Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.

BACKGROUND: Approaches to prevent and manage diabetes at a community population level are hindered because current strategies are not aligned with the structure and function of a community system. We describe a community-driven process based on local data and rapid prototyping as an alternative approach to create diabetes prevention and care management solutions appropriate for each community. We report on the process and provide baseline data for a 3-year case study initiative to improve diabetes outcomes in two rural Nebraska communities. METHODS: We developed an iterative design process based on the assumption that decentralized decision-making using local data feedback and monitoring will lead to the innovation of local sustainable solutions. Coalitions act as community innovation hubs and meet monthly to work through a facilitated design process. Six core diabetes measures will be tracked over the course of the project using the electronic health record from community clinics as a proxy for the entire community. RESULTS: Baseline data indicate two-thirds of the population in both communities are at risk for prediabetes based on age and body mass index. However, only a fraction (35% and 12%) of those at risk have been screened. This information led both coalitions to focus on improving screening rates in their communities. DISCUSSION: In order to move a complex system towards an optimal state (e.g., improved diabetes outcomes), stakeholders must have access to continuous feedback of accurate, pertinent information in order to make informed decisions. Conventional approaches of implementing evidence-based interventions do not facilitate this process.

Relationships of serum CC16 levels with smoking status and lung function in COPD.

BACKGROUND: The club cell secretory protein (CC16) has anti-inflammatory and antioxidant effects, and low CC16 serum levels have been associated with both risk and progression of COPD, yet the interaction between smoking and CC16 on lung function outcomes remains unknown. METHODS: Utilizing cross-sectional data on United States veterans, CC16 serum concentrations were measured by ELISA and log transformed for analyses. Spirometry was conducted and COPD status was defined by post-bronchodilator FEV1/FVC ratio < 0.7. Smoking measures were self-reported on questionnaire. Multivariable logistic and linear regression were employed to examine associations between CC16 levels and COPD, and lung function with adjustment for covariates. Unadjusted Pearson correlations described relationships between CC16 level and lung function measures, pack-years smoked, and years since smoking cessation. RESULTS: The study population (N = 351) was mostly male, white, with an average age over 60 years. An interaction between CC16 and smoking status on FEV1/FVC ratio was demonstrated among subjects with COPD (N = 245, p = 0.01). There was a positive correlation among former smokers and negative correlation among current or never smokers with COPD. Among former smokers with COPD, CC16 levels were also positively correlated with years since smoking cessation, and inversely related with pack-years smoked. Increasing CC16 levels were associated with lower odds of COPD (ORadj = 0.36, 95% CI 0.22-0.57, Padj < 0.0001). CONCLUSIONS: Smoking status is an important effect modifier of CC16 relationships with lung function. Increasing serum CC16 corresponded to increases in FEV1/FVC ratio in former smokers with COPD versus opposite relationships in current or never smokers. Additional longitudinal studies may be warranted to assess relationship of CC16 with smoking cessation on lung function among subjects with COPD.

Preferences of adults with cancer for systemic cancer treatment: do preferences differ based on age?

Background: We used the Therapy Preference Scale, a 30-item questionnaire, to determine cancer treatment preferences of adults with cancer. Methods: We used Wilcoxon's rank sum test and Fisher's exact test to compare the preferences of younger (<60 years) versus older adults (≥60 years). Results: While 56% of patients would accept treatment offering increased life expectancy at an expense of short-term side effects, 75% preferred maintenance of cognition, functional ability and quality of life to quantity of days. Oral instead of intravenous treatment (p = 0.003), shorter hospital stay (p = 0.03), preservation of cognitive function (p = 0.01) and avoidance of pain (p = 0.02) were more important to older patients compared with younger patients. Conclusion: Many patients prioritized maintenance of cognition, functional ability and quality of life; older patients valued oral treatment, shorter hospital stay, preservation of cognitive function and avoidance of pain.

Lay abstract Understanding the preferences of adults with cancer is important for physicians to develop personalized cancer treatment plans. We used a self-reported 30-item questionnaire, the Therapy Preference Scale, to help patients express their preferences with regard to safety, efficacy and other aspects of therapy. While 56% of the patients in our study would accept treatment offering increased life expectancy at an expense of short-term side effects, 75% preferred maintenance of cognition, functional ability and quality of life to quantity of days. Compared with younger patients, older patients preferred oral instead of intravenous treatment, shorter hospital stay, preservation of cognitive function and avoidance of pain.

Endovascular Repair of Blunt Thoracic Aortic Trauma is Associated With Increased Left Ventricular Mass, Hypertension, and Off-target Aortic Remodeling.

BACKGROUND: Aortic elasticity creates a cushion that protects the heart from pressure injury, and a recoil that helps perfuse the coronary arteries. TEVAR has become first-line therapy for many aortic pathologies including trauma, but stent-grafts stiffen the aorta and likely increase LV afterload. OBJECTIVE: Test the hypothesis that trauma TEVAR is associated with LV mass increase and adverse off-target aortic remodeling. METHODS: Computed Tomography Angiography (CTA) scans of 20 trauma TEVAR patients (17 M/3 F) at baseline [age 34.9 ±â€Š18.5 (11.4-71.5) years] and 5.1 ±â€Š3.1 (1.1-12.3) years after repair were used to measure changes in LV mass, LV mass index, and diameters and lengths of the ascending thoracic aorta (ATA). Measurements were compared with similarly-aged control patients without aortic repair (21 M/21 F) evaluated at similar follow-ups. RESULTS: LV mass and LV mass index of TEVAR patients increased from 138.5 ±â€Š39.6 g and 72.35 ±â€Š15.17 g/m2 to 173.5 ±â€Š50.1 g and 85.48 ±â€Š18.34 g/m2 at the rate of 10.03 ±â€Š12.79 g/yr and 6.25 ±â€Š10.28 g/m2/yr, whereas in control patients LV characteristics did not change. ATA diameters of TEVAR patients increased at a rate of 0.60 ±â€Š0.80 mm/yr, which was 2.4-fold faster than in controls. ATA length in both TEVAR and control patients increased at 0.58 mm/yr. Half of TEVAR patients had hypertension at follow-up compared to only 5% at baseline. CONCLUSIONS: TEVAR is associated with LV mass increase, development of hypertension, and accelerated expansile remodeling of the ascending aorta. Although younger trauma patients may adapt to these effects, these changes may be even more important in older patients with other aortic pathologies and diminished baseline cardiac function.

Development and validation of the Therapy Preference Scale to understand patients´ systemic cancer treatment preferences.

We incorporated questions related to safety, effectiveness and other characteristics of systemic cancer treatment into a self-report questionnaire - the Therapy Preference Scale - that captures patients´ preferences. The authors asked 20 experts to assess content validity and an additional 20 experts, patients and community members to examine face validity and guide revisions. Key revisions included shortening the length, clarifying constructs and providing details to explain the context and trade-offs necessary to balance the risks and benefits of cancer treatment. The content validity index for the final questionnaire was 1.0, indicating that all questions were relevant. Reviewers expressed that the questionnaire would serve an important purpose. Experts, patients and community members guided revisions of the questionnaire and documented its value.

A Comparative Analysis of Survival and Funding Discrepancies in Cancers With High Mortality.

OBJECTIVE: Comparative analyses of survival and funding statistics in cancers with high mortality were performed to quantify discrepancies and identify areas for intervention. BACKGROUND: Discrepancies in research funding may contribute to stagnant survival rates in pancreatic ductal adenocarcinoma (PDAC). METHODS: The Surveillance, Epidemiology, and End Results database was queried for survival statistics. Funding data were obtained from the National Cancer Institute (NCI). Clinical trial data were obtained from www.clinicaltrials.gov. Cancers with high mortality were included for analyses. RESULTS: Since 1997, PDAC has received lesser funding ($1.41 billion) than other cancers such as breast ($10.52 billion), prostate ($4.93 billion), lung ($4.80 billion), and colorectal ($4.50 billion). Similarly, fewer clinical trials have been completed in PDAC (n = 608) compared with breast (n = 1904), lung (n = 1629), colorectal (n = 1080), and prostate (n = 1055) cancer. Despite this, since 1997, dollars invested in PDAC research produced a greater return on investment with regards to 5-year overall survival (5Y-OS) compared with breast, prostate, uterine, and ovarian cancer. Incremental cost-effectiveness analysis demonstrates that millions (liver, non-Hodgkin lymphoma, and melanoma) and billions (colorectal and lung) of dollars were required for each additional 1% increase in 5Y-OS compared with PDAC. Funding of research towards early diagnosis of PDAC has decreased by 19% since 2007. For nearly all cancers, treatment-related research receives the highest percentage of NCI funding. CONCLUSIONS: Funding of PDAC research is significantly less than other cancers, despite its higher mortality and greater potential to improve 5Y-OS. Increased awareness and lobbying are required to increase funding, promote research, and improve survival.

Vagus nerve stimulation with tachycardia detection provides additional seizure reduction compared to traditional vagus nerve stimulation.

PURPOSE: This study investigates the clinical and cost effectiveness of switching from traditional vagus nerve stimulation (VNS) to responsive VNS (rVNS), which has an additional ictal tachycardia detection and stimulation (AutoStim) mode. METHODS: Retrospective chart review was used to collect data from patients with medically refractory epilepsy who underwent generator replacements. Patients with confounding factors such as medication changes were excluded. Vagus nerve stimulation parameters, seizure frequency, and healthcare costs were collected for the 1-year period following generator replacement with the rVNS device. RESULTS: Documented seizure frequency was available for twenty-five patients. After implant with rVNS, 28% of patients had an additional ≥50% seizure reduction. There was a significant decrease in the average monthly seizure count (p = 0.039). In patients who were not already free of disabling seizures (n = 17), 41.2% had ≥50% additional seizure reduction. There was no difference in healthcare costs during the 1-year follow-up after the rVNS implant compared with one year prior. CONCLUSIONS: Ictal tachycardia detection and stimulation provided a significant clinical benefit in patients who were not free of disabling seizures with treatment from traditional VNS. There was no additional increase in healthcare costs during the first year after device replacement.

Mixed method study of quality of life for children with trisomy 18 and 13 after cardiac surgery.

BACKGROUND AND OBJECTIVES: Cardiac surgical interventions for children with trisomy 18 and trisomy 13 remain controversial, despite growing evidence that definitive cardiac repair prolongs survival. Understanding quality of life for survivors and their families therefore becomes crucial. Study objective was to generate a descriptive summary of parental perspectives on quality of life, family impact, functional status, and hopes for children with trisomy 18 and trisomy 13 who have undergone heart surgery. METHODS: A concurrent mixed method approach utilising PedsQL™ 4.0 Generic Core Parent Report for Toddlers or the PedsQL™ Infant Scale, PedsQL™ 2.0 Family Impact Module, Functional Status Scale, quality of life visual analogue scale, and narrative responses for 10 children whose families travelled out of state to access cardiac surgery denied to them in their home state due to genetic diagnoses. RESULTS: Parents rated their child's quality of life as 80/100, and their own quality of life as 78/100 using validated scales. Functional status was rated 11 by parents and 11.6 by providers (correlation 0.89). On quality of life visual analogue scale, all parents rated their child's quality of life as "high" with mean response 92.7/100. Parental hopes were informed by realistic perspective on prognosis while striving to ensure their children had access to reaching their full potential. Qualitative analysis revealed a profound sense of the child's relationality and valued life meaning. CONCLUSION: Understanding parental motivations and perceptions on the child's quality of life has potential to inform care teams in considering cardiac interventions for children with trisomy 18 and trisomy 13.

Aromatherapy improves nausea, pain, and mood for patients receiving pediatric palliative care symptom-based consults: A pilot design trial.

OBJECTIVE: The role of aromatherapy in supportive symptom management for pediatric patients receiving palliative care has been underexplored. This pilot study aimed to measure the impact of aromatherapy using validated child-reported nausea, pain, and mood scales 5 minutes and 60 minutes after aromatherapy exposure. METHODS: The 3 intervention arms included use of a symptom-specific aromatherapy sachet scent involving deep breathing. The parallel default control arm (for those children with medical exclusion criteria to aromatherapy) included use of a visual imagery picture envelope and deep breathing. Symptom burden was sequentially assessed at 5 and 60 minutes using the Baxter Retching Faces scale for nausea, the Wong-Baker FACES scale for pain, and the Children's Anxiety and Pain Scale (CAPS) for anxious mood. Ninety children or adolescents (mean age 9.4 years) at a free-standing children's hospital in the United States were included in each arm (total n = 180). RESULTS: At 5 minutes, there was a mean improvement of 3/10 (standard deviation [SD] 2.21) on the nausea scale; 2.6/10 (SD 1.83) on the pain scale; and 1.6/5 (SD 0.93) on the mood scale for the aromatherapy cohort (p < 0.0001). Symptom burden remained improved at 60 minutes post-intervention (<0.0001). Visual imagery with deep breathing improved self-reports of symptoms but was not as consistently sustained at 60 minutes. SIGNIFICANCE OF RESULTS: Aromatherapy represents an implementable supportive care intervention for pediatric patients receiving palliative care consults for symptom burden. The high number of children disqualified from the aromatherapy arm because of pulmonary or allergy indications warrants further attention to outcomes for additional breathing-based integrative modalities.

Ecological model of school engagement and attention-deficit/hyperactivity disorder in school-aged children.

School engagement protects against negative mental health outcomes; however, few studies examined the relationship between school engagement and attention-deficit hyperactivity disorder (ADHD) using an ecological framework. The aims were to examine: (1) whether school engagement has an independent protective association against the risk of ADHD in children, and (2) whether environmental factors have an association with ADHD either directly or indirectly via their association with school engagement. This cross-sectional study used data from the 2011-2012 National Survey of Children's Health, which collected information about children's mental health, family life, school, and community. The sample contained 65,680 children aged 6-17 years. Structural equation modeling was used to estimate the direct association of school engagement and ADHD and indirect associations of latent environmental variables (e.g., family socioeconomic status (SES), adverse childhood experiences (ACEs), environmental safety, and neighborhood amenities) and ADHD. School engagement had a direct and inverse relationship with ADHD (ß = - 0.35, p < 0.001) such that an increase in school engagement corresponds with a decrease in ADHD diagnosis. In addition, family SES (ß = - 0.03, p = 0.002), ACEs (ß = 0.10, p < 0.001), environment safety (ß = - 0.10, p < 0.001), and neighborhood amenities (ß = - 0.01, p = 0.025) all had an indirect association with ADHD via school engagement. In conclusion, school engagement had a direct association with ADHD. Furthermore, environmental correlates showed indirect associations with ADHD via school engagement. School programs targeted at reducing ADHD should consider family and community factors in their interventions.

Docosahexaenoic acid enhances amphiregulin-mediated bronchial epithelial cell repair processes following organic dust exposure.

Injurious dust exposures in the agricultural workplace involve the release of inflammatory mediators and activation of epidermal growth factor receptor (EGFR) in the respiratory epithelium. Amphiregulin (AREG), an EGFR ligand, mediates tissue repair and wound healing in the lung epithelium. Omega-3 fatty acids such as docosahexaenoic acid (DHA) are also known modulators of repair and resolution of inflammatory injury. This study investigated how AREG, DHA, and EGFR modulate lung repair processes following dust-induced injury. Primary human bronchial epithelial (BEC) and BEAS-2B cells were treated with an aqueous extract of swine confinement facility dust (DE) in the presence of DHA and AREG or EGFR inhibitors. Mice were exposed to DE intranasally with or without EGFR inhibition and DHA. Using a decellularized lung scaffolding tissue repair model, BEC recolonization of human lung scaffolds was analyzed in the context of DE, DHA, and AREG treatments. Through these investigations, we identified an important role for AREG in mediating BEC repair processes. DE-induced AREG release from BEC, and DHA treatment following DE exposure, enhanced this release. Both DHA and AREG also enhanced BEC repair capacities and rescued DE-induced recellularization deficits. In vivo, DHA treatment enhanced AREG production following DE exposure, whereas EGFR inhibitor-treated mice exhibited reduced AREG in their lung homogenates. These data indicate a role for AREG in the process of tissue repair after inflammatory lung injury caused by environmental dust exposure and implicate a role for DHA in regulating AREG-mediated repair signaling in BEC.

Modeling Glaucoma: Retinal Ganglion Cells Generated from Induced Pluripotent Stem Cells of Patients with SIX6 Risk Allele Show Developmental Abnormalities.

Glaucoma represents a group of multifactorial diseases with a unifying pathology of progressive retinal ganglion cell (RGC) degeneration, causing irreversible vision loss. To test the hypothesis that RGCs are intrinsically vulnerable in glaucoma, we have developed an in vitro model using the SIX6 risk allele carrying glaucoma patient-specific induced pluripotent stem cells (iPSCs) for generating functional RGCs. Here, we demonstrate that the efficiency of RGC generation by SIX6 risk allele iPSCs is significantly lower than iPSCs-derived from healthy, age- and sex-matched controls. The decrease in the number of RGC generation is accompanied by repressed developmental expression of RGC regulatory genes. The SIX6 risk allele RGCs display short and simple neurites, reduced expression of guidance molecules, and immature electrophysiological signature. In addition, these cells have higher expression of glaucoma-associated genes, CDKN2A and CDKN2B, suggesting an early onset of the disease phenotype. Consistent with the developmental abnormalities, the SIX6 risk allele RGCs display global dysregulation of genes which map on developmentally relevant biological processes for RGC differentiation and signaling pathways such as mammalian target of rapamycin that integrate diverse functions for differentiation, metabolism, and survival. The results suggest that SIX6 influences different stages of RGC differentiation and their survival; therefore, alteration in SIX6 function due to the risk allele may lead to cellular and molecular abnormalities. These abnormalities, if carried into adulthood, may make RGCs vulnerable in glaucoma. Stem Cells 2017;35:2239-2252.

Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis.

BACKGROUND: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

Lighting conditions used during visual shade matching in private dental offices.

STATEMENT OF PROBLEM: To our knowledge, no data are available on the actual lighting that is used for visual shade matching in private dental offices. PURPOSE: The purpose of this study was to determine the shade matching practices and interest in continuing education in dental practices and to determine the quantity and quality of the ambient lighting used during visual shade matching in a sample cohort of dentists in private practices. MATERIAL AND METHODS: Thirty-two private practices were enrolled, and each completed a 1-page survey on the clinic's shade matching practices. A spectrophotometer was used to measure the ambient lighting in each practice, collecting data on color temperature (Kelvin), color rendering index (CRI), and light intensity (foot candles/fc). A 2-sided nonparametric sign test was used to compare the true median color temperature with the standard (5500°K). A 1-sided t test was used to compare the CRI with the standard (CRI >90) (α=.05 for all statistical analyses). RESULTS: All dental practitioners surveyed used mainly visual shade matching in their practices. Of those, 87.5% showed interest in attending continuing education on this topic, with 56.3% preferring a clinical demonstration course. The mean color temperature was 4152.9°K and was significantly different from the standard 5500°K (P<.001). The 1-sided t test indicated that the mean CRI was less than 90 (P=1). The 95% confidence interval for the intensity was 80.7 to 111.6 fc. CONCLUSIONS: The ambient light in the majority of the 32 dental private practices measured was not ideal for visual shade matching.

Inequality in Children's Physical Activity Across Time-Segmented Youth Sport Practice.

Purpose: Youth sport (YS) is a community system for promoting children's physical activity (PA). Studies have examined mean PA during YS practices, but few have examined inequalities in the distribution of PA among children during practice time. This study examined PA inequality in time-segmented YS practices and differences in inequality by time segment characteristics. Methods: Children's PA and YS practices were examined using accelerometer and video observation data from a sample of YS teams (n = 36 teams, n = 101 practices) for third- through sixth-grade children (n = 392), approximately eight to 12 years old, in two rural U.S. communities. Practices were time-segmented into smaller units (episodes; n = 991). Episodes were assigned codes for purpose (e.g. warm-up), member arrangement (e.g. whole group), and setting demand (i.e. fosters participation, creates exclusion). Group accelerometer data were paired with episodes, and the Gini coefficient quantified inequality in activity counts and minutes of moderate-to-vigorous PA (MVPA). Beta generalized estimating equations examined the influence of episode structure on PA inequality. Results: Warm-up (Gini = 0.22), fitness (Gini = 0.24), and sport skill (Gini = 0.24) episodes had significantly lower inequality (p < .05) in activity counts than other purpose types. Management (Gini = 0.32) and strategy (Gini = 0.40) episodes had significantly greater inequality (p < .05) in MVPA minutes than other purpose types. Episodes fostering participation (Gini = 0.32) had significantly lower activity count inequality (p < .05) than episodes creating exclusion (Gini = 0.35). Conclusion: PA inequality among children during YS varied by practice structure. Metrics such as the Gini coefficient can illuminate inequalities in PA and may be useful for guiding efforts to improve population PA in children. Trial Registration: This study is registered at www.clinicaltrials.gov (Identifier: NCT03380143).

Short-term fear of movement improves less after anterior cruciate ligament reconstruction with concomitant meniscus repair.

BACKGROUND: Psychological response is important in return-to-sport decisions for athletes recovering from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare psychological response after ACLR with a concomitant meniscus repair compared to isolated ACLR. METHODS: Thirty-five individuals completed the Tampa Scale of Kinesiophobia (TSK) and Anterior Cruciate Ligament Return-to-Sport after Injury (ACL-RSI) scale before ACLR and 2, 4, and 6 months after ACLR. Participants were dichotomized based on presence of concomitant meniscus repair (Yes/No). Separate group X time repeated measures analyses of variance were conducted for both scales. RESULTS: Participants were 65.7% female, 19.1 ± 4.7 years old with BMI of 24.9 ± 4.4 kg/m2. Sixteen individuals had an isolated ACLR with 19 individuals having an ACLR with concomitant meniscus repair. For the TSK, there was a group × time interaction effect(p = 0.028), with improvement in TSK scores for the isolated ACLR group (ACLR:2 months = 24.8 ± 3.7; 4 months = 22.0 ± 5.7; 6 months: 19.9 ± 5.9; Meniscus Repair:2 months = 25.5 ± 4.7; 4 months = 24.1 ± 5.0; 6 months: 23.8 ± 4.7). Six months after ACLR, TSK scores were worse in the meniscus repair group(p = 0.036). For the ACL-RSI, there was no interaction(p = 0.07). CONCLUSION: Concomitant meniscus repair with ACLR results in less post-operative improvement in kinesiophobia through 6 months after ACLR compared to isolated ACLR.

Reliability of an Instrumented Pressure Walkway for Measuring Walking and Running Characteristics in Young, Athletic Individuals.

Background: Spatiotemporal parameters of gait are useful for identifying pathological gait patterns and presence of impairments. Reliability of the pressure-sensitive ZenoTM Walkway has not been established in young, active individuals without impairments, and no studies to this point have included running. Purpose: The purposes of this study were to 1) determine if up to two additional trials of walking and running on the ZenoTM Walkway are needed to produce consistent measurements of spatiotemporal variables, and 2) establish test-retest reliability and minimal detectable change (MDC) values for common spatiotemporal variables measured during walking and running. Study Design: Cross-Sectional Laboratory Study. Methods: Individuals (n=38) in this cross-sectional study walked and ran at self-selected comfortable speed on a pressure-sensitive ZenoTM Walkway. Twenty-one participants returned for follow-up testing between one and 14 days later. Intraclass correlation coefficients (ICCs) were used to assess reliability of spatiotemporal variable means using three, four, or five passes over the ZenoTM Walkway and to assess test-retest reliability of spatiotemporal variables across sessions. Results: All variables showed excellent reliability (ICC > 0.995) for walking and running when measured using three, four, or five passes. Additionally, all variables demonstrated moderate to excellent test-retest reliability during walking (ICC: 0.732-0.982) and running (ICC: 0.679-0.985). Conclusion: This study establishes a reliable measurement protocol of three one-way passes when using the ZenoTM Walkway for walking or running analysis. This is the first study to establish reliability of the ZenoTM Walkway during running and in young, active individuals without neuromusculoskeletal pathology. Level of Evidence: 3b.

Longitudinal changes in cognitive and physical function and health-related quality of life in older adults with acute myeloid leukemia.

INTRODUCTION: Many older adults with acute myeloid leukemia (AML) do not receive chemotherapy because of physicians' and patients' concern for toxicities and functional decline. This highlights the critical and urgent need to generate knowledge of functional changes following new treatments. MATERIALS AND METHODS: As a part of a pragmatic single-center trial, 59 older adults ≥60 years with AML completed geriatric assessment and health-related quality of life measures before treatment and at one month and three months after chemotherapy initiation. Changes in scores of various geriatric assessment measures were computed by subtracting the baseline score from the one-month and three-month scores for each patient. Established cut-offs were used to determine a clinically meaningful change (improvement or worsening). This study provides results of descriptive exploratory analyses. RESULTS: Patients experienced significant comorbidity burden and a high prevalence of functional impairments before treatment, with 56% of patients having ≥2 comorbid conditions, 69% having abnormal cognitive function (using Montreal Cognitive Assessment), 69% having impaired objective physical function (using Short Physical Performance Battery), and 64% having a positive depression screen (Patient Health Questionnaire-9). Patients (n = 53) received treatment with predominantly low-intensity chemotherapy; six patients received intensive chemotherapy. Among those who completed some or all of the three-month evaluation (N = 43), from baseline before treatment to three months later, cognitive function improved (38.7%) or remained stable (38.7%), objective physical function improved (51.6%) or remained stable (22.6%), and depression scores improved (9.4%) or remained stable (53.1%). Global health status score and role functioning moderately improved by a score of >16. DISCUSSION: An exploratory analysis of our phase 2 trial demonstrated improvement or stabilization of cognitive and physical function and depression score at three months in a high proportion of older survivors of AML, despite a high prevalence of frailty and significant comorbidity burden at baseline. These results demonstrate success of treatment in improving cognitive and physical function and depression score, and, if confirmed in larger studies, should encourage oncologists to offer chemotherapy to older adults with AML. CLINICAL TRIAL REGISTRATION: The study is registered in the ClinicalTrials.gov ID: NCT03226418.

Rural and Agricultural Natural Disaster Stress and Recovery: A Comparison.

This study used a novel survey instrument to evaluate the hypothesis that U.S. agricultural producers have significantly different stress and recovery experiences following acute-onset natural disaster compared to their non-agricultural counterparts. Participants were recruited through local organizations and targeted email and social media in communities in Arkansas and Nebraska that had experienced violent tornadoes in 2014 and/or severe flooding in 2019. The survey instrument incorporated the Brief Resilience Scale, the Revised Impact of Event Scale referencing two time points, the Posttraumatic Growth Inventory-Short Form, and original questions. Demographic, exposure, stress, and recovery measures were analyzed in SAS with Chi-square tests, t-tests, Wilcoxon tests, and multiple linear regression modeling to test for differences between agricultural and non-agricultural groups in resilience, event exposure, stress symptoms in the week after the event, stress symptoms in the month before the survey, a calculated recovery ratio, and posttraumatic growth. Analysis sample (N = 159) contained 20.8% agricultural occupation, 71.1% female, and 49.1% over age 55. No significant differences were found between agricultural and non-agricultural participants when comparing resilience, stress, or recovery ratio measures. Unadjusted posttraumatic growth score was significantly lower in the agriculture group (P = .02), and an occupation group by sex interaction was significantly associated with posttraumatic growth score (P = .02) when controlled for number of initial posttraumatic stress symptoms in the adjusted model, with agricultural women showing lower growth. Overall, there was no evidence of significant difference in disaster stress and recovery between agricultural and rural, non-agricultural groups in this study. There was some evidence that women in agriculture may have lower levels of recovery. Data indicated that rural residents continue to experience posttraumatic-type symptoms up to 8 years beyond the acute-onset natural disaster events. Communities should include strategies to support mental and emotional health in their preparedness, response, and recovery plans with intentional inclusion of agricultural populations.

Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work.

BACKGROUND: Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged. METHODS: Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children's hospitals and five programmatic domains. RESULTS: 104 children's hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of consultants. Academically-affiliated children's hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5. CONCLUSIONS: While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults.