What We Are Missing: Using Machine Learning Models to Predict Vitamin C Deficiency in Patients with Metabolic and Bariatric Surgery.

PURPOSE: Vitamin C (VC) is implicated in many physiological pathways. Vitamin C deficiency (VCD) can compromise the health of patients with metabolic and bariatric surgery (patients). As symptoms of VCD are elusive and data on VCD in patients is scarce, we aim to characterize patients with measured VC levels, investigate the association of VCD with other lab abnormalities, and create predictive models of VCD using machine learning (ML). METHODS: A retrospective chart review of patients seen from 2017 to 2021 at a tertiary care center in Northeastern USA was conducted. A 1:4 case mix of patients with VC measured to a random sample of patients without VC measured was created for comparative purposes. ML models (BayesNet and random forest) were used to create predictive models and estimate the prevalence of VCD patients. RESULTS: Of 5946 patients reviewed, 187 (3.1%) had VC measures, and 73 (39%) of these patients had VC<23 µmol/L(VCD. When comparing patients with VCD to patients without VCD, the ML algorithms identified a higher risk of VCD in patients deficient in vitamin B1, D, calcium, potassium, iron, and blood indices. ML models reached 70% accuracy. Applied to the testing sample, a "true" VCD prevalence of ~20% was predicted, among whom ~33% had scurvy levels (VC<11 µmol/L). CONCLUSION: Our models suggest a much higher level of patients have VCD than is reflected in the literature. This indicates a high proportion of patients remain potentially undiagnosed for VCD and are thus at risk for postoperative morbidity and mortality.

Loss of lower extremity bone mineral density 1 year after denosumab is discontinued in persons with subacute spinal cord injury.

Twelve months following discontinuation of denosumab, the percent decrease in mean bone mineral density (BMD) values at the hip and knee regions were similar between both the denosumab and placebo groups. These findings emphasize the need for additional trials to understand the effect of continued administration of denosumab after subacute spinal cord injury (SCI) to avoid this demineralization. OBJECTIVE: To determine changes in BMD 1 year after denosumab was discontinued in participants with subacute SCI who had drug treatment initiated within 90 days post SCI and continued for 1 year. METHODS: Fourteen participants who completed a randomized, double-blinded, placebo-controlled drug trial (parent study: denosumab 60 mg (Prolia, Amgen Inc., n = 8) or placebo (n = 6); administered at baseline, 6, and 12 months) were followed 12 months after the 18 months from baseline primary end point was completed. The BMD of skeletal regions below the SCI at higher risk of fracture was measured [total hip, distal femur epiphysis (DFE), distal femur metaphysis (DFM), and proximal tibia epiphysis (PTE)] by dual energy X-ray absorptiometry. RESULTS: The percent decreases in mean BMD values at all regions of the hip and knee from 18 to 30 months were similar in both the denosumab and placebo groups. However, at 30 months, the absolute values for mean BMD remained significantly higher in the drug treatment than that of the placebo group at the DFM (p = 0.03), DFE (p = 0.04), and PTE (p = 0.05). CONCLUSIONS: In persons with SCI who initiated denosumab treatment during the subacute injury phase and maintained treatment for 1 year, the discontinuation of drug resulted in percent loss of mean BMD similar to that of the placebo group, with absolute mean BMD values at the knee regions at the 12-month follow-up visit significantly higher in the drug treatment than those in the placebo group. These data underscore the need to study continued administration of denosumab after subacute SCI to avoid marked demineralization in the sublesional skeleton upon discontinuation of this agent.

Generation of a Reference Dataset to Permit the Calculation of T-scores at the Distal Femur and Proximal Tibia in Persons with Spinal Cord Injury.

Persons with traumatic spinal cord injury (SCI) have severe bone loss below the level of lesion with the distal femur (DF) and proximal tibia (PT) being the skeletal regions having the highest risk of fracture. While a reference areal bone mineral density (aBMD) database is available at the total hip (TH) using the combined National Health and Nutrition Examination Survey (NHANES) III study and General Electric (GE) combined (GE/NHANES) to calculate T-score (T-scoreGE/NHANES), no such reference database exists for aBMD of the DF, and PT. The primary objectives of this study were (1) to create a reference dataset of young-healthy able-bodied (YHAB) persons to calculate T-score (T-scoreYHAB) values at the DF and PT, (2) to explore the impact of time since injury (TSI) on relative bone loss in the DF and PT regions using the two computation models to determine T-score values, and (3) to determine agreement between T-score values for a cohort of persons with SCI using the (T-scoreYHAB) and (T-scoreGE/NHANES) reference datasets. A cross-sectional prospective data collection study. A Department of Veterans Affairs Medical Center and a Private Rehabilitation Hospital. A normative reference aBMD database at the DF and PT was collected in 32 male and 32 female Caucasian YHAB participants (n=64) and then applied to calculate T-score values at the DF and PT in 105 SCI participants from a historical cohort. The SCI participants were then grouped based on TSI epochs (E-I: TSI < 1y, E-II: TSI 1-5y, E-III: TSI 6-10y, E-IV: TSI 11-20y, E-V: TSI > 20y). N/A. The knee and hip aBMD values were obtained by dual energy X-ray absorptiometry (GE Lunar iDXA) using standard clinical software for proximal femur orthopedic knee software applications. There were no significant differences in mean aBMD values across the four YHAB age subgroups (21-25, 26-30, 31-35, and 36-40 yr of age) at the TH, DF, and PT; mean aBMD values were higher in men compared to the women at all skeletal regions of interest. Using the mean YHAB aBMD values to calculate T-score values at each TSI epoch for persons with SCI, T-score values decreased as a function of TSI, and they continued to decline for 11-20 yr. Moderate kappa agreement was noted between the YHAB and the GE/NHANES reference datasets for the T-score cutoff criteria accepted to diagnose osteoporosis (i.e., SD <-2.5). A homogeneous reference dataset of YHAB aBMD values at the DF and PT was applied to calculate T-score values in persons with chronic SCI. There was a moderate level of agreement at the TH between the YHAB and GE/NHANES reference datasets when applying the conventional T-score cutoff value for the diagnosis of osteoporosis.

Adverse perioperative outcomes among patients undergoing gastrointestinal cancer surgery: Quantifying attributable risk from malnutrition.

BACKGROUND: Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood. METHODS: Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined. RESULTS: The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%. CONCLUSION: Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.

Relationships between T-scores at the hip and bone mineral density at the distal femur and proximal tibia in persons with spinal cord injury.

Objective: To identify T-score values at the total hip (TH) and femoral neck (FN) that correspond to the cutoff value of <0.60 g/cm2 for heightened risk of fracture at the distal femur (DF) and proximal tibia (PT).Design: Retrospective analysis of data in a research center's database. Setting: Community-based individuals with spinal cord injury (SCI). Participants: 105 unique individuals with SCI. Outcome Measurements: DXA derived areal BMD (aBMD) and T-score of the DF, PT, TH, and FN. Results: The aBMD at the DF and PT regions were predictors of T-scores at the TH (R2 = 0.63, P < 0.001 and R2 = 0.65, P < 0.001) and FN (R2 = 0.55, P < 0.001 and R2 = 0.58, P < 0.001). Using the DF and PT aBMD of 0.60 g/cm2 as a value below which fractures were more likely to occur, the predicted T-score was -3.1 and -3.5 at the TH and -2.6 and -2.9 at the FN, respectively. However, when the predicted and observed T-score values disagree outside the 95% limit of agreement, the predicted T-score values are lower than the measured T-score values, overestimating the measured values between -2.0 and -4.0 SD. Conclusion: The DF and PT cutoff value for aBMD of 0.60 g/cm2 was a moderate predictor of T-score values at the TH and FN, with considerable inaccuracies outside the clinically acceptable limits of agreement. As such, the direct measurement of knee aBMD in persons with SCI should be performed, whenever possible, prior to prescribing weight bearing upright activities, such as robotic exoskeletal-assisted walking.

Effect of transplant status in CD19-targeted CAR T-cell therapy: a systematic review and meta-analysis.

Chimeric antigen receptor (CAR) T-cell therapy has shown promise for relapsed/refractory malignancies. Many patients have undergone prior hematopoietic stem cell transplant (HSCT), yet effects of transplant status on CAR T-cell therapy efficacy and safety have not been reported. The purpose of the study is to systematically evaluate the likelihood of achieving optimum response, severe cytokine release syndrome (sCRS), and neurotoxicity in the context of CAR T-cell therapy for HSCT-naïve patients versus those with prior HSCT. Trials were identified in ClinicalTrials.gov, Cochrane Library, and PubMed, and through reference pearl growing. Included studies used CD19-directed CAR T-cells for relapsed/refractory B-lineage Acute Lymphoblastic Leukemia and B cell Chronic Lymphocytic Leukemia, enrolled both HSCT-naïve and prior-HSCT patients, and denoted transplant status with outcomes. Six studies were included for optimum response, five for sCRS incidence, and four for neurotoxicity incidence. The pooled odds ratio for optimum response was 1.57 favoring HSCT-naïve patients (95% CI 0.54-4.61), whereas the pooled odds ratios for sCRS and neurotoxicity were 1.41 (95% CI 0.51-3.94) and 1.37 (95% CI 0.28-6.77), respectively, toward HSCT-naïve patients. Odds ratios were non-statistically significant. Overall risk of bias was moderate. While pooled estimates showed an advantage among HSCT-naïve patients for achieving optimum response and increased likelihood for sCRS and neurotoxicity, findings were not statistically significant. Any differences in efficacy and safety of CAR T-cell therapy cannot be verifiably attributed to transplant status, and additional controlled trials with increased sample sizes are needed to determine whether suggestive patterns favoring HSCT-naïve patients are validated.

Effectiveness of Manual Therapy for Pain and Self-reported Function in Individuals With Patellofemoral Pain: Systematic Review and Meta-analysis.

Study Design Systematic literature review with meta-analysis. Background Management of patellofemoral pain (PFP) may include the utilization of manual therapy (MT) techniques to the patellofemoral joint, surrounding soft tissues, and/or lumbopelvic region. Objectives To determine the effectiveness of MT, used alone or as an adjunct intervention, compared to standard treatment or sham for reducing pain and improving self-reported function in individuals with PFP. Methods An electronic literature search was conducted in the PubMed, Ovid, Cochrane Central Register of Controlled Trials, and CINAHL databases for studies investigating MT for individuals with PFP. Studies published through August 2017 that compared MT (local or remote to the knee), used alone or in combination with other interventions, to control or sham interventions were included. Patient-reported pain and functional outcomes were collected and synthesized. Trials were assessed via the Cochrane risk-of-bias tool, and a meta-analysis of the evidence was performed. Results Nine studies were included in the review, 5 of which were rated as having a low risk of bias. The use of MT, applied to the local knee structure, was associated with favorable short-term changes in self-reported function and pain in individuals with PFP, when compared to a comparison (control or sham) intervention. However, the changes were clinically meaningful only for pain (defined as a 2-cm or 2-point improvement on a visual analog scale or numeric pain-rating scale). The evidence regarding lumbopelvic manipulation was inconclusive for pain improvement in individuals with PFP, based on 3 studies. Conclusion The data from this review cautiously suggest that MT may be helpful in the short term for decreasing pain in patients with PFP. Several studies integrated MT into a comprehensive treatment program. Changes in self-reported function with the inclusion of MT were shown to be significant, but not clinically meaningful. The limitations in the studies performed to date suggest that future research should determine the optimal techniques and dosage of MT and perform longer follow-up to monitor long-term effects. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(5):358-371. Epub 6 Jan 2018. doi:10.2519/jospt.2018.7243.

Metabolic impact of 100% fruit juice consumption on antioxidant/oxidant status and lipid profiles of adults: An Evidence-Based review.

One hundred percent fruit juice (FJ) contains bioactive compounds with antioxidant activity. As such, this fruit form has the potential to improve antioxidant status and mediate outcomes influenced by redox status. A systematic review of the literature published between 1995 and 2013 was conducted using PubMed database to evaluate associations between intake of 100% FJ and markers of antioxidant/oxidant status and blood lipid levels in healthy, free-living adults ≥18 years. Data extraction and analysis was conducted according to the Academy of Nutrition and Dietetics Evidence Analysis Process. Limited evidence from ten clinical trials meeting inclusion/exclusion criteria suggests potential improvements in a variety of antioxidant or oxidants biomarkers postconsumption of 100% FJ. Weak evidence from five studies suggests that one or more blood lipid measures may be positively influenced by consumption of 100% FJ. Heterogeneity in study methodology including biomarkers, 100% FJ type, dosage, and intervention duration precludes the ability to make evidence-based recommendations regarding a specific dose-duration-juice effect. Key characteristics in study designs were identified which must either be controlled or statistically adjusted for in future investigations in order to obtain a more accurate understanding of the complex relationship between metabolic outcomes and consumption of 100% FJ in context of a healthy dietary pattern.

Inspiratory muscle strength relative to disease severity in adults with stable cystic fibrosis.

BACKGROUND: Due to heterogeneity in pulmonary disease, current literature may misrepresent inspiratory muscle involvement in cystic fibrosis (CF). This study investigated inspiratory muscle strength (IMS) relative to disease severity in adults with CF. METHODS: Maximal inspiratory pressure (MIP) was assessed in 58 adults with stable CF grouped by disease severity (20 mild, 20 moderate, 18 severe) and compared to 20 controls. Relationships between MIP, lung function, dyspnea and anthropometrics were evaluated using multivariable linear models. RESULTS: MIP in cmH2O and %-predicted was decreased in advanced CF lung disease as compared to mild disease and healthy controls (p<0.05). Disease severity accounted for 24% of the variance in IMS after controlling for confounding variables (p<0.001). CONCLUSIONS: IMS is decreased in some adults with stable CF with moderate and severe pulmonary disease, and is related to dyspnea. Future studies should determine if decreased IMS contributes inefficient breathing patterns, respiratory pump dysfunction, and/or exercise intolerance in advanced CF.

Development and Validation of the Guide for Effective Nutrition Interventions and Education (GENIE): A Tool for Assessing the Quality of Proposed Nutrition Education Programs.

OBJECTIVE: To develop and validate the Guide for Effective Nutrition Interventions and Education (GENIE), a checklist of research-based quality indicators for nutrition education programs. DESIGN: A prospective test of criterion validity and inter-rater reliability of a new tool comparing expert assessments and trained reviewer GENIE scores of the same nutrition education proposals. PARTICIPANTS: Ten nutrition education experts; 13 volunteer reviewers. VARIABLES MEASURED: GENIE's face, content, and criterion validity and inter-rater reliability compared using expert assessments and reviewer objective and subjective scores. ANALYSIS: Reviewer scores compared using Spearman correlation. Inter-rater reliability tested using intra-class correlation (ICC), Cronbach alpha, and ANOVA. Criterion validity tested using independent t test and point bi-serial correlation to compare reviewer with expert scores. RESULTS: Correlation found between total objective and total subjective scores. Agreement found between reviewers across proposals and categories considering subjective scores (F = 7.21, P < .001; ICC = 0.76 [confidence interval, 0.53-0.92]) and objective scores (F = 7.88, P < .001; ICC = 0.82 [confidence interval, 0.63-0.94]). Relationship was not significant (r = .564, P = .06) between expert and reviewer proposal scoring groups (high, medium, and low). CONCLUSIONS AND IMPLICATIONS: Results support the validity and reliability of GENIE as a tool for nutrition education practitioners, researchers, and program funding agencies to accurately assess the quality of a variety of nutrition program plans.

Registered dietitians' roles in decision-making processes for PEG placement in the elderly.

PURPOSE: The role of registered dietitians (RDs) in decision-making for percutaneous endoscopic gastrostomy (PEG) placement was explored. The ethical climate in their workplace and the relationship between decision-making and the ethical climate were examined. METHODS: The survey included 67 RDs in complex continuing care and long-term care settings in Ontario. Descriptive statistics were used to describe roles, ethical climate, and professional characteristics. Pearson's and nonparametric correlations were used to examine relationships between roles, ethical climate, and professional characteristics. RESULTS: Among the respondents, 97% thought RDs had a role in decision-making processes. The majority of RDs were usually or always involved in two roles: identifying relevant nutrition issues (91.2%) and discussing feeding options and alternatives (80.7%). Dietitians' roles in decision-making processes were more extensive when their relationship with physicians was positive (r=0.321, P=0.016), they had adequate knowledge (r=0.465, P<0.001) and adequate skills (r=0.520, P<0.001), and they were more satisfied with their role (r=0.554, P<0.001). CONCLUSIONS: Registered dietitians performed a variety of roles in decision-making processes concerning PEG placement in the elderly. A positive working relationship with physicians, knowledge, skills, and role satisfaction significantly increase RDs' involvement with patients and families.

Online Education Improves Canadian Dietitians' Attitudes and Knowledge Regarding Recommending and Ordering Multivitamin/Mineral Supplements.

PURPOSE: To determine the attitudes and knowledge of Fraser Health registered dietitians (RDs) regarding recommending and ordering multivitamin/mineral supplements prior to and following an online education module. METHODS: The educational intervention consisted of narrated slides with electronic resources. After undergoing external review for face and content validity, 6 attitude questions and a 15-item knowledge test were administered pre- and postintervention. The attitude questionnaire utilized a 5-point Likert scale and had a maximum summative score of 30 points. The knowledge test was worth a maximum of 15 points. RESULTS: Of the eligible RDs (n = 123), 57 (46.3%) completed the study and 55 participants were included in the final analyses. Summative attitude scores were higher on the post-intervention questionnaire compared with the preintervention questionnaire (t = 92.5, P < 0.001). The proportion of correctly answered knowledge questions pre- (78.0% ± 10.0%) to postintervention (mean = 87.4% ± 6.0%) increased significantly (t = 7.16, P < 0.001). CONCLUSIONS: Postintervention, RD attitudes and knowledge improved confirming that the education strategy was effective. Future work should focus on optimizing the module and knowledge questions.

Prevalence and correlates of postdiagnosis initiation of complementary and alternative medicine among patients at a comprehensive cancer center.

PURPOSE: Patients with cancer increasingly use complementary and alternative medicine (CAM) in conjunction with conventional oncology treatments. Previous studies have not investigated postdiagnosis initiation of CAM therapies or independent correlates of use of individual CAM modalities. The purpose of this study was to determine the prevalence and correlates of individual CAM modalities initiated after cancer diagnosis. METHODS: A cross-sectional survey was conducted of a random sample of adults with a cancer diagnosis (N = 1,228) seeking care at a National Cancer Institute-designated comprehensive cancer center within a 12-month period. RESULTS: The majority of patients were female (64.7%), white (86.9%), and married (72.8%).Three-quarters (75.2%) used at least one CAM modality, and 57.6% of those using CAM initiated use after cancer diagnosis. For all CAM therapies combined, women were 1.7 times more likely than men to initiate any CAM therapy after cancer diagnosis. However, when CAM modalities were differentiated by type, men and women were equally likely to initiate all therapies except for psychotherapy and mind-body approaches. Postdiagnosis initiation of every CAM modality, except mind-body therapies, differed by cancer type. CONCLUSION: A significant proportion of patients initiated CAM use after diagnosis. However, specific type of CAM initiated varied by demographics and cancer type, suggesting there is not a "typology" of CAM user. Optimal comprehensive cancer treatment, palliation, and survivorship care will require patient and provider education regarding CAM use by modality type; improved provider-patient communication regarding potential benefits, limitations, and risks; and institutional policies to support integrated conventional and CAM treatment.