Risk Of Chronic Health Conditions Research Articles

Waterscapes meet socio‐ecological models: A relational framework to examine water insecurity and human health and well‐being

Abstract Water insecurity, the inability to benefit from affordable, adequate, reliable and safe water, is one of the greatest contemporary threats facing humans. While ‘water insecurity’, as a concept, is globally recognized and serves an essential function in policymaking, it does not capture the multiple, relational connections between Indigenous peoples and local communities (IPLCs) and water systems. We contend that studies of water insecurity and health among IPLCs can be improved by applying a systematic approach to the concept of waterscapes. The term waterscape describes the socio‐natural relations between humans and water. To make examining waterscapes more systematic and to draw attention to the importance of health within waterscapes, we use a four‐tiered socio–ecological approach to describe the multi‐level interactions between IPLCs and local water systems in the Amazonian watershed. We then apply this four‐tiered model to the case of the Belo Monte dam in the Brazilian Amazon to identify the specific health impacts of disrupting the Xingu River waterscape. Applying the four‐tiered socio‐ecological approach to the Belo Monte case study showed that this dam led to flooding and compromised water quality that local people associated with an increased risk for chronic health conditions, such as kidney and renal diseases, and vector‐borne diseases, such as dengue. Displacement due to the dam threatened food security, economic security, community cohesion and the cultural survival of multiple IPLCs along the Xingu river. Our approach uncovers not only the direct consequences of the dam on water insecurity but also the broader implications for community well‐being and cultural integrity, addressing the diverse challenges arising from human‐water interactions. The four‐tiered approach for assessing waterscapes offers a framework that enables a comprehensive examination of the intricate relations between water and humans. While there are overlaps among the levels, this framework is applicable to other situations where mining, oil extraction and the construction of hydrovías are substantially altering local waterscapes. Tools such as this one can promote more meaningful engagement between researchers, policymakers, and IPLCs in defining the range of outcomes to be considered in social and environmental impact assessments. Read the free Plain Language Summary for this article on the Journal blog.

Socioeconomic inequalities in early adulthood disrupt the immune transcriptomic landscape via upstream regulators

Disparities in socio-economic status (SES) predict many immune system-related diseases, and previous research documents relationships between SES and the immune cell transcriptome. Drawing on a bioinformatically-informed network approach, we situate these findings in a broader molecular framework by examining the upstream regulators of SES-associated transcriptional alterations. Data come from the National Longitudinal Study of Adolescent to Adult Health (Add Health), a nationally representative sample of 4543 adults in the United States. Results reveal a network—of differentially expressed genes, transcription factors, and protein neighbors of transcription factors—that shows widespread SES-related dysregulation of the immune system. Mediational models suggest that body mass index (BMI) plays a key role in accounting for many of these associations. Overall, the results reveal the central role of upstream regulators in socioeconomic differences in the molecular basis of immunity, which propagate to increase risk of chronic health conditions in later-life.

Risk of chronic health conditions in lesbian, gay, and bisexual survivors of adolescent and young adult cancers.

In the general population, individuals with minoritized sexual orientation and gender identity have a higher burden of chronic health conditions than heterosexual individuals. However, the extent to which sexual orientation is associated with excess burden of chronic conditions in adolescent and young adult cancer survivors (AYACS) is unknown. Lesbian, gay, and bisexual (LGB) AYACSs, LGB individuals without a history of cancer, and heterosexual AYACSs were identified by self-reported data from the cross-sectional National Health Interview Survey (2013-2020). Socioeconomic factors and the prevalence of chronic health conditions were compared between groups using χ2 tests. Logistic regression methods were used to determine the odds of chronic conditions by socioeconomic factors within and between survivor and comparison groups. One hundred seventy LGB cancer survivors, 1700 LGB individuals without a history of cancer, and 1700 heterosexual cancer survivors were included. Compared with heterosexual survivors, LGB survivors were less likely to be married (p=.001) and more likely to have never been married (p<.001). LGB survivors were more likely to have incomes between 100% and 200% of the federal poverty level than LGB individuals without a history of cancer (p=.012) and heterosexual survivors (p=.021) and were less likely to report incomes >200% the federal poverty level. LGB survivors had higher odds of chronic health conditions than LGB individuals without a history of cancer (odds ratio, 2.45; p<.001) and heterosexual survivors (odds ratio, 2.16; p=.003). LGB AYACSs are at increased risk of having chronic health conditions compared with both LGB individuals without a history of cancer and heterosexual AYACSs.

Describing Physical Activity Patterns of Truck Drivers Using Actigraphy

BackgroundTruck driving is a highly sedentary occupation that places workers at risk for chronic health conditions, such as obesity and high blood pressure. The primary purpose of this study was to objectively describe truck drivers' typical physical activity (PA) patterns. MethodsWe used ∼7–10-day baseline PA actigraphy data samples from drivers in the Safety & Health Involvement For Truckers (SHIFT) study (n = 394). Driver PA patterns (e.g., average number of ≥10 minute Freedson bouts per week, time in bouts, and common days/times for PA) were summarized with descriptive analyses. We also compared objective accelerometer data to self-reports. ResultsDrivers' weekly PA averaged 14.4 minutes (SD = 37.0), and most PA occurred between 5–6 pm on Tuesdays and Wednesdays. Drivers overestimated self-reported weekly exercise by over 60 min/week compared to accelerometer data. ConclusionOur results suggest that objective PA assessment may be warranted over self-report when possible, and timing may be key in future PA intervention work with truck drivers.

Socioeconomic Status and Chronic Health Conditions in Asian Survivors of Adolescent and Young Adult Cancers.

Purpose: While there are known disparities in socioeconomic status (SES) and health outcomes among racially and ethnically minoritized adolescent and young adult (AYA; ages 15-39 years at diagnosis) cancer survivors compared with White survivors, outcomes in the Asian survivor population are understudied. To better understand the association of an AYA cancer diagnosis with SES and health outcomes within a minoritized population, the current study makes comparisons between individuals of the same race or ethnicity with and without a history of AYA cancer. Methods: Non-Hispanic, Asian AYA cancer survivors and non-Hispanic, Asian age- and sex-matched controls were identified from self-reported data in the National Health Interview Survey (2009-2020). Prevalence of chronic health conditions and socioeconomic factors were compared between groups using chi-square tests. Odds of chronic conditions by SES factors were determined within and between survivors and controls using logistic regression methods. Results: One hundred and thirty-one survivors and 1310 controls were included. Survivors were less likely to be married compared with controls; however, there were no differences in other SES factors examined. Survivors had higher odds of at least one chronic condition diagnosis (odds ratio = 4.17, p < 0.001) compared with controls. Of the chronic conditions assessed, survivors had higher odds of arthritis, pulmonary disease, and hypertension compared with controls. Conclusions: Asian AYA cancer survivors are at increased risk of chronic health conditions compared with Asian individuals without a cancer history. Culturally adapted targeted interventions are needed to improve health outcomes for this population.

Excess risk of chronic health conditions in Black adolescent and young adult cancer survivors.

The US population of adolescent and young adult (age 15-39 years at diagnosis) cancer survivors is growing. Previous studies have identified racial and ethnic disparities in survival and health outcomes in racially minoritized survivors, including Black survivors, compared with White survivors. However, comparisons should be made between those of the same race or ethnicity with and without a history of AYA cancer to fully understand the association of a cancer diagnosis with socioeconomic status (SES) and health outcomes within a minoritized population. Non-Hispanic Black AYA cancer survivors and non-Hispanic Black age- and sex-matched controls were identified from self-reported data from the National Health Interview Survey (2009-2018). SES factors and chronic health conditions prevalence were compared between survivors and controls using chi-square tests. Survey-weighted logistic regression models were used to determine odds of chronic conditions by SES factors within and between survivors and controls. Interactions between each variable and cancer group were assessed. A total of 445 survivors and 4450 controls were included. Survivors were less likely than controls to be married, have family income >45K/year, have completed a bachelor's degree or higher, and have private insurance. Survivors had higher odds than controls of having at least one (odds ratio (OR): 7.02, p<0.001) and ≥3 (OR: 4.44, p<0.001) chronic conditions. Survivors had higher odds of each chronic condition assessed including cardiovascular disease, diabetes, and hypertension. Survivors had higher odds of having chronic health conditions compared with controls across all SES variables. A cancer diagnosis during adolescence and young adulthood is associated with poor SES outcomes and increased odds of comorbidities within the Black population, thus further exacerbating existing disparities. Black AYA cancer survivors have a very high risk of developing chronic health conditions after cancer treatmentand interventions are needed to improve long-term health outcomes for this population.

Physical activity interventions for adults with hearing loss: a systematic review

ABSTRACT Growing epidemiological evidence suggests that adults with hearing loss engage in less physical activity than those without, which may increase the risk of chronic health conditions. This review aimed to systematically evaluate existing evidence assessing the effectiveness of physical activity interventions in adults with hearing loss. The review also aimed to identify the behaviour change techniques used in the included studies. A systematic search of the literature was completed and reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Two studies met the eligibility criteria, both found overall improvements for physical function, namely, aerobic fitness and muscle strength in adults with hearing loss. Limited evidence was available for the impact on psychosocial wellbeing. The evidence was judged to be of low quality and subject to bias. Further theoretically driven, high-quality intervention studies that incorporate additional behaviour techniques (e.g., providing additional environmental cues) are necessary.

Cumulative burden of late, major surgical intervention in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS) cohort.

Multimodal cancer therapy places childhood cancer survivors at increased risk for chronic health conditions, subsequent malignancies, and premature mortality as they age. We aimed to estimate the cumulative burden of late (>5 years from cancer diagnosis), major surgical interventions among childhood cancer survivors, compared with their siblings, and to examine associations between specific childhood cancer treatments and the burden of late surgical interventions. We analysed data from the Childhood Cancer Survivor Study (CCSS), a retrospective cohort study with longitudinal prospective follow-up of 5-year survivors of childhood cancer (diagnosed before age 21 years) treated at 31 institutions in the USA, with a comparison group of nearest-age siblings of survivors selected by simple random sampling. The primary outcome was any self-reported late, major surgical intervention (defined as any anaesthesia-requiring operation) occurring 5 years or more after the primary cancer diagnosis. The cumulative burden was assessed with mean cumulative counts (MCC) of late, major surgical interventions. Piecewise exponential regression models with calculation of adjusted rate ratios (RRs) evaluated associations between treatment exposures and late, major surgical interventions. Between Jan 1, 1970, and Dec 31, 1999, 25 656 survivors were diagnosed (13 721 male, 11 935 female; median follow-up 21·8 years [IQR 16·5-28·4]; median age at diagnosis 6·1 years [3·0-12·4]); 5045 nearest-age siblings were also included as a comparison group. Survivors underwent 28 202 late, major surgical interventions and siblings underwent 4110 late, major surgical interventions. The 35-year MCC of a late, major surgical intervention was 206·7 per 100 survivors (95% CI 202·7-210·8) and 128·9 per 100 siblings (123·0-134·7). The likelihood of a late, major surgical intervention was higher in survivors versus siblings (adjusted RR 1·8, 95% CI 1·7-1·9) and in female versus male survivors (1·4; 1·4-1·5). Survivors diagnosed in the 1990s (adjusted RR 1·4, 95% CI 1·3-1·5) had an increased likelihood of late surgery compared with those diagnosed in the 1970s. Survivors received late interventions more frequently than siblings in most anatomical regions or organ systems, including CNS (adjusted RR 16·9, 95% CI 9·4-30·4), endocrine (6·7, 5·2-8·7), cardiovascular (6·6, 5·2-8·3), respiratory (5·3, 3·4-8·2), spine (2·4, 1·8-3·2), breast (2·1, 1·7-2·6), renal or urinary (2·0, 1·5-2·6), musculoskeletal (1·5, 1·4-1·7), gastrointestinal (1·4, 1·3-1·6), and head and neck (1·2, 1·1-1·4) interventions. Survivors of Hodgkin lymphoma (35-year MCC 333·3 [95% CI 320·1-346·6] per 100 survivors), Ewing sarcoma (322·9 [294·5-351·3] per 100 survivors), and osteosarcoma (269·6 [250·1-289·2] per 100 survivors) had the highest cumulative burdens of late, major surgical interventions. Locoregional surgery or radiotherapy cancer treatment were associated with undergoing late surgical intervention in the same body region or organ system. Childhood cancer survivors have a significant burden of late, major surgical interventions, a late effect that has previously been poorly quantified. Survivors would benefit from regular health-care evaluations aiming to anticipate impending surgical issues and to intervene early in the disease course when feasible. US National Institutes of Health, US National Cancer Institute, American Lebanese Syrian Associated Charities, and St Jude Children's Research Hospital.

Congenital anomalies and health outcomes among survivors of childhood cancer: A report from the childhood cancer survivor study.

e22021 Background: Although congenital anomalies are established risk factors for developing childhood cancer, less is known about health outcomes among survivors of childhood cancer with known congenital anomalies. Therefore, we estimated the risk of chronic health conditions (CHCs) and subsequent malignant neoplasms (SMNs) among survivors of childhood cancer by congenital anomaly status in the Childhood Cancer Survivor Study (CCSS). Methods: Overall, 22,247 five-year survivors self-reported congenital anomalies. We included 16 conditions present at birth, excluding self-reported genetic conditions. Patient-reported CHCs were graded using the Common Terminology Criteria for Adverse Events (CTCAE v. 4.03). Self-reported SMNs were confirmed through pathology report review. Hazard ratios (HR) of CHCs comparing survivors with vs. without congenital anomalies and their 95% confidence intervals (CI) were estimated using Cox regression with age as the time scale, adjusted for race/ethnicity, education, household income, health insurance, and original cancer treatment. Results: Among survivors (median age at cancer diagnosis 6 years (range 3-12), age at follow-up 31 years (range 25-39)), 16.9% (n = 3880) reported a congenital anomaly. The most common anomalies included: large/multiple birth marks (n = 1540, 40.4%); congenital heart defects (n = 693, 18.4%); and kidney, bladder, or genital abnormalities (n = 607, 14.6%). Relative to survivors without anomalies, those with anomalies more commonly had astrocytoma, Wilms tumor, and neuroblastoma primary cancers (p &lt; 0.001), treated with radiation (p = 0.011), cyclophosphamide (p &lt; 0.001), anthracyclines (p &lt; 0.001), and epipodophyllotoxins (p = 0.044), and younger age at cancer diagnosis (11.3% vs. 5.7% diagnosed prior to one year of age, p &lt; 0.001). Survivors with anomalies were more likely to develop any CHC (CTCAE grades 1-5 HR: 1.31, 95% CI: 1.23, 1.39); severe, disabling, life-threatening or fatal CHCs (grades 3-5 HR: 1.42 (95% CI: 1.28, 1.58); and multiple CHCs (≥2 conditions HR: 1.36, 95% CI: 1.27, 1.46; ≥3 conditions HR: 1.49, 95% CI: 1.37, 1.63). Survivors with anomalies had increased risk for adverse outcomes across multiple systems (all p &lt; 0.001), including: hearing/vision/speech (HR: 1.37); urinary (HR: 1.42); hormonal/endocrine (HR: 1.24); heart/circulatory (HR: 1.35); digestive (HR: 1.49); and brain systems (HR: 1.42). We observed no differences in the risk of any SMN by congenital anomaly status (HR: 1.12, 95% CI: 0.90, 1.38). Conclusions: In our assessment, survivors of childhood cancer with self-reported congenital anomalies had an increased risk of developing CHCs compared to survivors without reported anomalies, but no increased risk of SMNs. Evaluating congenital anomalies allows identification of a population of childhood cancer survivors at high risk for poor long-term health outcomes.

Abstract 4514: Variations of blood DNA methylation associated with cancer treatment exposures among childhood cancer survivors of African ancestry

Abstract We previously showed that cancer treatment associated DNA methylation (DNAm) signatures were present decades following the cancer diagnosis in childhood cancer survivors (CCS) of European ancestry (EA) and that treatment associated DNAm sites mediated the causal pathway from specific treatment exposures to increased risk of chronic health conditions (CHCs). This new analysis further evaluated and compared the treatment and DNAm associations in CCS of African ancestry (AA) from the St. Jude Lifetime Cohort Study. Cancer treatments were abstracted from medical records. DNAm was measured using MethylationEPIC BeadChip with blood-derived DNA. Among 370 AA CCS (53.2% female, median age at blood draw=31.2 [range=18.4-65.1] years), treatments included alkylating agents (54.6%), anthracyclines (48.6%), epipodophyllotoxins (29.2%), corticosteroids (33.0%), and vincristine (61.6%), and radiation therapy (RT) to brain (26.5%), chest (27.6%), abdomen (22.7%), and pelvis (21.6%). Epigenome-wide association study (EWAS) for each treatment, using multivariable linear regression adjusting for sex, age at blood draw, leukocyte cell subtype proportions, genotype principal components and DNAm principal components, showed little inflation with genomic control (GC) factor between 1.1 (brain-RT) and 1.2 (chest-RT). A total of 93 5′-cytosine-phosphate-guanine-3′ (CpG) was associated with one or more cancer treatments (GC-adjusted P&amp;lt;9 × 10−8), including epipodophyllotoxins (n=46), alkylating agents (n=38), corticosteroids (n=3), anthracyclines (n=3), abdominal-RT (n=3), chest-RT (n=2), and pelvic-RT (n=1). A total of 60 differentially methylated regions (DMRs) was identified using DMRcate R package, including alkylating agents (n=28), epipodophyllotoxins (n=22), corticosteroids (n=3), abdominal-RT (n=4), chest-RT (n=2), and anthracyclines (n=1). A total of 39 CpGs from EWAS were nested within 21 DMRs. 92.1% (650/706) chemo-associated CpGs in EA were replicated in AA CCS, and 98.9% (86/87) chemo-associated CpGs in AA were replicated in EA CCS. In contrast, 66.7% (4/6) RT-associated CpGs in AA were replicated in EA CCS, and 71.7% (638/890) RT-associated CpGs in EA were replicated in AA CCS. Moreover, the four CpGs that partially mediated the effect of abdominal-RT on hypercholesterolemia in EA were not associated with abdominal-RT in AA CCS, further suggesting substantial difference in RT-associated CpGs as compared to chemo-associated CpGs between AA and EA CCS. Future studies by including a larger sample size of AA CCS are warranted to assess the difference in treatment-associated DNAm alterations and subsequent disparity in risk of treatment-related CHCs between AA and EA CCS. The DNAm sites can be used as predictors for risk management (treatment decision-making) and potential mechanistic targets for intervention for those at the greatest risk of CHCs. Citation Format: Qian Dong, Sarmistha Das, Cheng Chen, John Easton, Heather L. Mulder, Emily Walker, Geoffrey Neale, Deo Kumar Srivastava, I-Chan Huang, Jinghui Zhang, Melissa M. Hudson, Leslie L. Robison, Kirsten K. Ness, Nan Song, Zhaoming Wang. Variations of blood DNA methylation associated with cancer treatment exposures among childhood cancer survivors of African ancestry. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4514.

Evaluation of a co-designed educational e-resource about oral health for community nurses: study protocol

BackgroundOral health is a crucial aspect of health and wellbeing for older people. Poor oral health has been found to significantly increase the risk of chronic health conditions and poor quality of life for older people. Nurses practicing in the community are well-placed to provide oral health care to older people in their own homes, yet there has been little research in this field to develop accessible support for them to do so. Previous literature, reviewed in an earlier phase of this work, revealed that there has, historically, been a paucity of oral health care education for nurses and very few educational resources have been developed in this field.MethodsThis study will evaluate an educational e-resource which has been co-designed by service users, carers and clinicians. In the first phase of research, evidence of promise will be evaluated by analysing quantitative data on community nurses’ oral health attitudes and self-efficacy for oral health assessments of older people. In the second phase of research, facilitators and barriers to community nurses’ provision of oral health care to older people and the acceptability of the educational e-resource will be evaluated.DiscussionThis research will investigate the potential of an educational e-resource to improve community nurses’ capabilities to deliver oral health care to older people in their own homes. This research will inform both future intervention design and understanding of community nurses’ knowledge and attitudes about oral health care. Facilitators and barriers to provision of this care for older people will also be explored.

Identifying Risk Factors for Blindness From Glaucoma at First Presentation to a Tertiary Clinic

Glaucoma is the leading cause of irreversible blindness, a crippling disability resulting in higher risks of chronic health conditions. To better understand disparities in blindness risk, we identified risk factors of blindness on first presentation to a glaucoma clinic using a large clinical database. Retrospective cross-sectional study. We used electronic health records of glaucoma patients from the Duke Ophthalmic Registry. International Classification of Diseases codes were used to identify glaucoma and exclude concurrent diseases. Blindness classification was based on the definition of legal blindness. Risk factors included gender, race, marital status, age, intraocular pressure, diabetes history, income level, and education. Odds ratios (ORs) and 95% CIs were calculated for risk factors using univariable and multivariable logistic regression. Our cohort consisted of 3753 patients, with 192 (5%) blind on first presentation. In univariable models, African American / Black race (OR 2.48, 95% CI 1.83-3.36), single marital status (1.74, 95% CI 1.25-2.44), prior diabetes diagnosis (2.23, 95% CI 1.52-3.27), and higher intraocular pressure (1.29 per 1 SD higher, 95% CI 1.13-1.46) were associated with increased risk of presenting blind, whereas higher annual income (0.75, 95% CI 0.65-0.86) and education (0.77, 95% CI 0.69-0.85) were associated with lower risk. These associations remained significant and in the same direction in a multivariable model apart from income, which became insignificant. Using a large real-world clinical database, we identified risk factors associated with presentation with blindness among glaucoma patients. Our results highlight disparities in health care outcomes and indicate the importance of targeted education to reduce disparities in blindness.

Excess risk of chronic health conditions in Hispanic survivors of adolescent and young adult cancers.

There is a growing population of survivors of adolescent and young adult (AYA) cancers (age 15-39years at diagnosis). Studies in AYA cancer survivors have identified racial and ethnic disparities in long-term outcomes. To understand the extent to which a cancer diagnosis exacerbates pre-existent health disparities within a minoritized population, comparisons should be made to those of the same race or ethnicity without a cancer history. Self-reported data from the National Health Interview Survey (2009-2018) were used to identify Hispanic AYA cancer survivors and Hispanic age- and sex-matched controls. SES factors (marital status, income, education, insurance) and prevalence of chronic health conditions were compared between groups using chi-square tests. The log-odds of chronic conditions were modeled by survey-weighted logistic regression with relation to age at survey, sex, marital status, education, family income, and cancer group (control versus cancer), together with interactions between each variable and cancer group (survivors vs. controls). Five hundred thirty-nine survivors and 5390 controls were included. Compared with controls, survivors were less likely to be married and have family income > 45K/year, and more likely to be insured and have completed some college. Survivors had higher odds than controls of chronic health conditions (odds ratio (OR): 7.39, p < 0.001 for at least 1 and OR: 4.78, p < 0.001 for 3 or more) including cardiovascular disease, diabetes, and hypertension. Female sex, higher educational attainment, and public insurance were each associated with increased odds of chronic conditions in Hispanic AYA survivors. An AYA cancer diagnosis is associated with poor SES outcomes and increased odds of comorbidities within the Hispanic population. Cancer history can exacerbate underlying health disparities. Screening for chronic conditions is especially important in minoritized populations.

Understanding the Impact of Adverse Childhood Experiences (ACEs) on Children at the Boys and Girls Club of Tippecanoe County, Indiana

Background/Objective:Children with multiple Adverse Childhood Experiences (ACEs) have been shown to be at greater risk for chronic health conditions. Providing Trauma-Informed Care (TIC) to children with ACEs has been linked to better downstream health outcomes. Out-of-school time (OST) programs, such as Boys and Girls Clubs (BGC), can play an important role in supporting children with ACEs. Currently, BGC of Tippecanoe County does not require staff or volunteers to participate in training on ACEs or TIC. This study aims to determine the number of ACEs that children at BGC experience, and subsequently if training for staff and volunteers should be required.&#x0D; Methods:An anonymous survey was developed using a template from ACEs Aware. The survey included ten ACEs questions and nine Related Life Events questions (considered additional ACEs in this study). An optional demographics section was also included. Caregivers of children at BGC were asked to participate. Staff and volunteers were also surveyed regarding their history of training in TIC.&#x0D; Results:A total of 64 surveys were distributed to parents and 52 were completed (81.3% response rate). Of the completed surveys, the mean number of ACEs experienced per child was 4.6, the median was 3, and the mode was 2. The maximum number of ACEs experienced by a child was 14. Fifty percent of the staff and volunteers surveyed (n = 18) had no formal TIC training. Further data analysis is still in progress.&#x0D; Conclusion and Potential Impact:Children who attend BGC may experience on average a higher number of ACEs than the general population. Requiring training on ACEs and TIC for staff and volunteers may help better identify and respond to child behaviors linked to ACEs. Helping children feel safe and empowered through TIC provided at OST programs may have a positive impact on their physical and social health.

STRATEGIES TO IMPLEMENT AGE-FRIENDLY CARE FOR OLDER ADULTS ACROSS CONVENIENT CARE CLINICS

Abstract A growing proportion of the population in the United States are older adults, and they are frequent users of convenient care clinics. This is particularly true for older adults from systematically marginalized communities who may be at greater risk for chronic health conditions and unmet healthcare needs. These trends render convenient care clinics critical sites to reimagine the provision of care for older adults. To improve the quality of care the CVS MinuteClinic implemented the Institute of Healthcare Improvement’s Age-Friendly Health Systems 4Ms Framework (assessing What Matters, Medication, Mentation, and Mobility). Research to evaluate two interventions (reflective learning and virtual clinic participation) to improve healthcare providers’ (HCP) uptake of the 4Ms was implemented. After the interventions, HCPs were provided a self-administered online survey to capture qualitative reports of reflections on learning and implementing the 4Ms. A total of 32 providers from both groups completed the survey. Using a codebook thematic analysis approach, facilitators and barriers for implementation were identified as were HCPs’ innovative approaches to consistently and effectively implement the 4Ms. Facilitator themes were the presence of resources (e.g., peer coaches) and the perceived value of the 4Ms model. Barrier themes included time, documentation issues, workflow challenges, HCP stress, and HCP comfort. Innovation themes included designing efficient workflows, scaffolded 4Ms learning, and collaboration. These findings underscore the supports/innovations to amplify and challenges to address to support HCPs in learning and implementing the 4Ms to improve the quality of care for older adults.

SENSE OF PURPOSE IN LIFE AND ALLOSTATIC BURDEN IN TWO LONGITUDINAL COHORTS

Abstract Sense of purpose in life has been linked with better physical health, longevity, and reduced risk for disability and dementia, but the mechanisms linking purposefulness with diverse health outcomes is unclear. Chronic activation and dysregulation of neural, immune, and other bodily systems, known as allostatic load, may contribute to these underlying mechanisms. Specifically, sense of purpose may promote better physiological regulation in response to stressors and health challenges, leading to lower allostatic burden and disease risk over time. Data from the nationally representative US Health and Retirement Study (HRS) and English Longitudinal Study on Ageing (ELSA) (Total N=5846; Mean Age=67.24, SD=10.68, 59.08% female) were used to examine associations between sense of purpose and repeated assessments of allostatic load across 8 and 12 years of follow-up. Allostatic load scores were constructed from 12 blood-based and anthropometric biomarkers of cardiovascular, metabolic, immune, and lung function, with higher scores representing higher allostatic burden. Population-weighted multilevel models revealed that sense of purpose in life was associated with lower overall levels of allostatic load in HRS (b = -0.22, 95% CI: -0.27,-0.17) and in ELSA (b = -0.19, 95% CI: -0.35,-0.03). Sense of purpose in life did not predict rate of change in allostatic load in either sample. Associations with sense of purpose were highest among cardiovascular and immune biomarkers, suggesting that preservation of these bodily systems may underlie associations between purposefulness and reduced risk for chronic health conditions. Discussion will focus on biological and behavioral pathways connecting sense of purpose in life and health.

Rare site and age of presentation: Prostatic sarcoma of the Ewing family in an adolescent

Ewing sarcoma/primitive neuroectodermal tumor (PNET) is the second most primary malignant bone tumor in children and adolescents between 10 and 25 years. The extraosseous sarcomas are rare and often cause diagnostic confusion for clinicians. The cell of origin is unclear, but exhibits rapid growth and recurrence, leading to a poor survival rate of 10% only. This imposes an increased risk of chronic health conditions, financial burden, and impaired quality of life. We report the uncommon presentation in age and site of the tumor in the peri-prostatic tissue of a 14-year-old boy and discuss our treatment approach. An exploratory observational case study was conducted. The ultrasound of an enlarged pelvis mass showed a large heterogeneously hyperechoic lesion with central necrosis and increased vascularity in the mass. The magnetic resonance imaging scan and histopathology of the transrectal ultrasound-guided biopsy specimen confirmed the prostate tumor. The transrectal biopsy proved to be a feasible and effective diagnostic tool for such an unclear pelvic mass. The extraskeletal manifestation of Ewing’s sarcoma imposes diagnostic confusion, but the case fulfilled the extraosseous Ewing sarcoma’s diagnostic characteristic. The Ewing’s sarcoma/PNET of the prostate being rare and posing a poor prognosis needs vigilant differential diagnosis and a multidisciplinary treatment approach for optimal and cost-effective treatments.

Late Morbidity and Mortality after Autologous Blood or Marrow Transplantation (BMT) for Lymphoma in Children, Adolescents and Young Adults - a Report from the BMT Survivor Study (BMTSS)

Introduction: Autologous BMT is an integral part of consolidation and/or salvage therapy for children, adolescents and young adults with Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). However, there is paucity of information regarding the long-term outcome after autologous BMT for lymphoma performed in this age group. We address this gap by leveraging the BMTSS to determine the magnitude of risk of chronic health conditions as well as cause-specific late mortality in patients undergoing autologous BMT for lymphoma between 1980 and 2014 at City of Hope, University of Minnesota or University of Alabama at Birmingham. Methods: To be included in this analysis, patients had to have received a single or tandem autologous BMT before age 40y and survived ≥2y after transplantation. BMT recipients (n=583 [HL: 59.7%; NHL: 40.3%]) and a sibling comparison group (n=330) completed a 255-item survey, and self-reported sociodemographics and chronic health conditions. A severity score (grade 3 [severe], 4 [life threatening] or 5 [fatal]) was assigned to the conditions using CTCAE v5.0. Vital status and cause of death information was ascertained using the National Death Index (NDI), medical records and Accurint databases. Logistic regression estimated the odds of grade 3-4 conditions in BMT recipients alive at study participation compared to siblings. Fine-Gray regression estimated the hazard of grades 3-5 chronic health conditions among BMT recipients (alive and deceased), treating death as a competing risk. Results: Median age at BMT was 30.0y (range: 2.0-39.0); median length of follow-up was 9.6y (2.0-32.1) and median age at study participation was 41.1y (13.7-67.1). Severe/life-threatening chronic health conditions in BMT survivors compared with siblings: By age 45y, the cumulative incidence of a grade 3-4 chronic health condition was 31.2% (95%CI; 25.5-37.0) among the BMT survivors and 12.9% (95%CI; 8.8-17.7) among the siblings (p<0.0001) (Figure 1). BMT survivors were at a 3.2-fold greater odds of a grade 3-4 condition (aOR=3.2, 95%CI=2.2-4.8) compared to siblings. Greater odds were observed among BMT survivors vs. siblings for the following conditions: joint replacement (OR=4.9, 95%CI=1.7-13.7), cataract (OR=4.2; 95%CI=1.4-13.0), cardiovascular disease (OR=2.2, 95%CI=1.2-4.0), and multiple conditions (OR=4.9; 95%CI=2.6-9.5). Severe/life-threatening/fatal chronic health conditions among BMT recipients: The 20y cumulative incidence of grade 3-5 conditions for the entire cohort was 46.8% (95%CI=41.6-51.7%). The 20y cumulative incidence was 42.1% (95%CI=34.2-49.7%) for patients with NHL and 49.6% (95%CI=42.9-56.0%) for patients with HL, placing HL patients at a 1.4-fold higher adjusted hazard of grade 3-5 conditions (95%CI=1.0-1.8, p=0.0232). Late mortality in BMT survivors: Conditional on surviving the first 2y after BMT, the all-cause mortality rate was 54.3% (95%CI=48.8-59.4%) at 25y from BMT (HL: 62.6%; NHL: 42.3%). The adjusted hazards of all-cause mortality were higher in HL patients (HR=1.8, 95%CI, 1.3-2.4; reference: NHL), and among Black patients (HR=3.0, 95%CI, 1.9-4.6; reference: non-Hispanic white). Causes of death were available for 84% of the cohort, and included primary disease (35%), subsequent neoplasm (16%), infection (13%), cardiac disease (8%), pulmonary disease (3%), and homicide/suicide/accident (3%). As shown in Figure 2, relapse-related mortality (RRM) plateaued after 20y from BMT, whereas the non-relapse-related mortality (NRM) continued to climb, crossing RRM at 20y from BMT. The 25y cumulative incidence of RRM was 28% (95%CI=22-34%), while that for NRM was 37% (95%CI=31-44%). Patients with HL were at increased risk for RRM (HR=2.3, 95%CI=1.3-3.8, p=0.0029; reference: NHL). The hazard of NRM was greater among HL patients (HR=1.7, 95%CI=1.1-2.7), and Black patients (HR=3.1, 1.5-6.4; reference: non-Hispanic white). Conclusions: The burden of severe/life-threatening chronic health conditions was 3-fold higher in autologous BMT recipients for lymphoma when compared with a non-BMT sibling comparison group. Patients with HL were at increased risk of a severe/life-threatening/fatal conditions as well as late mortality, when compared to patients with NHL. Finally, Black patients were at a higher risk for non-relapse-related mortality. These findings suggest a need for long-term surveillance among the vulnerable sub-populations. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Epigenetic Age Acceleration and Risk for Chronic Health Conditions in a Diverse Cohort of Survivors of Childhood Acute Lymphoblastic Leukemia

Background: Survivors of childhood cancer are at risk for multiple treatment related morbidities, including the early onset of chronic health conditions (CHC) that are late effects of cancer treatment. Epigenetic age acceleration (EAA), i.e., DNA methylation (DNAm)-predicted age in excess of chronologic age, characterizes survivors of childhood cancer vs. controls that have no cancer history and is suggestive of premature, accelerated aging in this population. Further, among these survivors, greater EAA is associated with cardiometabolic, pulmonary, and neurologic late effects of cancer treatment. We examined the relationship between EAA and CHC in a diverse cohort of survivors of childhood leukemia, to better understand the impact of DNAm on outcome disparities. Approach: The study population included survivors of acute lymphoblastic leukemia (ALL) diagnosed at Texas Children's Hospital between 1992 and 2013 and seen at least once in the Texas Children's Cancer Center Long-Term Survivor Clinic. Demographics, diagnosis, treatment data, and date of onset and type of CHC were abstracted from the electronic health record. CHCs were defined as diagnoses attributed to the patient in the medical record and present for ≥ 1 year. CHCs were categorized by system. Germline DNA was obtained from survivors at least one year off therapy, and analyzed on an iScan System by Illumina MethylationEPIC BeadChip array in the Baylor College of Medicine Lab for Translational Genomics. Methylation data were processed using minfi, normalized with noob, and EAA estimated using the Horvath calculator. Clinical determinants of EAA were identified overall and at specified time periods after the completion of therapy using multivariable linear regression. The relationship between EAA and CHCs were assessed by multivariable Cox regression in a subset of Hispanics and non-Hispanic White (NHW) survivors. All analyses were adjusted for age at diagnosis, age at follow-up, Hispanic ethnicity yes/no, alkylator yes/no, anthracycline yes/no, and cranial radiation therapy (CRT) yes/no. Results: Cases included 268 survivors of ALL: 174 Hispanic, 156 NHW, 29 Black, 6 Asian, and 3 multi-racial. Younger age at diagnosis was associated with endocrine CHC (OR 0.84, 95% CI 0.70, 1.00) and neuropsychiatric CHC, specifically communication disorder (OR 0.82, 95% CI 0.67, 1.00). Older age at diagnosis was associated with obesity (OR 1.14, 95% CI 1.02, 1.28) and depression (OR 1.16, 95% CI 1.02, 1.33). Hispanics were more likely than NHW to have communication disorder (OR 2.92, 95% CI 1.03, 8.27) and learning disability (OR 2.48, 95% CI 1.03, 5.98). EAA was estimated in 171 samples obtained from 96 Hispanics and 75 NHW that were an average of 9.0 years from diagnosis (range: 1.3-21.9y) and stratified into time periods in survivorship: 3-7 years from diagnosis (n=53), 7-13 years from diagnosis (n=73), and >13 years from diagnosis (n=32). CRT was the only factor associated with EAA, including at both the early (beta 3.30, SE 1.31) and late (beta 5.13, SE 1.71) time points. Although EAA did not differ significantly between Hispanics and NHW, Hispanics exposed to CRT demonstrated a more than 4 year increase in EAA (beta=4.47 EAA years, p-value=0.0002), with a null effect on EAA in NHW (Table 1). The relationship between EAA and CHC differed in early vs. late survivorship. In adjusted analyses, EAA determined from samples obtained 3-7 years from diagnosis was associated with any neuropsychiatric CHC, and specifically with learning disability (HR: 1.44, 95% CI: 1.10, 1.87). In contrast, EAA determined from samples obtained >7 years from diagnosis was associated with a greater risk for obesity (HR: 1.21, 95% CI: 1.04, 1.42) and a lower risk for osteopenia (HR: 0.83, 95% CI: 0.70, 0.98). Conclusions: Results from this study confirm prior work indicating an association between EAA and risk for CHC in survivors of childhood cancer. In addition, our findings indicate that the relationship between EAA and specific CHC changes in early vs. late survivorship. Moreover, EAA results in Hispanics vs. NHW suggest a differential response to treatment exposures by survivor ethnicity, specifically with respect to CRT. Future directions of this work include validation of these findings in a diverse, multi-institutional survivor cohort. Table 1: Linear regression model of EAA in Hispanic and Non-Hispanic White survivors of ALL Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Long-term diagnosis-specific sickness absence, disability pension, and healthcare use in 1305 young adult childhood cancer survivors and in 6430 references; a Swedish ten-year prospective cohort study.

BackgroundChildhood cancer survivors (CCS) are at high risk of chronic health conditions. We aimed to explore young adult CCS’ and matched references’ future diagnoses-specific healthcare use, sickness absence (SA), and disability pension (DP).MethodsWe performed a prospective cohort study with microdata from seven nationwide Swedish registers. We included 1305 young adult CCS born 1983–1988 and living in Sweden in 2008 and 6430 matched references and followed them for ten years (2009–2018) regarding mean annual specialized outpatient visits, inpatient days, and SA (spells >14 days) and/or DP (SADP) days, overall and by eight diagnostic groups. Risk factors for >90 SADP days in 2018 were explored as odds ratios (OR) with 95% confidence intervals (CI) by adjusted logistic regression.ResultsApproximately 80% of CCS and 90% of references did not have SADP in the ten-year follow-up. Mean SADP days/year was higher among CCS (40–50 days/year), particularly in CNS tumor survivors (76–83 days/year), compared to references (12–18 days/year). Most SADP days were DP days. CCS had more mean outpatient visits (1.6–1.8 visits/year) and inpatient days (0.8–1.7 days/year) than references (0.8–1.2 visits/year and 0.6–0.75 days/year, respectively). The main healthcare use and SADP diagnoses were neoplasms and psychiatric disorders among all CCS, along with nervous system and endocrine conditions among CNS tumor survivors. The risk of SADP >90 days in 2018 was higher among female compared to male CCS (OR = 2.34, 95% CI 1.67–3.32), those with elementary schooling compared to high school/university education (OR = 6.52, 95% CI 4.49–9.49), and survivors of CNS tumors compared to other malignancies (OR hematological versus CNS = 2.88, 95% CI 1.95–4.28; OR hematological versus non-CNS solid tumors = 0.71, 95% CI 0.45–1.09).ConclusionsMost CCS did not have SADP as young adults; nevertheless, their risk of SADP was higher than among matched references. CNS tumor survivors were at particularly high risk of SADP.