Scoping Literature Review: Experiences of Sexual and Gender Minority Older Adults, With Diagnoses of Dementia, Who Use Residential Long-Term Services and Supports.

The number of sexual and gender minority (SGM) older adults utilizing residential long-term supports and services (LTSS) will increase in the forthcoming decades. Paradoxically, while requiring more LTSS services than their non-SGM counterparts, SGM older adults are less likely to access these services, partly due to fears of discrimination. Furthermore, SGM older adults living with Alzheimer's disease and related dementias (AD/ADRD) present unique challenges and opportunities for LTSS facilities. This article provides a scoping review on the intersection between experiences of SGM older adults with AD/ADRD who use residential LTSS. This review identified three themes: (1) the experiences of discrimination among SGM residents in LTSS facilities, (2) the need for comprehensive staff training in residential LTSS to ensure proper care of SGM populations, and (3) the crucial role of inclusive facility policies. As the number of SGM older adults is expected to increase, further research is necessary.

"Going Back in the Closet": Addressing Discrimination Against Sexual and Gender Minority Residents in Long-Term Services and Supports by Providing Culturally Responsive Care.

Sexual and gender minority (SGM) older adults face discrimination in long-term services and supports (LTSS). Yet, SGM older adults use LTSS disproportionately higher relative to their non-SGM counterparts. The discrimination is compounded by existing disparities, resulting in worse health outcomes and well-being for SGM older adults. Guided by socioecological model, we posit that training LTSS staff in SGM responsive care and implementing SGM anti-discrimination policies will be needed to improve care. Considering accessibility and turnover challenges, training should be online, interactive, and easily accessible. Studies that assess interventions for SGM responsive care are needed to guide policy and practice.

Unrecognized sexual dysfunction in gay and bisexual men after prostate cancer treatment: the antecedents and impact of anodyspareunia.

BACKGROUND: Anodyspareunia may be an adverse outcome of prostate cancer (PCa) treatment for gay, bisexual, and other men who have sex with men (GBM). AIM: The aims of this study were to (1) describe the clinical symptoms of painful receptive anal intercourse (RAI) in GBM following PCa treatment, (2) estimate the prevalence of anodyspareunia, and (3) identify clinical and psychosocial correlates. METHODS: This was a secondary analysis of baseline and 24-month follow-up data from the Restore-2 randomized clinical trial of 401 GBM treated for PCa. The analytic sample included only those participants who attempted RAI during or since their PCa treatment (N = 195). OUTCOMES: Anodyspareunia was operationalized as moderate to severe pain during RAI for ≥6 months that resulted in mild to severe distress. Additional quality-of-life outcomes included the Expanded Prostate Cancer Index Composite (bowel function and bother subscales), the Brief Symptom Inventory-18, and the Functional Assessment of Cancer Therapy-Prostate. RESULTS: Overall 82 (42.1%) participants reported pain during RAI since completing PCa treatment. Of these, 45.1% experienced painful RAI sometimes or frequently, and 63.0% indicated that the pain was persistent. The pain at its worst was moderate to very severe for 79.0%. The experience of pain was at least mildly distressing for 63.5%. Painful RAI worsened for a third (33.4%) of participants after completing PCa treatment. Of the 82 GBM, 15.4% were classified as meeting criteria for anodyspareunia. Antecedents of anodyspareunia included a lifelong history of painful RAI and bowel dysfunction following PCa treatment. Those reporting symptoms of anodyspareunia were more likely to avoid RAI due to pain (adjusted odds ratio, 4.37), which was negatively associated with sexual satisfaction (mean difference, -2.77) and self-esteem (mean difference, -3.33). The model explained 37.2% of the variance in overall quality of life. CLINICAL IMPLICATIONS: Culturally responsive PCa care should include the assessment of anodyspareunia among GBM and explore treatment options. STRENGTHS AND LIMITATIONS: This is the largest study to date focused on anodyspareunia among GBM treated for PCa. Anodyspareunia was assessed with multiple items characterizing the intensity, duration, and distress related to painful RAI. The external validity of the findings is limited by the nonprobability sample. Furthermore, the cause-and-effect relationships between the reported associations cannot be established by the research design. CONCLUSIONS: Anodyspareunia should be considered a sexual dysfunction in GBM and investigated as an adverse outcome of PCa treatment.

The Effects of Prostate Cancer Treatment on Role-In-Sex in Gay and Bisexual Men: Mixed Methods Results from the Restore-1 and Restore-2 Studies.

Gay and bisexual men (GBM) with prostate cancer experience worse sexual and mental health outcomes following prostate cancer treatment than heterosexual men. Emerging evidence suggests that GBM may change their role-in-sex in response to treatment effects. The purpose of this study was to describe the impact of prostate cancer treatment on role-in-sex, to estimate the prevalence of such changes, and to determine the impact on quality of life and mental health. We conducted semi-structured interviews with 30 sexual minority prostate cancer patients. Then, we recruited 401 gay and bisexual prostate cancer patients into a study assessing the effects of rehabilitation. Qualitative data were analyzed using descriptive thematic analysis. Differences in quality of life and mental health outcomes were analyzed using multivariate analyses of variance. Prostate cancer treatment resulted in loss of role-in-sex for many patients. When changes in role-in-sex occurred, the shifts were predominantly from tops to bottoms. Those with a current top role-in-sex had significantly better sexual and mental health outcomes than either versatiles or bottoms. Clinical implications include the need for providers to ask about role-in-sex in order to address disparities in health outcomes by sexual orientation and to provide culturally appropriate care to sexual minority patients.

Prevalence and Risk Factors for Sexually Transmitted Infections in Gay and Bisexual Prostate Cancer Survivors: Results From the Restore-2 Study.

Background: Equitable cancer survivorship care for gay and bisexual male (GBM) prostate cancer survivors should be responsive to their sexual health needs. Rates of sexually transmitted infections (STIs) are higher among GBM compared to heterosexual men across the lifespan. In addition, evidence suggests that GBM will use a variety of strategies to cope with sexual dysfunction that may increase risk for STIs. The purpose of this study was to determine the prevalence of STIs following prostate cancer treatment among GBM and identify risk factors. Methods: In 2019, 401 GBM previously treated for prostate cancer were recruited into the Restore-2 Study. They completed a baseline online questionnaire with items assessing STIs diagnosed since being treated for prostate cancer. Any STI diagnoses was regressed on demographic, clinical, and relationship related variables using binary logistic regression. Results: Forty-five participants (11.4%) were diagnosed with an STI during or following their prostate cancer treatment. The mostly commonly diagnosed STI was syphilis (4.3%), followed by gonorrhoea (2.8%), and chlamydia (2.5%). Four participants were infected with HIV following their prostate cancer treatment. Independent risk factors for STI diagnosis included time since prostate cancer diagnosis (aOR = 1.18; 95% CI: 1.10-1.26), nonmonogamous sexual relationship (aOR = 11.23; 95% CI: 2.11-59.73), better sexual function (aOR = 1.02; 95% CI: 1.01-1.04), penile injection treatment (aOR = 3.28; 95% CI: 1.48-7.29), and multiple sex partners (aOR = 5.57; 95% CI: 1.64-18.96). Conclusions: GBM prostate cancer survivors are at risk for STIs. Culturally responsive STI prevention should be incorporated into cancer survivorship plans, particularly as men are treated for and regain sexual function over time.

Racial/Ethnic Differences in Health-Related Quality of Life Among Gay and Bisexual Prostate Cancer Survivors.

Introduction: Prostate cancer treatment has established effects on the health-related quality of life (HRQOL) of patients. While racial/ethnic differences in HRQOL have been explored in heterosexual patients, this is the first study to examine racial/ethnic differences in a cohort of sexual minority prostate cancer survivors. Methods: We used data from the Restore-1 study, an online cross-sectional survey of sexual and gender minority (SGM) prostate cancer survivors in North America, to explore the association between race/ethnicity and HRQOL. General mental and physical HRQOL was assessed using the Short-Form Health Survey version 2 (SF-12). The frequency and distress of prostate cancer specific symptoms was assessed using the Expanded Prostate Cancer Composite (EPIC) scale. Multivariable linear regression was used to estimate mean differences in HRQOL between sexual minority men of color and their white, non-Hispanic counterparts after adjustment for pertinent demographic and medical characteristics. Results: Among 190 participants, 23 (12%) self-identified as non-white and/or Hispanic. In unadjusted analysis, sexual minority men of color compared to their white counterparts reported worse HRQOL scores in the EPIC hormonal summary (73.8 vs. 81.8) and hormonal function (70.9 vs 80.5) domains. Clinically important differences between men of color and their white counterparts were seen in the EPIC bowel function (mean difference (MD): -4.5, 95% CI: -9.9, 0.8), hormonal summary (MD: -8.0, 95% CI: -15.6, -0.4), hormonal function (MD: -9.6, 95% CI: -17.6, -1.6), and hormonal bother (MD: -6.7, 95% CI: -14.4, 1.1) domains. After adjustment for covariates, clinically important differences persisted between men of color and white, non-Hispanic men on the hormonal summary (74.4 vs. 81.7), hormonal function (71.3 vs. 80.3), and hormonal bother (77.0 vs. 82.7) domains. Conclusions: This exploratory study provides the first evidence that sexual minority men of color may have worse HRQOL outcomes compared to white, non-Hispanic sexual minority men following prostate cancer treatment.

Health Disparities of Sexual Minority Patients Following Prostate Cancer Treatment: Results From the Restore-2 Study.

PURPOSE: The NIH has identified sexual and gender minority persons as a health disparity population but little is known about cancer outcomes in these populations. The purpose of this study was to identify disparities in sexual minority prostate cancer patient-reported outcomes, to examine within group differences, and to test for alternative explanations for identified differences. MATERIALS AND METHODS: In 2019, we recruited 401 gay and bisexual prostate cancer patients into the Restore-2 study, a randomized controlled trial of rehabilitation program tailored for sexual minority men. RESULTS: Compared to the normative (heterosexual) EPIC sample, participants had significantly worse urinary, bowel and hormonal function, better sexual function, and no difference on bother scores. They also had worse depression and overall mental health, and worse physical, social/family, functional, prostate specific and overall well-being quality of life outcomes. Across measures, no differences by age, gay versus bisexual orientation, race/ethnicity, and relationship status were observed. Those who had hormonal treatment had worse sexual and hormonal function than those who had radiation or surgery only. Those with a longer time since treatment had better urinary function. Differences remained when participants were matched to normative samples on cancer stage and time since treatment. CONCLUSIONS: This, the largest study of sexual minority prostate cancer patients to date, confirms health disparities in prostate cancer quality of life outcomes. Findings appear reliable and robust. To improve the clinical care of prostate cancer, it will be important to address the health disparities experienced by sexual minority prostate cancer patients.

Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study.

BACKGROUND: Existing measures of sexual functioning in prostate cancer survivors focus primarily on erectile function and do not adequately measure the experiences of sexual minority men. AIM: To develop and psychometrically evaluate a new scale to measure sexual functioning among sexual minority men with prostate cancer. METHODS: Sexual minority prostate cancer patients (n = 401) completed an online battery of urinary and sexual functioning tests in 2019, including a new 37-item instrument about their sexual functioning post-treatment for prostate cancer. OUTCOMES: We used confirmatory factor analysis to determine the construct validity of a new scale including five subscales: a four-factor model for all participants (n = 401) evaluated Sexual Satisfaction, Sexual Confidence, Frequency of Sexual Problems, and Urinary Incontinence in Sex. A single-factor model completed only by participants who had attempted or desired receptive anal sex (n = 255) was evaluated in the fifth subscale: Problematic Receptive Anal Sex. To evaluate criterion validity, we calculated the intercorrelations between each Sexual Minorities and Prostate Cancer Scale (SMACS) subscale and four related scales: the Expanded Prostate Cancer Index Composite-50 (EPIC), the Functional Assessment of Cancer Therapy-Prostate, the Brief Symptom Inventory-18, and the International Consultation on incontinence questionnaire. Cronbach's alphas were calculated to measure internal consistency (ie, reliability). RESULTS: Cronbach's alpha values ranged from 0.64 to 0.89. Loadings (0.479-0.926) and model fit indices were strong (Root Mean Square Error of Approximation: 0.085, Standardized root mean squared residual: 0.063, comparative fit index: 0.927, Tucker-Lewis Index: 0.907). For criterion validity, Sexual Satisfaction, Sexual Confidence, and Frequency of Sexual Problems were moderately correlated with EPIC function and bother scores (r = 0.50-0.72) and Urinary incontinence in sex correlated moderately with EPIC Urinary Function and International Consultation on incontinence questionnaire scores (0.45-0.56). CLINICAL IMPLICATIONS: The SMACS can be used by clinicians and researchers to comprehensively measure sexual functioning in sexual minority men, in conjunction with existing scales. STRENGTHS AND LIMITATIONS: This new scale is validated in a large, geographically diverse cohort of sexual minority cancer survivors and fills an important gap in existing measures of sexual functioning. Limitations include a lack of a validation sample. CONCLUSION: The SMACS is a valid and reliable new scale that measures sexual minority men's experience of urinary incontinence in sex, problematic receptive anal sex, and sexual distress. Polter EJ, Kohli N, Rosser BRS, et al. Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study. J Sex Med 2022;19:529-540.

Prostate cancer disclosure and sexual orientation: Understanding outness to healthcare providers as a situational or consistent phenomenon.

OBJECTIVE: In this study, we investigated if outness is more a situational or a consistent characteristic in gay, bisexual, and other men who have sex with men (GBM) treated for prostate cancer and how the disclosure of sexual orientation impacts provider discussions of sexual side effects. METHODS: Data came from Restore, an online cross-sectional survey of 193 GBM prostate cancer survivors living in North America and were analyzed using various statistical models. RESULTS: Disclosure of sexual orientation and of living with prostate cancer were not significantly correlated. Participants who were out regarding sexual orientation were more likely to report that their surgeons and urologists discussed the sexual side effects of treatment. CONCLUSION: Outness appears to be a situational phenomenon. GBM prostate cancer survivors who were out regarding sexual orientation received more discussion surrounding sexual side effects of prostate cancer treatment from their providers. PRACTICE IMPLICATIONS: It is important for healthcare providers to inquire about patient's sexual orientation to provide holistic care to these patients to address health disparities within this group.

Pain and Loss of Pleasure in Receptive Anal Sex for Gay and Bisexual Men following Prostate Cancer Treatment: Results from the Restore-1 Study.

Prostate cancer treatments disrupt receptive anal intercourse (RAI) for gay and bisexual men (GBM). Sexual dysfunction following prostate cancer treatment may include severe pain in the anorectum during RAI (i.e., anodyspareunia). The purpose of this study was to explore the impact of prostate cancer and its treatments on RAI among GBM. Data were from a cross-sectional online survey of 100 GBM prostate cancer survivors who reported pleasurable RAI prior to treatment. Approximately 47% of the sample reported recent RAI, which was more common among GBM in long-term relationships. RAI was also associated with engagement in other sexual behaviors (e.g., oral and insertive anal sex). Anodyspareunia was reported by 23% of the men who had attempted recent RAI. Anodyspareunia was negatively associated with mental health, performing oral sex on a partner, and bowel function. The overwhelming majority received no information from their healthcare providers about loss of RAI function prior to prostate cancer treatment. Culturally responsive cancer survivorship care may need to address the loss of RAI function for GBM prostate cancer survivors.

Navigating through incontinence: A qualitative systematic review and meta-aggregation of the experiences of family caregivers.

BACKGROUND: Community dwelling older adults who are care dependent are highly affected by incontinence, resulting in substantial informal caregiver burden. Understanding the experiences of these caregivers is needed to develop supportive programs that reduce caregiver burden and rates of institutionalization for care recipients. OBJECTIVES: This systematic review aimed to critically appraise and synthesize the qualitative literature on the perceptions, experiences, and consequences of informal caregivers managing incontinence in community dwelling older adults. DESIGN: A qualitative evidence synthesis using meta-aggregation. DATA SOURCES: CINAHL, Embase, Ovid Medline, PsycInfo, Scopus, and ProQuest Dissertations and Theses. REVIEW METHODS: A comprehensive search was conducted to identify qualitative studies of all designs, published in English from January 1970 to November 2020, reporting on the experiences of unpaid adult family members or friends providing care at home to an adult aged 60 or older with urinary and/or fecal incontinence. Screening, data extraction, and quality appraisal were conducted independently by two reviewers, with disagreements resolved by consensus with all team members. Joanna Briggs Institute (JBI) processes were used to assess study quality, and the dependability and credibility of both study findings and synthesized findings. All articles included met predetermined criteria. RESULTS: Database searches yielded 1165 references, of which 117 full-text documents were screened. Seven articles of moderate to high methodological quality met eligibility criteria and were included. Studies occurred in nine countries with 134 participants who were mostly female spouses of the care recipient. From these eligible studies, 49 findings were extracted with 35 equivocal or credible findings eligible for meta-aggregation. Findings were synthesized into the following four categories: 1) emotional responses, 2) physical, financial, and social consequences, 3) family roles and caregiver support, and 4) management and coping strategies. CONCLUSIONS: Informal caregivers experience many physical, psychosocial, and financial challenges in caring for an older family member with incontinence. Educational and supportive programs for managing incontinence should be multi-component and tailored to meet the individual needs of informal caregivers. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing incontinence. PROSPERO REGISTRATION: CRD42017069185.

Every urologist and oncologist should know about treating sexual and gender minority prostate cancer patients: translating research findings into clinical practice.

In 2016, the NIH designated sexual and gender minorities (SGM) a health disparity population. The next year, the American Society of Clinical Oncology highlighted the need to improve the suboptimal cancer and survivorship care received by SGM populations. There are currently no evidence-based training programs in culturally competent care of prostate cancer patients who are gay, bisexual and/or transgender. In this selective review, we summarize findings from the largest quantitative studies focused on sexual minority prostate cancer survivors and from 65 interviews with NIH staff, clinicians, and cancer clinics in 11 US cities. The report is divided into three parts and uses a question and answer format to address 21 questions relevant to clinicians providing care to SGM prostate cancer patients. First, we identify population-specific issues that are culturally relevant in the care of SGM patients with prostate cancer. While a body of research has emerged on sexual minority prostate cancer patients, the literature on gender minorities is limited to single case reports and inadequate to inform practice. This review covers definitions, population size, cultural and historical context, sexual behavior, population invisibility, sexual orientation and gender identity (SOGI) in the electronic medical record, disparities and evidence of discrimination in treatment provision. The second part focuses on promoting evidence-informed, patient-centered care. This includes current practices in assessing sexual orientation, management of disclosure of sexual orientation, how to address common problems sexual minority men experience post-treatment, common questions sexual minority patients have, management of urinary incontinence, HIV and STI risk during and post-treatment, and sub-groups of sexual minority patients with worse outcomes. It then identifies how male partners differ in prostate cancer support, current research on rehabilitation for sexual minority men, issues in advanced prostate cancer, and things to avoid with minority patients. Finally, we examine the cultural divide between provider and patient, advocating for cultural humility when working with minority patients. Training programs and continuing education can help providers both to become more aware of their own cultural assumptions, informed about health disparities, and able to provide quality care, and to make clinics more welcoming to SGM patients.

Individual Differences in Response to Supervised Exercise Therapy for Peripheral Artery Disease.

Nonresponse to exercise has been extensively examined in young athletes but is seldom reported in studies of aerobic exercise interventions in older adults. This study examined the prevalence of nonresponse and poor response to exercise in functional and quality of life outcomes and response patterns between and among older adults undergoing 12-weeks of supervised exercise therapy for the management of peripheral artery disease (N = 44, mean age 72.3 years, 47.7% female). The prevalence of nonresponse (no change/decline in performance) in walking distance was 31.8%. The prevalence of poor response (lack of a clinically meaningful improvement) was 43.2%. Similar patterns of response were observed in both objective and patient-reported measures of physical function. All participants improved in at least one outcome; only two participants improved in all measured outcomes. Additional research should examine modifiable predictors of response to inform programming and maximize an individual's potential benefit from exercise therapy.

Benefits and Harms of Prescription Drugs and Supplements for Treatment of Clinical Alzheimer-Type Dementia.

BACKGROUND: Effects of drug treatment of clinical Alzheimer-type dementia (CATD) are uncertain. PURPOSE: To summarize evidence on the effects of prescription drugs and supplements for CATD treatment. DATA SOURCES: Electronic bibliographic databases (inception to November 2019), ClinicalTrials.gov (to November 2019), and systematic review bibliographies. STUDY SELECTION: English-language trials of prescription drug and supplement treatment in older adults with CATD that report cognition, function, global measures, behavioral and psychological symptoms of dementia (BPSD), or harms. Minimum treatment was 24 weeks (≥2 weeks for selected BPSD). DATA EXTRACTION: Studies with low or medium risk of bias (ROB) were analyzed. Two reviewers rated ROB. One reviewer extracted data; another verified extraction accuracy. DATA SYNTHESIS: Fifty-five studies reporting non-BPSD outcomes (most ≤26 weeks) and 12 reporting BPSD (most ≤12 weeks) were analyzed. Across CATD severity, mostly low-strength evidence suggested that, compared with placebo, cholinesterase inhibitors produced small average improvements in cognition (median standardized mean difference [SMD], 0.30 [range, 0.24 to 0.52]), no difference to small improvement in function (median SMD, 0.19 [range, -0.10 to 0.22]), no difference in the likelihood of at least moderate improvement in global clinical impression (median absolute risk difference, 4% [range, 2% to 4%]), and increased withdrawals due to adverse events. In adults with moderate to severe CATD receiving cholinesterase inhibitors, low- to insufficient-strength evidence suggested that, compared with placebo, add-on memantine inconsistently improved cognition and improved global clinical impression but not function. Evidence was mostly insufficient about prescription drugs for BPSD and about supplements for all outcomes. LIMITATION: Most drugs had few trials without high ROB, especially for supplements, active drug comparisons, BPSD, and longer trials. CONCLUSION: Cholinesterase inhibitors and memantine slightly reduced short-term cognitive decline, and cholinesterase inhibitors slightly reduced reported functional decline, but differences versus placebo were of uncertain clinical importance. Evidence was mostly insufficient on drug treatment of BPSD and on supplements for all outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).

Brief Cognitive Tests for Distinguishing Clinical Alzheimer-Type Dementia From Mild Cognitive Impairment or Normal Cognition in Older Adults With Suspected Cognitive Impairment.

BACKGROUND: The accuracy and harms of brief cognitive tests for identifying clinical Alzheimer-type dementia (CATD) are uncertain. PURPOSE: To summarize evidence on accuracy and harms of brief cognitive tests for CATD in older adults with suspected cognitive impairment. DATA SOURCES: Electronic bibliographic databases (from inception to November 2019) and systematic review bibliographies. STUDY SELECTION: English-language, controlled observational studies in older adults that evaluated the accuracy of brief cognitive tests (standalone tests; memory, executive function, and language tests; and brief multidomain batteries) for distinguishing CATD from mild cognitive impairment (MCI) or normal cognition as defined by established diagnostic criteria. Studies with low or medium risk of bias (ROB) were analyzed. DATA EXTRACTION: Two reviewers rated ROB. One reviewer extracted data; the other verified extraction accuracy. DATA SYNTHESIS: Fifty-seven studies met analysis criteria. Many brief, single cognitive tests were highly sensitive and specific for distinguishing CATD from normal cognition. These included standalone tests (clock-drawing test, median sensitivity 0.79 and specificity 0.88 [8 studies]; Mini-Mental State Examination, 0.88 and 0.94 [7 studies]; Montreal Cognitive Assessment, 0.94 and 0.94 [2 studies]; and Brief Alzheimer Screen, 0.92 and 0.97 [1 study]), memory tests (list delayed recall, 0.89 and 0.94 [5 studies]), and language tests (category fluency, 0.92 and 0.89 [9 studies]). Accuracy was lower in distinguishing mild CATD from normal cognition and distinguishing CATD from MCI. No studies reported on testing harms. LIMITATIONS: Studies were small. Few test metrics were evaluated by multiple studies. Few studies directly compared different tests, scores, cut points, or test combinations. CONCLUSION: Many brief, single cognitive tests accurately distinguish CATD from normal cognition in older adults but are less accurate in distinguishing mild CATD from normal cognition or CATD from MCI. No studies reported on testing harms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).

Influence of Changes in Sedentary Time on Outcomes of Supervised Exercise Therapy in Individuals with Comorbid Peripheral Artery Disease and Type 2 Diabetes.

BACKGROUND: Although supervised exercise therapy (SET) is effective in improving walking distance among adults with symptomatic peripheral artery disease (PAD), some research suggests that individuals with comorbid PAD and type 2 diabetes mellitus (T2DM) may experience a blunted response to SET. It is unknown whether free-living sedentary time changes during SET, and if increases in sedentary time could, in part, explain poor response to SET. The purposes of this pilot study were to (1) determine if older adults with PAD (with and without T2DM) engaging in SET change their sedentary behavior and (2) examine the relationship between changes in sedentary behavior and SET outcomes. We hypothesized that decreased sedentary time during SET would be associated with greater improvements in six-minute walk test (6MWT) total distance and other key SET outcomes. METHODS: Participants (n = 44) initiating a 12-week SET program completed the 6MWT, Short Physical Performance Battery, Walking Impairment Questionnaire, and accelerometer-assessed sedentary behavior at SET initiation, 6 weeks, and 12 weeks. RESULTS: Participants' mean age was 72.3 (7.1) years, mean ankle-brachial index was 0.71 (0.25), and 47.7% were female. On average, sedentary time did not change after SET, although there was substantial variability (-40% to +38% change in minutes of sedentary time/day). Participants with T2DM experienced greater improvements in claudication onset distance than participants without T2DM (mean = 35 m, P = 0.044, 95% confidence interval = 1.6 to 115.4 m). Neither changes in sedentary time from baseline to 6 weeks (P = 0.419) nor T2DM (P = 0.154) predicted changes in 6MWT total distance from baseline to 12 weeks. CONCLUSIONS: As SET availability increases, further examination of factors that may influence SET outcomes will help maximize benefits of this proven therapy.

Mammography Screening Practices in Average-Risk Women Aged 40-49 Years in Primary Care: A Comparison of Physician and Nonphysician Providers in Minnesota.

Background: Breast cancer screening practices and the influence of clinical guidelines or recommendations are well documented for physicians, but little is known about the screening practices of nonphysician providers (physician assistants and advanced practice registered nurses). The seven breast cancer screening guidelines or recommendations on the use of mammography have the most variation for screening average-risk women 40-49 years of age. Therefore, to better understand the practices of nonphysicians, this study will compare the practices of physicians with nonphysician providers for women 40-49 years of age. Materials and Methods: Minnesota physicians and nonphysicians were e-mailed an anonymous cross-sectional survey, which asked primary care providers about their mammography screening practices for average-risk women 40-44 and 45-49 years of age and to rate the influence of seven breast cancer screening recommendations on the use of mammography in their practice. Comparisons across providers' demographic and professional characteristics were conducted using chi-squared and Fisher's exact tests, as appropriate, and multivariate logistic regression analyses. Results: Of the respondents who practiced primary care (193 physicians, 50 physician assistants, and 197 advanced practice registered nurses), 66.7% reported recommending mammography for women at ages 40-44 and 77.2% recommended mammography for women at ages 45-49. Nonphysician providers were more likely to recommend screening in both these age groups (p < 0.05). Having a self-identified interest in women's health was associated with more mammography screening in both age groups. The American Cancer Society guideline was endorsed as influential by the most respondents. Conclusions: Breast cancer screening practices vary between physicians and nonphysician providers for women 40-49 years of age at average risk. Targeted interventions may help reduce practice variation and ensure high-value care.

Health-related quality of life by human immunodeficiency virus status in a cross-sectional survey of gay and bisexual prostate cancer survivors.

OBJECTIVE: Prostate cancer is the most common invasive cancer in gay and bisexual men (GBM). Despite the unique sexual and urinary concerns of this group, studies of prostate cancer rehabilitation have primarily focused on heterosexual men. GBM also have high prevalence of human immunodeficiency virus (HIV), which may be associated with lower health-related quality of life (HRQOL). We examined the association between HIV status and HRQOL in a cohort of GBM with prostate cancer. METHODS: Data from the Restore study, a cross-sectional online survey of GBM treated for prostate cancer, were used to examine this association. The Expanded Prostate Cancer Index Composite (EPIC) assessed function, bother, and summary measures in four domains: urinary, sexual, bowel, and hormone. Overall physical and mental HRQOL was assessed using the Short-Form Health Survey (SF-12). Multivariate analysis of variance and linear regression were used to evaluate the association between HIV status and HRQOL scores after adjustment for demographic and sexual characteristics. RESULTS: Of 192 participants, 24 (12.4%) reported an HIV diagnosis. After adjustment for covariates, HIV-positive status was associated with lower scores on the EPIC urinary (mean difference [MD]: -13.0, 95% CI, -21.4 to -4.6), sexual (MD: -12.5, 95% CI, -21.9 to -3.2), and bowel (MD: -5.9, 95% CI, -11.7 to -0.2) domains. No significant associations were observed between HIV status and other outcomes. CONCLUSIONS: HIV status may be associated with poorer urinary, sexual, and bowel HRQOL in GBM prostate cancer survivors.

A mixed methods study of perceived barriers to physical activity, geriatric syndromes, and physical activity levels among older adults with peripheral artery disease and diabetes.

Previous studies suggest a myriad of factors prevent individuals from engaging in physical activity; however, less is known about barriers faced by individuals with multiple chronic conditions, such as peripheral artery disease (PAD) and type 2 diabetes, and how these barriers may impact engagement in physical activity. To date, there are no studies that integrate simultaneous assessment of perceived barriers to physical activity and engagement in physical activity in older adults with PAD and diabetes. This integration is key to understanding the implications of barriers to physical activity and to developing strategies to address those barriers. Therefore, this study investigated the unique physical activity experiences of older adults with PAD and diabetes. This study used a concurrent mixed methods design. Ten adults aged 65 years and older with PAD and diabetes completed semistructured interviews about experiences with physical activity, self-reported questionnaires assessing quality of life and fear of falling, and measures of physical function (eg, 6-minute walk test, chair stand, gait speed). Physical activity was measured objectively with accelerometry. Inductive content analysis was used to identify themes, and integrated analysis was performed to evaluate patterns among qualitative and quantitative variables. On average, participants were 74 years old and spent 10% of their time in moderate or vigorous physical activity (range: 3%-18%); 80% of participants were men. Barriers to physical activity identified through qualitative interviews included lack of accessibility, lack of enjoyment of activity, lack of motivation, and pain and physical health. Facilitators to physical activity were social support, accessibility and convenience, and enjoyment of the activity. Participants with more sedentary time and less moderate or vigorous physical activity tended to report greater fear of falling and greater barriers to physical activity and achieved lower distances in 6-minute walk tests. This research provides insight into both the nature of perceived barriers to physical activity and engagement in physical activity among older adults with PAD and diabetes. The integration of self-reported measures and objective measures facilitates our understanding of the lived experiences of individuals with these conditions. Study findings can be used to support further investigation into factors that influence engagement in physical activity in individuals with PAD and diabetes and to assist in the development of strategies to address identified barriers.