The influence of age on T cell generation and TCR diversity

The ability to mount protective immune responses depends on the diversity of T cells. T cell diversity may be compromised by the declining thymic output of new T cells. The aging process imposes a threat to diversity, because thymic function deteriorates. In this study we have examined the relationship between thymic production, homeostatic T cell proliferation and TCR beta-chain diversity in young (approximately 25 years), middle-aged ( approximately 60 years), and elderly adults (approximately 75 years). TCR excision circles (TREC) as a marker of thymic output exponentially decreased by >95% between 25 and 60 years of age. The frequency of Ki67(+) cycling CD4 T cells remained steady, and surprisingly, the diversity of the naive CD4 T cell repertoire was maintained at approximately 2 x 10(7) different TCR beta-chains. After the age of 70 years, TRECs only slightly declined, but homeostatic proliferation doubled. The diversity of the T cell pool drastically contracted to 200,000 TCR beta-chains. Also, the phenotypic distinction between naive and memory CD4 T cells became fuzzy. The collapse in CD4 T cell diversity during the seventh and eighth decades indicates substantial T cell loss and implies that therapeutic measures to improve vaccine responses will have to include strategies for T cell replenishment.

Use of CTX-I and PINP as bone turnover markers: National Bone Health Alliance recommendations to standardize sample handling and patient preparation to reduce pre-analytical variability

The National Bone Health Alliance (NBHA) recommends standardized sample handling and patient preparation for C-terminal telopeptide of type I collagen (CTX-I) and N-terminal propeptide of type I procollagen (PINP) measurements to reduce pre-analytical variability. Controllable and uncontrollable patient-related factors are reviewed to facilitate interpretation and minimize pre-analytical variability.

INTRODUCTION

The IOF and the International Federation of Clinical Chemistry (IFCC) Bone Marker Standards Working Group have identified PINP and CTX-I in blood to be the reference markers of bone turnover for the fracture risk prediction and monitoring of osteoporosis treatment. Although used in clinical research for many years, bone turnover markers (BTM) have not been widely adopted in clinical practice primarily due to their poor within-subject and between-lab reproducibility. The NBHA Bone Turnover Marker Project team aim to reduce pre-analytical variability of CTX-I and PINP measurements through standardized sample handling and patient preparation.

METHODS

Recommendations for sample handling and patient preparations were made based on review of available publications and pragmatic considerations to reduce pre-analytical variability. Controllable and un-controllable patient-related factors were reviewed to facilitate interpretation and sample collection.

RESULTS

Samples for CTX-I must be collected consistently in the morning hours in the fasted state. EDTA plasma is preferred for CTX-I for its greater sample stability. Sample collection conditions for PINP are less critical as PINP has minimal circadian variability and is not affected by food intake. Sample stability limits should be observed. The uncontrollable aspects (age, sex, pregnancy, immobility, recent fracture, co-morbidities, anti-osteoporotic drugs, other medications) should be considered in BTM interpretation.

CONCLUSION

Adopting standardized sample handling and patient preparation procedures will significantly reduce controllable pre-analytical variability. The successful adoption of such recommendations necessitates the close collaboration of various stakeholders at the global stage, including the laboratories, the medical community, the reagent manufacturers and the regulatory agencies.

Response of biochemical markers of bone turnover to hormone replacement therapy: impact of biological variability

Biochemical markers of bone turnover may be useful to monitor patients taking hormone replacement therapy (HRT). The aim of this study was to assess the utility of markers in monitoring HRT by comparing the response of a large panel of markers to HRT with their within subject variability. We measured the response of markers to transdermal estradiol in 11 postmenopausal women over 24 weeks. We measured the within subject variability of markers in 11 untreated healthy postmenopausal women over the same period. The mean decrease in markers of bone formation after 24 weeks treatment ranged from 19% for procollagen type I C-terminal propeptide (PICP) to 40% for procollagen type I N-terminal propeptide (PINP). The mean decrease in markers of bone resorption ranged from 10% for tartrate-resistant acid phosphatase (TRAP) to 67% for C-terminal cross-linked telopeptide The least significant change (LSC at p < 0.05), calculated from the within subject variability in the untreated group, was used to define response. LSC for osteocalcin was 21%, bone alkaline phosphatase 28%, PICP 24%, PINP 21%, type I collagen telopeptide 28%, TRAP 17%, urinary calcium 90%, hydroxyproline 75%, total deoxypyridinoline 47%, free pyridinoline 36%, free deoxypyridinoline 26%, N-terminal cross-linked telopeptide 70%, and C-terminal cross-linked telopeptide 132%. The greatest number of responders after 24 weeks of treatment were found using PINP and osteocalcin (9 each), and free deoxypyridinoline (8 each) and total deoxypyridinoline (8 each) and total deoxypyridinoline (7 each). Lumbar spine bone mineral density defined four patients as responders. The ability to detect a response differs between markers and is not dependent on the magnitude of response to therapy.

Interventions to improve care related to colorectal cancer among racial and ethnic minorities: a systematic review

OBJECTIVE

To systematically review the literature to identify interventions that improve minority health related to colorectal cancer care.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, and Cochrane databases, from 1950 to 2010.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Interventions in US populations eligible for colorectal cancer screening, and composed of ≥50 % racial/ethnic minorities (or that included a specific sub-analysis by race/ethnicity). All included studies were linked to an identifiable healthcare source. The three authors independently reviewed the abstracts of all the articles and a final list was determined by consensus. All papers were independently reviewed and quality scores were calculated and assigned using the Downs and Black checklist.

RESULTS

Thirty-three studies were included in our final analysis. Patient education involving phone or in-person contact combined with navigation can lead to modest improvements, on the order of 15 percentage points, in colorectal cancer screening rates in minority populations. Provider-directed multi-modal interventions composed of education sessions and reminders, as well as pure educational interventions were found to be effective in raising colorectal cancer screening rates, also on the order of 10 to 15 percentage points. No relevant interventions focusing on post-screening follow up, treatment adherence and survivorship were identified.

LIMITATIONS

This review excluded any intervention studies that were not tied to an identifiable healthcare source. The minority populations in most studies reviewed were predominantly Hispanic and African American, limiting generalizability to other ethnic and minority populations.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Tailored patient education combined with patient navigation services, and physician training in communicating with patients of low health literacy, can modestly improve adherence to CRC screening. The onus is now on researchers to continue to evaluate and refine these interventions and begin to expand them to the entire colon cancer care continuum.

Establishing a reference range for bone turnover markers in young, healthy women

INTRODUCTION

Biochemical markers of bone turnover (BTMs) are important in determining fracture risk in postmenopausal women; high levels being associated with increased risk. A proposed goal of anti-resorptive therapy is to reduce BTMs to the lower half of the reference range for healthy young pre-menopausal women. Our aims were a) to establish reference ranges for bone alkaline phosphatase (bone ALP), crosslinked C- and N-telopeptides of type I collagen (betaCTX, NTX), osteocalcin (OC) and procollagen type I N propeptide (PINP) in pre-menopausal women and b) to investigate the determinants of these BTMs.

METHODS

BTMs were measured in peripheral blood and second morning void urine collected from 200 healthy pre-menopausal women ages 30 to 45 years. Each subject completed a short medical and lifestyle questionnaire.

RESULTS

BTMs were higher before the age of 35 years than after it. BTMs were higher in women with low BMI (betaCTX and OC), low alcohol consumption (PINP), current smoking habit (bone ALP and NTX), and around time of ovulation (NTX).

CONCLUSIONS

We recommend that the age range 35 to 45 years should be used when establishing BTM reference ranges in women.

A comparison study of an elementary school-based health center: effects on health care access and use

OBJECTIVE

To assess the effects of an elementary school-based health center (SBHC) on access to and the use of physical and mental health services by children aged 4 to 13 years.

STUDY DESIGN

A retrospective cohort analysis of parent surveys from a comparable intervention (SBHC) and a comparison of urban elementary schools.

INTERVENTION

Elementary SBHC services, including preventive physical health care; the care of minor short-term illnesses, injuries, and stable ongoing medical conditions, dental screenings; and mental health counseling.

PARTICIPANTS

All parents of students at both schools were asked to complete a survey. Return rates on the survey were 78.3% (570/728) and 77.0% (440/571) at the intervention and comparison schools, respectively.

MAIN OUTCOME MEASURES

The use of health services, access to health services, and health service satisfaction.

RESULTS

Compared with respondents at comparison schools, respondents whose children had access to an SBHC had less difficulty (P = .01) receiving physical health care for their children, ie, treatment of illnesses and injuries, immunizations, and physical examinations (odds ratio, 0.66; 95% confidence interval, 0.48-0.91). Access to an SBHC was independently and significantly related to less emergency department use (odds ratio, 0.63; 95% confidence interval, 0.40-0.99; P<.05), a greater likelihood of having had a physician's visit since the school year began (odds ratio, 1.92; 95% confidence interval, 1.39-2.65; P<.01), and a greater likelihood of having had an annual dental examination (odds ratio, 1.36; 95% confidence interval, 1.01-1.83; P<.05). Measured by a 12-item scale, respondents who reported the SBHC as their most-used health service were significantly more satisfied with their service than respondents who mostly used community clinics (z=-5.21; P<.01) or hospital clinics (z=-4.03; P<.01).

CONCLUSIONS

Independent of insurance status and other confounding variables, underserved minority children with SBHC access have better health care access and use than children without SBHC access, signifying that SBHCs can be an effective component of health delivery systems for these children.

Encephalopathy after bladder irrigation with alum: case report and literature review

A 70-year-old man with advanced obstructive nephropathy began to hemorrhage from the bladder after decompression with a Foley catheter. Manifestations of encephalopathy appeared after continuous irrigation with 1% alum for 2 days and were associated with elevated serum aluminum concentrations. Repeated treatments with deferoxamine and hemodialysis accomplished some aluminum removal, but the patient succumbed to bronchopneumonia. Brain aluminum content was not excessive at autopsy. A literature review suggests that intact renal function is essential to rapid disposal of a parenteral aluminum load and indicates that most reported instances of encephalopathy after alum irrigation have occurred in patients with compromised renal function. We conclude that alum should not be employed as a bladder irrigant in patients with acute or chronic renal failure.

Characterization of an α-l-fucosidase from the periodontal pathogen Tannerella forsythia

The periodontal pathogen Tannerella forsythia expresses several glycosidases which are linked to specific growth requirements and are involved in the invasion of host tissues. α-l-Fucosyl residues are exposed on various host glycoconjugates and, thus, the α-l-fucosidases predicted in the T. forsythia ATCC 43037 genome could potentially serve roles in host-pathogen interactions. We describe the molecular cloning and characterization of the putative fucosidase TfFuc1 (encoded by the bfo_2737 = Tffuc1 gene), previously reported to be present in an outer membrane preparation. In terms of sequence, this 51-kDa protein is a member of the glycosyl hydrolase family GH29. Using an artificial substrate, p-nitrophenyl-α-fucose (KM 670 μM), the enzyme was determined to have a pH optimum of 9.0 and to be competitively inhibited by fucose and deoxyfuconojirimycin. TfFuc1 was shown here to be a unique α(1,2)-fucosidase that also possesses α(1,6) specificity on small unbranched substrates. It is active on mucin after sialidase-catalyzed removal of terminal sialic acid residues and also removes fucose from blood group H. Following knock-out of the Tffuc1 gene and analyzing biofilm formation and cell invasion/adhesion of the mutant in comparison to the wild-type, it is most likely that the enzyme does not act extracellularly. Biochemically interesting as the first fucosidase in T. forsythia to be characterized, the biological role of TfFuc1 may well be in the metabolism of short oligosaccharides in the periplasm, thereby indirectly contributing to the virulence of this organism. TfFuc1 is the first glycosyl hydrolase in the GH29 family reported to be a specific α(1,2)-fucosidase.

Stress and oesophageal motility in normal subjects and patients with irritable bowel syndrome

Patterns of oesophageal motility were recorded in 17 healthy volunteers and 12 patients with the irritable bowel syndrome. Recordings were taken at rest and under stress by hyperventilation, a dichotic hearing challenge and a cold pressor test. In healthy volunteers the dichotic hearing challenge was associated with a significant increase in the mean amplitude of oesophageal peristalsis from 69.9 mmHg to 82.4 mmHg (p less than 0.01) and in the percentage of simultaneous waves from 9.7% to 24.5% (p less than 0.01). The cold pressor test increased the peristaltic amplitude from 69.9 mmHg to 87.1 mmHg (p less than 0.001) and the percentage of simultaneous waves from 9.7% to 34.4% (p less than 0.01). Both manoeuvres were associated with increases in pulse and blood pressure. In patients with irritable bowel syndrome, the resting mean oesophageal peristaltic amplitude was higher than that seen in normal volunteers (95.9 mmHg v 69.9 mmHg p less than 0.05). Changes in oesophageal motility during stress were similar in these patients to those seen in normal subjects although the changes were not significant. This study refutes the hypothesis that symptoms of irritable bowel syndrome and their association with stress are attributable to increased sensitivity of oesophageal motility to disruption by stressful stimuli.

A large-scale, short-term, media-based weight loss program

BACKGROUND

This article describes the evaluation of a media-based weight loss and nutrition program.

METHODS

Fifteen broadcasts were aired on a Chicago television news program over a three-week period in November of 1986. Some participants (n = 37) received the television program and an accompanying manual, and some (n = 37) received, in addition to the television and media interventions, encouragement to attend self-help groups dealing with obesity.

RESULTS

Repeated measures analysis of variance tests were performed, and planned comparisons were conducted only if main effects were significant. At posttesting, those participants attending the self-help groups lost an average of more than nine pounds, whereas those provided only the television program and manual had decreased by less than a pound. Those attending the groups had significantly decreased their percent of dietary fat intake, significantly increased aerobic exercise, and had significantly more hopefulness, motivation, and stimulus control.

DISCUSSION

The findings suggest that short-term mass media programs by themselves were probably not very effective, but when supplemented by a self-help manual and support groups may be able to produce significant short-term weight loss.

Adherence to raloxifene therapy: assessment methods and relationship with efficacy

Response to therapy depends on patient compliance but accurate assessment is difficult and adequate levels of adherence are uncertain. Adherence to raloxifene treatment may be assessed more accurately by electronic monitoring than by counting returned tablets. The level of adherence is positively associated with the degree of bone response.

INTRODUCTION

Adherence to study medication is usually estimated by counting returned tablets. This method relies on subjects' honesty and may be inaccurate. We aimed to assess adherence more accurately, and examine its effect on measures of bone response, by using electronic monitoring.

METHODS

Osteopenic women, ages 50 to 80, were prescribed daily raloxifene for 2 years. Electronic bottle caps (Medication Event Monitoring System (MEMS), Aardex) recorded the date and time on opening. Returned tablets were also counted. We measured bone mineral density (BMD) in duplicate at the spine and hip at baseline and 2 years. We also measured urinary N-terminal cross-linked telopeptide of type I collagen (NTX) at baseline, 1 and 2 years. We calculated the percentage changes in BMD and NTX from mean baseline to mean follow up measurements. Percentage adherence was assessed by both methods for 71 subjects that completed the study.

RESULTS

The two methods correlated significantly (p <0.001, Spearman's rho = 0.73) but the tablet count showed a higher median adherence than the MEMS caps (95.7 vs. 85.0%, p <0.001), with greater divergence at lower adherence levels. MEMS adherence in 65 subjects with complete data correlated with NTX response (p <0.01, rho = -0.33) but with BMD response only at the femoral neck. However, adherence in the lowest quartile was associated with poorer BMD response at all sites (p <0.05).

CONCLUSION

Tablet counts may give similar results overall but conceal substantial individual non-adherence. Monitoring caps may assess adherence more accurately than tablet counts and would be the preferred method in clinical trials. The degree of adherence is associated with both bone turnover and BMD responses to anti-resorptive therapy.

Evaluating screening colonoscopy quality in an uninsured urban population following patient navigation

Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.

ID: 89: RESIDENTIAL SEGREGATION AND SPATIAL CLUSTERING OF COLONOSCOPY RESOURCES WITHIN THE CITY OF CHICAGO

Background

In Illinois for the year 2015, colorectal cancer (CRC) is projected to cause 2,090 deaths, making it the leading cause of non-tobacco related cancer mortality. African American or black Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent CRC screening is known to increase early diagnosis and reduce cancer related death. Colonoscopy is the most commonly performed screening modality and diagnostic colonoscopy is required for follow up of abnormal non-invasive screening tests.

The City of Chicago is home to 2.7 million residents, of whom 31% are non-Hispanic white and 37% are non-Hispanic black. Chicago is known to have significant residential racial segregation with 69% of the total non-Hispanic black population living within communities located south of Roosevelt Avenue, on Chicago's south side. Relatively homogenous minority communities, such as Chicago's south side, are prone to the development of healthcare inequities that may result in the development of healthcare disparities.

Objective

The objective of this study was to use geographic information systems and geospatial analysis to investigate the spatial distribution of healthcare facilities that perform colonoscopy within the City of Chicago.

Methods

Population demographic data by census block was obtained from the U.S. Census Bureau, 2009–2013 American Community Survey 5-Year Estimates. The locations of facilities performing colonoscopy procedures were identified through internet search; review of Illinois Department of Public Health hospital listings; and ambulatory surgery center (ASC) accreditation listings. Each facility was contacted by phone to confirm performance of on-site colonoscopy and to obtain the number of on-site endoscopy procedure rooms. The addresses of facilities were geocoded using GPS Visualizer. City of Chicago census tract boundaries were mapped using U.S. Census Bureau Tiger Line shapefiles. Maps were created and geospatial analysis was performed using Esri ArcMap version 10.2.

Results

Within the City of Chicago, a total of 41 facilities were identified that perform on-site colonoscopy. Of the 41 facilities, 26 were hospital-based and 15 were ASC-based. 10 of 26 (38%) Hospital-based colonoscopy sites and 3 of 15 (20%) ASC-based colonoscopy sites were located on Chicago's south side. There were a total of 134 endoscopy procedure rooms reported across the 41 facilities. 30 of the 134 (22%) endoscopy procedure rooms were located on Chicago's south side. Spatial overlap was observed between areas with clustering of endoscopy procedure rooms and census tracts with greater than 80% non-Hispanic white race.

Conclusions

There is an unequal distribution of colonoscopy facilities and endoscopy procedure rooms across the City of Chicago with geographic clustering of colonoscopy infrastructure observed on Chicago's north side within census tracts comprised of greater than 80% non-Hispanic white race. Census tracts containing high proportions of non-Hispanic black race were clustered on Chicago's south side within areas with a relative paucity of colonoscopy infrastructure. The spatial clustering of colonoscopy procedure rooms represents a healthcare resource inequity that may contribute to the persistence of disparities in CRC related mortality among non-Hispanic black communities in Chicago.

Abstract B77: Knowledge of screening colonoscopy results and follow up recommendations among navigated patients

Purpose: Patient navigation (PN) programs have increased colorectal screening (CRS) rates in uninsured patient populations. The University of Chicago (UC) partnered with the American Cancer Society (ACS) to develop a CRS initiative at the UC to improve CRS outcomes. Unlike many PN programs, the UC ACS program solely utilized community-placed navigators. Along with addressing barriers, navigators provided one-to-one patient education, pre-procedure instructions, scheduling, appointment and bowel prep reminders. Prior to their screening exam, none of the UC navigated patients had ever received care within the UC network.

The efficacy of CRS programs depends on patient awareness of results and follow-up recommendations. Currently, the only data on awareness of colonoscopy surveillance recommendations is limited to a predominantly Caucasian insured population with known adenomas. Yet it is unclear what a predominately African- American navigated patient population knows about their colonoscopy results and follow-up recommendations. Therefore, our objectives were to determine UC navigated patients' knowledge of colonoscopy results and follow-up recommendations compared to non-navigated patients.

Methods: Between Jan. to June 2014, 194 patients obtained a screening colonoscopy with one of the physicians, who were also providers for the UC ACS program. Most, 143 patients met inclusion criteria (navigated patients: initial screening colonoscopy, asymptomatic, uninsured, and age &gt; 45 / non-navigated patients: screening colonoscopy, asymptomatic, insured, and age &gt;45). A brief semi-structured telephone survey was utilized to assess patient's beliefs about CRS, knowledge of their results, and follow-up recommendations. All patients were surveyed between 4-25 weeks post colonoscopy. Statistical analysis included chi-square and logistical regression (p &lt;0.05).

Results: Of the 143 patients meeting inclusion criteria, 97 patients were reached by phone (68%). Only 1 patient refused to complete the survey providing a 98% response rate. Of the 25 ACS patients meeting inclusion criteria, 18 patients completed the survey compared to 78/119 non-navigated patients. Around 90% of the navigated patient population identified as African American (AA), compared to 64% of the non-navigated patients.

There were no statistically significance differences between navigated and non-navigated patients for sex, ethnicity, race, and education level. Non-navigated patients were more likely to report a higher income and having a primary care physician (p&lt;0.05).

Approximately 40% of navigated patients said “no” or “unsure” when asked if colon cancer could be prevented compared to 35% of non-navigated patients (p = 0.37).

100% of the navigated patients correctly reported their colonoscopy findings compared to 79.5% of the non-navigated patients (p=0.04). ACS navigation was the only significant variable found on logistical regression. In contrast, only 44.4% of the navigated patients reported the correct follow-up recommendations compared to 70.5% of non-navigated patients (p=0.04). Logistical regression analysis showed that level of patient education (OR=.32; p=0.02) and having an adenoma (OR=4.1; p=0.02) correlated with knowledge of follow-up recommendations.

Conclusions: Despite education and access to care, our study highlights the need for continued education around CRS, since less that 40% of both navigated and non-navigated patients reported screening as a colon cancer preventative procedure. Although navigated patients were more aware of their colonoscopy results than non-navigated patients, this patient population was less aware of their follow-up recommendations. Future studies need to focus on minority populations in order to ensure equal benefit from CRS and to reduce disparities from this often-preventable cancer.

Citation Format: Cassandra D.L Fritz, Keith Naylor, Karen Kim. Knowledge of screening colonoscopy results and follow up recommendations among navigated patients. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B77.

P–028 Single centre retrospective analysis of endocrine stimulation therapy prior to microsurgical testicular sperm retrieval (mTESE) in men with hypogonadism and non-obstructive azoospermia (NOA)

Study question

What is the role of endocrine stimulation therapy prior to mTESE in men with hypogonadism and non obstructive azoospermia (NOA)?

Summary answer

In hypogonadal men there is a positive correlation between change of serum Testosterone (ΔT) before and after stimulation, and a successful mTESE.

What is known already

NOA is the most common cause of azoospermia and it is often associated with hypogonadism and testicular failure. It is common practice for endocrine stimulation therapies such as gonadotropines or selective estrogens receptor modulators to be used prior mTESE; however there is currently paucity of data regarding their efficacy.

Study design, size, duration

Retrospective analysis on infertile men with hypogonadism (defined as T &lt; 12nmol/L) and NOA who underwent mTESE with or without prior endocrine stimulation therapy (clomiphene or human chorionic gonadotropin). Retrospective data from 2015–2020, total number of patient: 71; stimulated group (N:40) vs unstimulated group (N:31).

Participants/materials, setting, methods

Retrospective study on infertile men who underwent mTESE with or without prior endocrine stimulation therapy. Hypogonadism was defined as serum testosterone (T) level &lt;12nm/L. We recorded demographic data, cause of testicular failure, previous testosterone therapy, duration and type of endocrine stimulation, pre-and post-stimulation hormone levels(T, FSH, LH), pre-operative hormone levels, successful sperm retrieval rate (at least 1 vial of viable sperm), average Johnsen score and total number of vials of sperm retrieved.

Main results and the role of chance

One-hundred-sixty-eight men underwent mTESE out of which 59 men received endocrine stimulation therapy for NOA between 2015–2020. Among them, we selected men with hypogonadism defined as serum T &lt; 12nmol/L which comprised 43% of the entire patient cohort. The hypogonadal group included 71 men, 28/71 had Klinefelter syndrome and 40/71 received endocrine stimulation for 13.9±9.2 months.

Testosterone levels significantly increased after endocrine stimulation (6.3±3.3nm/L vs 11.7±7.4nm/L) with mean change in serum testosterone (ΔT) of 5.7 nm/L (–5.5–23.3, N35). In the stimulated group, pre-operative serum T levels were significantly higher (11.7±7.4 vs 7.8±3.0 p:0.007) as compared to unstimulated men but the success rate of mTESE did not differ significantly (16/40–40%) vs 13/31–42%). Men with Klinefelter syndrome demonstrated significant differences with regards to age, lower T levels, higher FSH and LH levels, lower Johnsen score and success rates compared to other causes of NOA. Comparing men who had successful mTESE vs unsuccessful mTESE - higher T and lower FSH and LH seemed to correlate with successful sperm retrieval. Among men who received endocrine stimulation therapy the ΔT before and after stimulation seemed to correlate with successful sperm retrieval (AUC:0.701, SE:0.089, p:0.043). In the stimulated group a ΔT&gt;3.5nm/L showed a significant association with successful mTESE(p:0.041).

Limitations, reasons for caution

Retrospective study limitations.

Wider implications of the findings: Our study shows a significant improvement of serum T following endocrine stimulation therapy. Overall, in hypogonadal men, the hormonal stimulation seems not to be related to a higher success rate of mTESE but our data do suggest a positive correlation between ΔT before and after stimulation, and a successful mTESE.

Trial registration number

Not applicable

Interventions to reduce racial and ethnic disparities in colorectal cancer care: A systematic review

e16509

Background: Disparities in colorectal cancer (CRC) outcomes among underrepresented racial and ethnic minority patients continue to widen. We performed, and present here, the results of a systematic review of the literature evaluating interventions to reduce racial and ethnic disparities in CRC care. Methods: The MEDLINE, PsycINFO, CINAHL, and Cochrane databases were searched for articles that focused on interventions to reduce disparities in CRC screening, treatment, survivorship and end-of-life care from 1950 to 2010. Studies included were those that evaluated interventions in US populations that were composed of ≥50% racial/ethnic minorities (or that included a specific sub-analysis by race/ethnicity). Results: Following the electronic search, abstract and full text review, and reference reviews; a total of thirty-three studies were included in our final analysis. All of these were related to CRC screening; no studies evaluating the rest of the cancer care continuum were found. Nineteen studies (58%) were randomized controlled trials, nine (27%) were pre-test/post-test analyses, and five (15%) were cohort studies. Thirteen studies (39%) targeted African-American populations, eight (24%) targeted Hispanics, two (6%) targeted Asian populations, seven (21%) included a mixed population of ethnic minorities, and three (9%) were listed as “non-white” or included a subgroup analysis. The main results related to the magnitude of the effect of these patient-directed, patient navigator, and provider-directed interventions on CRC screening is outlined in the table below. Conclusions: Patient education involving personal contact, patient navigation services, and provider-directed education and reminder systems can modestly improve adherence to CRC screening among minority patients. Further studies targeting the rest of the colon cancer care continuum are needed. [Table: see text]

A Perspective Review on Diet Quality, Excess Adiposity, and Chronic Psychosocial Stress and Implications for Early-Onset Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer worldwide. Although the overall incidence of CRC has been decreasing over the past 40 y, early-onset colorectal cancer (EOCRC), which is defined as a CRC diagnosis in patients aged >50 y has increased. In this Perspective, we highlight and summarize the association between diet quality and excess adiposity, and EOCRC. We also explore chronic psychosocial stress (CPS), a less investigated modifiable risk factor, and EOCRC. We were able to show that a poor-quality diet, characterized by a high intake of sugary beverages and a Western diet pattern (high intake of red and processed meats, refined grains, and foods with added sugars) can promote risk factors associated with EOCRC development, such as an imbalance in the composition and function of the gut microbiome, presence of chronic inflammation, and insulin resistance. Excess adiposity, particularly obesity onset in early adulthood, is a likely contributor of EOCRC. Although the research is sparse examining CPS and CRC/EOCRC, we describe likely pathways linking CPS to tumorigenesis. Although additional research is needed to understand what factors are driving the uptick in EOCRC, managing body weight, improving diet quality, and mitigating psychosocial stress, may play an important role in reducing an individual's risk of EOCRC.

Abstract B88: Comparing screening colonoscopy bowel preparation quality in navigated uninsured and insured patient populations

Background: Racial and ethnic minority patients, as well as those with lower incomes and inadequate insurance, are less likely to complete preventative colorectal cancer (CRC) screening. Patient navigation is known to be an effective method for increasing the rates of CRC screening among minority groups and the medically underserved. The University of Chicago Medicine (UCM) is an active participant in the American Cancer Society's Colorectal Cancer Screening Initiative (ACS CCSI). The ACS CCSI began in August, 2012 with a goal of increasing access to and utilization of CRC screening among uninsured Illinois residents. In support of the CCSI, the UCM has partnered with Federally Qualified Healthcare Centers located on Chicago's South Side. Patients who participate in the CCSI at these healthcare sites receive: in-clinic patient navigation provided by an ACS trained navigator; they are provided GoLYTELY for bowel irrigation; and they are referred to UCM for screening colonoscopy. Prior to the day of their scheduled endoscopy, CCSI participants have no interaction or communication with the performing Gastroenterologist and they are responsible for adhering to the appropriate diet and completing the bowel preparation medications. Adequate bowel preparation is a quality measure for colonoscopy. Standard descriptors of bowel preparation include: “excellent”, no or minimal stool and small amounts of clear fluid; “Good”, no or minimal stool with large amounts of clear fluid; “Fair”, semisolid debris that are cleared with difficulty; and “Poor”, solid or semisolid debris that cannot be effectively cleared. Inadequate, “Fair” or “Poor”, bowel preparation is known to: lower rates of polyp detection; increase colonoscopy procedure duration; and contribute to earlier than recommended intervals for surveillance examination. Published studies have noted that uninsured patient populations are more likely to have an inadequate bowel preparation when compared with insured patient populations. The aim of this study was to assess bowel preparation among an insured university hospital population and an uninsured patient population who received navigation through the ACS CCSI.

Methods: This is a retrospective chart review of colonoscopies performed between 08/01/2012 and 07/01/2013. Inclusion criteria: adults age 50 and above who were eligible for guideline consistent CRC screening. Exclusion criteria: Patients referred for screening colonoscopy by a gastroenterologist. These patients are excluded as they may have received additional patient education and/or procedure related instructions that would likely impact the quality of their bowel preparation. Endoscopy procedure reports were reviewed for bowel preparation quality. Bowel preparation was summarized as Excellent/Good or Fair/Poor. Chi-Square and paired T-tests where used for statistical analysis.

Results: 228 outpatient colonoscopies were included in the review. 86 colonoscopies were performed as part of the ACS CCSI and 142 colonoscopies were performed as usual care. There was no difference in male gender comparing ACS CCSI and usual care (30% vs. 35%, p &gt; 0.50). The average age of ACS CCSI patients was younger than usual care (56.3 vs. 61.9 years, p &lt; 0.001). ACS CCSI patients were more likely to have an Excellent/Good bowel preparation compared to usual care (68.6% vs. 47.9%, p &lt; 0.005).

Conclusion: There are many barriers to effective CRC screening. Through the ACS CCSI, access to screening colonoscopies for the underserved in Illinois will increase. However, even with increased access, the quality of examination during colonoscopy can be impaired by inadequate bowel preparation thereby limiting its benefits and efficacy in preventing CRC. Our study found that an uninsured patient population that receives navigation through programs such as the ACS CCSI may achieve comparable, or in this population superior, rates of adequate quality of bowel preparation.

Citation Format: Keith Naylor, Cassandra Fritz, Helen Lam, Karen Kim. Comparing screening colonoscopy bowel preparation quality in navigated uninsured and insured patient populations. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B88. doi:10.1158/1538-7755.DISP13-B88

Abstract A49: From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development

Background: The Chicago South Side Cancer Disparities Initiative is a partnership between the University of Chicago and Chicago State University with the primary aim of developing a multi-faceted approach to cancer disparities education, training, and outreach. The current literature on direct community participation in curriculum development is minimal. Therefore, we developed a community-based participatory education (CPBE) model to provide community appropriate solutions to reduce local cancer disparities. In this study, CBPE was applied to develop a cancer-related health disparities curriculum for medical and public health students.

Objective: To use CBPE to develop a community-oriented cancer disparities curriculum that is specifically designed to assess the following content areas:

1) Are local communities interested in participating in curriculum design?

2) What should we teach students about disparities in their community?

3) How should community members be involved in the design and implementation of the curriculum?

4) What topics do community members think we should address?

Methods: A community town hall format was used to seek answers to the four content areas. Eighty-six community members from 19 different zip code areas of Chicago attended the town hall meeting. Participants were 14% men, 86% women with an average age of 51.7 years. An electronic Audience Response System (ARS) was used for the anonymous rapid collection of community response data. Using a mixed method approach, 4 quantitative and 3 qualitative survey questions were analyzed.

Results: 80% of community members heard of health disparities, 93% thought community members should be involved in cancer disparities curriculum development, 85% want to be involved in designing a cancer disparities curriculum and 81% reported an interest in taking the cancer disparities course.

Categorical themes were derived from the analysis of open-ended survey responses to potential curricular skills, knowledge and content. General questions followed by categorical themes are listed below:

1) What should students know to successfully interact with your community?

a) Importance of Community Empowerment

b) Root Causes and Solutions of Disparities

c) Knowledge specific to local community needs

2) How should community members be involved in curriculum design?

a) Student experiences in community engagement

b) Community perspectives on experience with disparities

3) What are the topics the disparities curriculum should address?

a) Root cause of Cancer Disparities

b) Solutions-“Prescription for Change”

c) Development of diverse relationships and interactions

Conclusion: The goal of Community Based Participatory Education (CBPE) is to directly involve community in health professional curriculum development. In this study, we outline the active role of the local community in creating an integrated cancer disparities curriculum for both health professionals and the community. The multiple themes identified will be used to prioritize and develop the curriculum. CBPE will provide the infrastructure for community appropriate solutions to reduce the number of health disparities plaguing the south-side Chicago community.

Citation Format: Cassandra D.L Fritz, Keith Naylor, Yashika Watkins, Thomas Britt, Lisa Hinton, Jennifer Jones, Gina Curry, Helen Lam, Karen Kim. From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A49. doi:10.1158/1538-7755.DISP13-A49

Information sharing for patient benefits: applying the Information Revolution to Telehealth in the UK

Seamless, integrated care within and between organisations requires a massive change in the way information is currently shared and used, so that information is available to patients, clinicians and NHS staff, where and when they need it. Establishing telehealth and telecare services extend this challenge and these new services will need to be integrated into the wider Information Revolution that is driving change across the NHS.

Patients expect, and assume, that the NHS, social care and other organisations are joined up and understand their needs implicitly. We also need to remember that for some patients having access to ‘their’ information and being involved in decisions about their care is very important. However, all patients want to be treated with dignity, and have confidence that care they receive is safe and effective—information sharing plays a pivotal role in this.

The information sharing challenges faced by organisations are common, and call for national solutions, while the implementations need to address the realities of the local landscape. What is emerging is a technology landscape that supports a mixture of local and national information sharing arrangements that will provide NHS and other organisations with the ability to choose the most appropriate and efficient technology solution to meet their business needs.

Historically the local data sharing has been beset by a range of technical and commercial problems that mean that many solutions are not reusable across the NHS while national approaches have been inflexible and often costly to implement. A key part of the new information landscape is the Interoperability Toolkit initiative, which is providing a national framework, supported by an accreditation scheme, that addresses these local information sharing challenges.

There is much that is already available to address the information needs for large-scale telehealth and telecare services. This talk will review what is available and highlight ongoing work to support telehealth and telecare specific requirements, building on the work done by the Continua Health Alliance and in partnership with Newham for the Whole System Demonstrators.