Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet?

Rectal cancer is a common cancer and shows an increased incidence with older age. Although the gold standard treatment is surgical excision, minimally invasive approaches are increasingly used and organ preservation is becoming a reasonable approach. The conservative treatment approach includes local excision, external beam radiotherapy and brachytherapy. However, these all carry a risk of side-effects. It is crucial to provide patients with information to quantify the improvement or detriment in quality of life with their cancer treatment. This can only be done with patient-reported outcome measures (PROMs) as tools within current and future trials. Colorectal cancer has numerous publications with specific PROMs. However, PROMs reporting in rectal cancer is more sparse; PROMs are generally extrapolated from colorectal cancer. Rectal PROMs trials hold small population samples and PROMs as an end point is scarce. We present a review of recent literature based on the PROMs reporting of quality of life for rectal cancer patients and introduce the CITRuS trial as an innovative feasibility study related to electronic PROMs data collection.

Prospectively Predicting Adult Depressive Symptoms from Adolescent Peer Dysfunction: a Sibling Comparison Study.

Previous studies have shown that peer dysfunction in adolescence predicts depression in adulthood, even when controlling for certain individual- and/or family-level characteristics. However, these studies have not controlled for numerous potential familial confounders, precluding causal inferences. The present study therefore used a sibling comparison design (i.e., comparing siblings within families) to test whether peer dysfunction (e.g., lack of friendships, victimization) in adolescence continues to predict depression in adulthood after accounting for unmeasured familial confounds and individual characteristics in adolescence. Participants' (N = 85) dysfunction with peers was assessed in adolescence (Mage = 13.21, SD = 3.47) by self- and parent-report, and adult depressive symptoms were assessed up to five times, up to 38 years later. Multilevel modeling was used to examine the effect of adolescent peer dysfunction on adult depressive symptoms after adjusting for familial confounds and/or individual characteristics in adolescence (e.g., baseline depressive symptoms, dysfunctional relations with siblings/parents). Both self-reported (b = 1.28, p < 0.001) and parent-reported (b = 0.56, p = 0.032) adolescent peer dysfunction were associated with greater depressive symptom severity in adulthood in unadjusted models. Self-reported (but not parent-reported) adolescent peer dysfunction continued to predict adult depressive symptoms after controlling for familial confounding and measured covariates such as adolescent depressive symptoms and relations with siblings and parents (b = 1.06, p = 0.035). Although confidence intervals were wide and the potentially confounding effects of numerous individual-level factors were not ruled out, these findings provide preliminary evidence that perceived peer dysfunction in adolescence may be an unconfounded risk factor for depressive symptoms in adulthood.

Environmental and Economic Performance of Hybrid Power-to-Liquid and Biomass-to-Liquid Fuel Production in the United States.

Power-to-liquids are a class of liquid drop-in fuels produced from electricity and carbon dioxide as the primary process inputs, which have the potential to reduce transportation's climate impacts. We quantify the economic and life cycle environmental characteristics of four electrofuel technology pathways that rely on the Fischer-Tropsch synthesis but produce synthesis gas via different schemes: power-to-liquid (PtL) via electrolysis and a reverse water gas shift (RWGS) reaction; PtL via co-electrolysis; gasification of biomass-to-liquid (BtL); and a hybrid power- and biomass-to-liquid (PBtL) pathway. The results indicate that the hybrid PBtL pathway is the most environmentally and economically promising option for electrofuel production, with results highly dependent on input electricity source characteristics such as cost and emissions. The carbon intensities of electricity generation that must not be exceeded for electrofuels to have lower life cycle emissions than conventional diesel are 222, 116, and 143 gCO2e/kWh for PBtL, PtL electrolysis + RWGS, and PtL co-electrolysis, respectively. We characterize the PBtL pathway in more detail by combining spatially resolved data on biomass cultivation, electricity generation, and cost-optimized hydrogen production from renewable electricity in the United States (US). We find that the private emissions abatement cost for PBtL fuels varies between 740 and 2000 $/tCO2e, depending primarily on the location of fuel production.

Implementation and Outcomes of Virtual Care Across a Tertiary Cancer Center During COVID-19.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few quantitative data support its rapid implementation and positive associations with service capacity and quality. Objective: To examine the outcomes of a cancer center-wide virtual care program in response to the COVID-19 pandemic. Design, Setting, and Participants: This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020. Main Outcomes and Measures: Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients. Results: The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946. Conclusions and Relevance: These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.

Neuromechanical Assessment of Activated vs. Resting Leg Rigidity Using the Pendulum Test Is Associated With a Fall History in People With Parkinson's Disease.

Leg rigidity is associated with frequent falls in people with Parkinson's disease (PD), suggesting a potential role in functional balance and gait impairments. Changes in the neural state due to secondary tasks, e.g., activation maneuvers, can exacerbate (or "activate") rigidity, possibly increasing the risk of falls. However, the subjective interpretation and coarse classification of the standard clinical rigidity scale has prohibited the systematic, objective assessment of resting and activated leg rigidity. The pendulum test is an objective diagnostic method that we hypothesized would be sensitive enough to characterize resting and activated leg rigidity. We recorded kinematic data and electromyographic signals from rectus femoris and biceps femoris during the pendulum test in 15 individuals with PD, spanning a range of leg rigidity severity. From the recorded data of leg swing kinematics, we measured biomechanical outcomes including first swing excursion, first extension peak, number and duration of the oscillations, resting angle, relaxation index, maximum and minimum angular velocity. We examined associations between biomechanical outcomes and clinical leg rigidity score. We evaluated the effect of increasing rigidity through activation maneuvers on biomechanical outcomes. Finally, we assessed whether either biomechanical outcomes or changes in outcomes with activation were associated with a fall history. Our results suggest that the biomechanical assessment of the pendulum test can objectively quantify parkinsonian leg rigidity. We found that the presence of high rigidity during clinical exam significantly impacted biomechanical outcomes, i.e., first extension peak, number of oscillations, relaxation index, and maximum angular velocity. No differences in the effect of activation maneuvers between groups with clinically assessed low rigidity were observed, suggesting that activated rigidity may be independent of resting rigidity and should be scored as independent variables. Moreover, we found that fall history was more common among people whose rigidity was increased with a secondary task, as measured by biomechanical outcomes. We conclude that different mechanisms contributing to resting and activated rigidity may play an important yet unexplored functional role in balance impairments. The pendulum test may contribute to a better understanding of fundamental mechanisms underlying motor symptoms in PD, evaluating the efficacy of treatments, and predicting the risk of falls.

Multimodal assessment of nigrosomal degeneration in Parkinson's disease.

BACKGROUND: Approximately forty percent of all dopaminergic neurons in SNpc are located in five dense neuronal clusters, named nigrosomes. T2- or T2*-weighted images are used to delineate the largest nigrosome, named nigrosome-1. In these images, nigrosome-1 is a hyperintense region in the caudal and dorsal portion of the T2- or T2*-weighted substantia nigra. In PD, nigrosome-1 experiences iron accumulation, which leads to a reduction in T2-weighted hyperintensity. Here, we examine neuromelanin-depletion and iron deposition in regions of interest (ROIs) derived from quantitative-voxel based morphometry (qVBM) on neuromelanin-sensitive images and compare the ROIs with nigrosome-1 identified in T2*-weighted images. METHODS: Neuromelanin-sensitive and multi-echo gradient echo imaging data were obtained. R2* was calculated from multi-echo gradient echo imaging data. qVBM analysis was performed on neuromelanin-sensitive images and restricted to SNpc. Mean neuromelanin-sensitive contrast and R2* was measured from the resulting qVBM clusters. Nigrosome-1 was segmented in T2*-weighted images of control subjects and its location was compared to the spatial location of the qVBM clusters. RESULTS: Two bilateral clusters emerged from the qVBM analysis. These clusters showed reduced neuromelanin-sensitive contrast and increased mean R2* in PD as compared to controls. Cluster-1 from the qVBM analysis was in a similar spatial location as nigrosome-1, as seen in T2*-weighted images. CONCLUSION: qVBM cluster-1 shows reduced neuromelanin-sensitive contrast and is in a similar spatial position as nigrosome-1. This region likely corresponds to nigrosome-1 while the second cluster may correspond to nigrosome-2.

The cost of infection: Argulus foliaceus and its impact on the swimming performance of the three-spined stickleback (Gasterosteus aculeatus).

For fish, there can be multiple consequences of parasitic infections, including the physical impacts on swimming and the pathological costs of infection. This study used the three-spined stickleback (Gasterosteus aculeatus) and the ectoparasitic fish louse, Argulus foliaceus, to assess both physical (including form drag and mass) and pathological effects of infection. Both sustained (prolonged swimming within an open channel flume) and burst (C-start) swimming performance were measured on individual fish before (trials 1-2) and after infection (trials 3-5). Experimental infection occurred shortly before the third trial, when the physical impacts of infection could be separated from any subsequent pathology as transmission of adult parasites causes instantaneous drag effects prior to observable pathology. Despite the relatively large size of the parasite and corresponding increase in hydrodynamic drag for the host, there were no observable physical effects of infection on either sustained or burst host swimming. By contrast, parasite-induced pathology is the most probable explanation for reduced swimming performance across both tests. All sticklebacks displayed a preference for flow refugia, swimming in low-velocity regions of the flume, and this preference increased with both flow rate and infection time. This study suggests that even with large, physically demanding parasites their induced pathology is of greater concern than direct physical impact.

Contact X-ray Brachytherapy as an Adjunct to a Watch and Wait Approach is an Affordable Alternative to Standard Surgical Management of Rectal Cancer for Patients with a Partial Clinical Response to Chemoradiotherapy.

AIMS: Emerging evidence suggests that contact X-ray brachytherapy (CXB) may increase the clinical complete response rate and durability when administered after standard chemoradiotherapy in patients with rectal cancer. The addition of CXB in partial responders is therefore probably cost-effective. The affordability of widening access to CXB in the UK, however, has not been evaluated. MATERIALS AND METHODS: Decision analytical modelling with Monte Carlo simulation was used to evaluate long-term costs for the management of patients with rectal cancers who were given a CXB boost when a clinical complete response was not initially achieved following chemoradiotherapy in order to facilitate a watch and wait approach. A third-party payer (National Health Service) perspective was adopted, probabilistic sensitivity analysis was carried out and a scenario analysis was performed to investigate the effect of the number of referral centres and number of patients treated with CXB. RESULTS: We estimate that 818 (95% confidence interval 628-1021) patients per year are eligible for CXB as an adjunct to a watch and wait approach in England and Wales. As this management is less costly than surgical management for each individual patient, the more patients treated, the more affordable the technology. Even if as few as 125 patients are treated nationally in 15 centres, the cost of implementing this technology would be less than £4 million. If the average number of patients treated in each centre is 30, this technology would be cost saving within 5 years. CONCLUSIONS: The cost of CXB is not prohibitive according to the National Institute for Health and Care Excellence threshold for implementation of new technology and may even be cost saving within 5 years compared with standard surgical management, depending on the uptake of the technology and the number of referral centres.

Obesity, underweight and BMI distribution characteristics of children by gross national income and income inequality: results from an international survey.

BACKGROUND: Economic wealth and income inequality may impact on childhood BMI distribution by affecting overconsumption of food and sedentary forms of transportation and entertainment across the whole or some of the population. OBJECTIVES: To determine whether BMI distribution of children differs by gross national income (GNI) per capita and Gini index derived from World Bank data. METHODS: Secondary analysis of largely self-reported height and weight data from a multi-country, cross-sectional study (ISAAC), of 77,963 children aged 6-7 (from 19 countries) and 205,388 adolescents aged 13-14 (from 36 countries), were used to examine underweight vs obesity prevalence and BMI distribution skewness, median and dispersion. RESULTS: Children and adolescents from 'lower' GNI countries had higher prevalence of underweight than those from 'higher' GNI countries (6% vs 3%, p = 0.03; 2% vs 1%, p = 0.05 respectively), but the prevalence of obesity was not different (2% vs 5%, p = 0.29; 2% vs 2%, p = 0.66). BMI distribution of participants from 'higher' GNI countries had higher median, without significant difference in skewness or dispersion compared to 'lower' GNI countries (higher medians +1.1 kg/m2 for 6-7 year olds, and + 0.7 kg/m2, +1.2 kg/m2 for 13-14 year old girls and boys respectively). Gini index was not associated with underweight or obesity prevalence in either children or adolescents, nor with any BMI distribution characteristics with one exception. Adolescent girls from higher income inequality countries had a greater median BMI (+0.7 kg/m2) and a less skewed BMI distribution. CONCLUSIONS: It appears that the obesogenic impact of economic prosperity affects all children similarly. Income inequality may have a gender specific effect affecting BMI distribution in adolescent girls.

Reducing the risk of iatrogenic Creutzfeldt-Jakob disease by improving the cleaning of neurosurgical instruments.

BACKGROUND: In all, there have been 178 variant Creutzfeldt-Jakob disease (vCJD) patients diagnosed in the UK, with an estimated maximum 1:2000 carriage rate based on archived appendix and tonsil tissue, implying that infection may be rare but carriage relatively frequent. Previous workers have identified that maintenance of surgical instruments in a humid atmosphere after use and prior to cleaning assists cleaning efficacy. Recently the Department of Health/Advisory Committee on Dangerous Pathogens UK have recommended a surgical instrument cleanliness threshold post cleaning of <5 µg protein per instrument side. AIM: To quantify cleanliness of neurosurgical instruments and to investigate cost-effective measures for improved cleaning. METHODS: Two instrument protein quantification methods were used: one based on the International Standard (15883 series) using sodium dodecyl sulphate elution and ortho-phthalaldehyde reaction, and a second in-situ protein fluorescence detection system (ProReveal) providing results per instrument side. In-vitro investigation of the efficacy of some commercial and in-house pre-clean wetting agents was undertaken using artificial test soil and stainless steel discs under standard conditions. In-vivo evaluation of best-performing in-vitro agents was undertaken on craniotomy sets. FINDINGS: ProReveal technology demonstrated that 163 out of 187 (87%) neurosurgical instruments had <5 µg residual protein per instrument side. The use of proprietary National Health Service plastic bags and sterile water-soaked wound pads were equivalent in efficacy to commercial pre-cleaning wetting products and significantly less expensive. CONCLUSION: Although we demonstrate low in-situ protein levels on neurosurgical instruments and the beneficial effects of keeping instruments moist, other cleaning critical-control points such as instrument loading patterns should also be monitored.

MLL2 conveys transcription-independent H3K4 trimethylation in oocytes.

Histone 3 K4 trimethylation (depositing H3K4me3 marks) is typically associated with active promoters yet paradoxically occurs at untranscribed domains. Research to delineate the mechanisms of targeting H3K4 methyltransferases is ongoing. The oocyte provides an attractive system to investigate these mechanisms, because extensive H3K4me3 acquisition occurs in nondividing cells. We developed low-input chromatin immunoprecipitation to interrogate H3K4me3, H3K27ac and H3K27me3 marks throughout oogenesis. In nongrowing oocytes, H3K4me3 was restricted to active promoters, but as oogenesis progressed, H3K4me3 accumulated in a transcription-independent manner and was targeted to intergenic regions, putative enhancers and silent H3K27me3-marked promoters. Ablation of the H3K4 methyltransferase gene Mll2 resulted in loss of transcription-independent H3K4 trimethylation but had limited effects on transcription-coupled H3K4 trimethylation or gene expression. Deletion of Dnmt3a and Dnmt3b showed that DNA methylation protects regions from acquiring H3K4me3. Our findings reveal two independent mechanisms of targeting H3K4me3 to genomic elements, with MLL2 recruited to unmethylated CpG-rich regions independently of transcription.

A Cost-Effectiveness Analysis of Contact X-ray Brachytherapy for the Treatment of Patients with Rectal Cancer Following a Partial Response to Chemoradiotherapy.

AIMS: Following chemoradiotherapy in patients with rectal cancer, the addition of contact X-ray brachytherapy (CXB) in partial responders might increase the proportion of patients with a clinical complete response (cCR) and who are thus suitable for watch and wait management. However, the long-term cost-effectiveness of this approach has not been evaluated. MATERIALS AND METHODS: Decision analytical modelling and a Markov simulation were used to compare long-term costs, quality-adjusted life years (QALYs) and cost-effectiveness from a third-party payer (National Health Service) perspective for treatment strategies after chemoradiotherapy; watch and wait with CXB when a cCR was not initially achieved after external beam radiotherapy (EBRT) (WWCXB), watch and wait with EBRT alone (WWEBRT) and radical surgery for all patients. The effect of uncertainty in model parameters and patient demographics was investigated. RESULTS: WWCXB had a higher QALY payoff than both radical surgery and WWEBRT and was less costly in most scenarios and demographic cohorts. In all plausible scenarios, WWCXB was the most cost-effective, at a threshold of £20 000/QALY. This finding was insensitive to uncertainty associated with model parameters. CONCLUSIONS: WWCXB is likely to be cost-effective compared with both WWEBRT alone and radical surgery. These findings support the use of CXB boost as an adjunct to a watch and wait strategy.

Energetic costs of mange in wolves estimated from infrared thermography.

Parasites, by definition, extract energy from their hosts and thus affect trophic and food web dynamics even when the parasite may have limited effects on host population size. We studied the energetic costs of mange (Sarcoptes scabiei) in wolves (Canis lupus) using thermal cameras to estimate heat losses associated with compromised insulation during the winter. We combined the field data of known, naturally infected wolves with a data set on captive wolves with shaved patches of fur as a positive control to simulate mange-induced hair loss. We predict that during the winter in Montana, more severe mange infection increases heat loss by around 5.2-12 MJ per night (1,240-2,850 kcal, or a 65-78% increase) for small and large wolves, respectively, accounting for wind effects. To maintain body temperature would require a significant proportion of a healthy wolf's total daily energy demands (18-22 MJ/day). We also predict how these thermal costs may increase in colder climates by comparing our predictions in Bozeman, Montana to those from a place with lower ambient temperatures (Fairbanks, Alaska). Contrary to our expectations, the 14°C differential between these regions was not as important as the potential differences in wind speed. These large increases in energetic demands can be mitigated by either increasing consumption rates or decreasing other energy demands. Data from GPS-collared wolves indicated that healthy wolves move, on average, 17 km per day, which was reduced by 1.5, 1.8, and 6.5 km for light, medium, and severe hair loss. In addition, the wolf with the most hair loss was less active at night and more active during the day, which is the converse of the movement patterns of healthy wolves. At the individual level, mange infections create significant energy demands and altered behavioral patterns, this may have cascading effects on prey consumption rates, food web dynamics, predator-prey interactions, and scavenger communities.

Can the Mini Nutritional Assessment (MNA) Be Used as a Nutrition Evaluation Tool for Subacute Inpatients over an Average Length of Stay?

OBJECTIVE: The prevalence of malnutrition in subacute inpatient settings has been reported to be 30-50%. While there are a number of nutrition evaluation tools which have been validated to diagnose malnutrition, the use of a validated nutrition evaluation tool to measure changes in nutritional status during an average length of stay for a subacute inpatient has not yet been tested. This study aims to determine the potential of the full MNA (full Mini Nutritional Assessment) and MNA (Mini Nutritional Assessment Short Form) scores to measure change in nutritional status over an average subacute inpatient stay (21 days). DESIGN: A prospective observational study. SETTING: The study was performed in three Rehabilitation and Geriatric Evaluation and Management (GEM) wards of the Kingston Centre, Monash Health, Melbourne, Australia. PARTICIPANTS: All patients ≥65 years admitted to these wards with an expected length of stay of at least 14 days were considered for inclusion in this study. MEASUREMENTS: Nutritional status was assessed on admission using the full MNA as part of usual dietetic care and patients were provided with nutrition intervention/diet therapy based on full MNA classification. Full MNA score (0-30), MNA score (0-14), anthropometry (weight and height) and nutritional biochemistry (serum albumin, transthyretin and C-reactive protein) were compared between admission and day 20.5 ± 2.4. RESULTS: Mean age (± SD) of 83 ± 7 years, n=114. For those patients diagnosed at risk of malnutrition or malnourished (n=103), there were significant increases in full MNA score (1.8 ± 2.4, p<0.001), MNA score (0.9 ± 1.7, p<0.001), weight (0.6 ± 2.5 kg, p=0.017) and serum albumin (1.4 ± 4.4 g/L, p=0.003) over the study period. All four of the full MNA domain sub-scores, also increased significantly in those patients diagnosed at risk of malnutrition or malnourished (n=103): anthropometric assessment (p<0.001), dietary assessment (p<0.001), general status assessment (p=0.019) and self-perceived health and nutrition states (p=0.033). CONCLUSION: Both the MNA and full MNA can be used to evaluate nutrition progress within the subacute inpatient setting over a three week time period, thereby providing clinicians with feedback on a patient's nutrition progress and assisting with ongoing care planning. Due to its ease of use and shorter time required to complete, the MNA may be the preferred nutrition evaluation tool in this setting.

Longitudinal determinants of walking, moderate, and vigorous physical activity in Australian adults.

OBJECTIVE: To explore longitudinal (demographic, socioeconomic, health and psychological) determinants of walking, moderate and vigorous physical activity. METHODS: The sample included 11,133 adult participants (5913 women; 5220 men) taken from the Household, Income and Labour Dynamics in Australia (HILDA) project. Demographic, socioeconomic, health and psychological data were collected in 2010 and estimates of walking, moderate and vigorous physical activity were collected in 2014. RESULTS: Participant age, sex, occupational status, working hours, and neighbourhood remoteness were most strongly related to total physical activity. Psychological traits (personality and distress sensitivity) were unrelated to subsequent physical activity, and health-related behaviours (diet variables and smoking frequency) were moderately related. Participant demographics (age and sex) were most important for vigorous intensity physical activity, and socioeconomic factors (e.g., neighbourhood remoteness, total income, occupational status, weekly hours worked) were most important for moderate intensity physical activity. CONCLUSIONS: This investigation shows that demographic, socioeconomic, and health-related variables are important determinants of adult physical activity levels, and that demographic and socioeconomic factors might become more or less important for different intensities of physical activity.

Trajectories and Predictors of Health-Related Quality of Life during Childhood.

OBJECTIVE: To identify distinct trajectories of health-related quality of life (HRQOL) during childhood, along with their predictors. STUDY DESIGN: A nationally representative sample of 2700 children aged 4-5 years at baseline was followed up every 24 months through to age 12-13 years. Parents reported the children's HRQOL and data on potential predictors at each wave (5 in total) as part of the Longitudinal Study of Australian Children. RESULTS: Growth mixture modeling identified 5 distinct trajectories of HRQOL during childhood. Eighty-five percent of children had consistently high levels of HRQOL from age 4-5 years to 12-13 years (healthy); 8% of children had a significant and continuous decrease in HRQOL over time (high risk); and a further 5.3% of children had decreases in HRQOL from age 4-5 years to 8-9 years, followed by increases through to 12-13 years (rebound). Finally, a small percentage (1.6%) of children had extremely low levels of HRQOL at age 4-5 years that increased over time (recovery). Maternal smoking, lower household income, living in a non-English speaking household, and nonparticipation in organized sports were predictive of poorer HRQOL trajectories when compared with children in the healthy trajectory. CONCLUSION: There are distinct trajectories of HRQOL during childhood. Most children (85%) have a healthy, stable pattern, but the remaining children have trajectories indicative of poor HRQOL. Participation in sports, maternal smoking, lower family income, and language spoken at home distinguish among these trajectories. Of these, participation in organized sports has received relatively little attention as a preventative health priority.

Risk-assessment-based approach to patients exposed to endoscopes contaminated with Pseudomonas spp.

Patients exposed to bronchoscopes contaminated with Pseudomonas aeruginosa are at increased risk of pseudomonal infection. The optimal methods for management and mitigation of risk following exposure are controversial. This article describes a two-phase risk assessment following pseudomonal contamination of a family of 75 endoscopes, detected through routine surveillance and attributed to one endoscope washer-disinfector. An initial risk assessment identified 18 endoscopes as high risk, based on the presence of lumens used for irrigation or biopsy. Exposure was communicated to the patients' clinical teams and a further clinical risk assessment of the exposed patients was performed. No patients developed complications due to pseudomonal infection.

Geriatric assessment predicts survival and toxicities in elderly myeloma patients: an International Myeloma Working Group report.

We conducted a pooled analysis of 869 individual newly diagnosed elderly patient data from 3 prospective trials. At diagnosis, a geriatric assessment had been performed. An additive scoring system (range 0-5), based on age, comorbidities, and cognitive and physical conditions, was developed to identify 3 groups: fit (score = 0, 39%), intermediate fitness (score = 1, 31%), and frail (score ≥2, 30%). The 3-year overall survival was 84% in fit, 76% in intermediate-fitness (hazard ratio [HR], 1.61; P = .042), and 57% in frail (HR, 3.57; P < .001) patients. The cumulative incidence of grade ≥3 nonhematologic adverse events at 12 months was 22.2% in fit, 26.4% in intermediate-fitness (HR, 1.23; P = .217), and 34.0% in frail (HR, 1.74; P < .001) patients. The cumulative incidence of treatment discontinuation at 12 months was 16.5% in fit, 20.8% in intermediate-fitness (HR, 1.41; P = .052), and 31.2% in frail (HR, 2.21; P < .001) patients. Our frailty score predicts mortality and the risk of toxicity in elderly myeloma patients. The International Myeloma Working group proposes this score for the measurement of frailty in designing future clinical trials. These trials are registered at www.clinicaltrials.gov as #NCT01093136 (EMN01), #NCT01190787 (26866138MMY2069), and #NCT01346787 (IST-CAR-506).