the Centers for Disease Control and Prevention (CDC) and National Association of County and City Health Officials, which involved a survey of the nation's 2,888 local health departments. Applying guidelines for each functional area drafted by the Office of Disease Prevention and Health Promotion/Office of the Assistant Secretary for Health, CDC, and the Public Health Foundation in conjunction with the health officers in five states, a score was created for each core public health function: (1) health-related data collection, surveillance, and outcomes monitoring, (2) protection of environment, housing, food, and water, (3) investigation and control of diseases and injuries, (4) public information and education, (5) accountability and quality assurance, (6) laboratory services, (7) training and education, and (8) leadership, policy development, and administration. The individual and summary scores provide a mechanism to measure and describe the 2,079 local health departments' performance of these core functions and to examine their relationship to several characteristics and practices--planning, administrative units, annual total expenditures, and jurisdiction population size. This article shows that the core performance index is highest for the data function and for local health departments serving a population of 50,000 or more people. In addition, the performance index increases as budget increases and is greater for all eight functions in those local health departments using health planning models such as Assessment Protocol for Excellence in Public Health (APEX-PH), Planned Approach to Community Health (PATCH), Healthy People 2000, or Healthy Communities 2000. These results may be used to facilitate cooperation between local, state, and federal health agencies and the communities they serve; strengthen the core functions at the local, state, and federal levels; and improve public health practice.

Drosophila virilis oskar transgenes direct body patterning but not pole cell formation or maintenance of mRNA localization in D. melanogaster

The Drosophila melanogaster gene oskar is required for both posterior body patterning and germline formation in the early embryo; precisely how oskar functions is unknown. The oskar transcript is localized to the posterior pole of the developing oocyte, and oskar mRNA and protein are maintained at the pole through early embryogenesis. The posterior maintenance of oskar mRNA is dependent upon the presence of oskar protein. We have cloned and characterized the Drosophila virilis oskar homologue, virosk, and examined its activity as a transgene in Drosophila melanogaster flies. We find that the cis-acting mRNA localization signals are conserved, although the virosk transcript also transiently accumulates at novel intermediate sites. The virosk protein, however, shows substantial differences from oskar: while virosk is able to rescue body patterning in a D. melanogaster oskar- background, it is impaired in both mRNA maintenance and pole cell formation. Furthermore, virosk induces a dominant maternal-effect lethality when introduced into a wild-type background, and interferes with the posterior maintenance of the endogenous oskar transcript in early embryogenesis. Our data suggest that virosk protein is unable to anchor at the posterior pole of the early embryo; this defect could account for all of the characteristics of virosk mentioned above. Our observations support a model in which oskar protein functions both by nucleating the factors necessary for the activation of the posterior body patterning determinant and the germ cell determinant, and by anchoring these factors to the posterior pole of the embryo. While the posterior body patterning determinant need not be correctly localized to provide body patterning activity, the germ cell determinant may need to be highly concentrated adjacent to the cortex in order to direct pole cell formation.