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Advani SD, Turner NA, North R, Moehring RW, Vaughn VM, Scales CD, Siddiqui NY, Schmader KE, Anderson DJ. Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections. J Urol 2024; 211:690-698. [PMID: 38330392 PMCID: PMC11003824 DOI: 10.1097/ju.0000000000003874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. MATERIALS AND METHODS This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme. RESULTS Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms. CONCLUSIONS Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.
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Affiliation(s)
- Sonali D Advani
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nicholas A Turner
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca North
- Duke Aging Center, Duke University School of Medicine, Durham, North Carolina
| | - Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Charles D Scales
- Department of Urology, Duke University School of Medicine, Durham, North Carolina
- Department Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Nazema Y Siddiqui
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Kenneth E Schmader
- Duke Aging Center, Duke University School of Medicine, Durham, North Carolina
- Durham VA Medical Center, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Gray SL, Brandt N, Schmader KE, Hanlon JT. Medication use quality and safety in older adults: 2022 update. J Am Geriatr Soc 2024; 72:1329-1337. [PMID: 38038490 PMCID: PMC11090755 DOI: 10.1111/jgs.18684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023]
Abstract
Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high-quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in-hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open-label parallel controlled trial in 39 Australian aged-care facilities to examine the effectiveness of a pharmacist-led intervention to reduce medication-induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Shelly L Gray
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Nicole Brandt
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Kenneth E Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Joseph T Hanlon
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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3
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Whitson HE, Banks WA, Diaz MM, Frost B, Kellis M, Lathe R, Schmader KE, Spudich SS, Tanzi R, Garden G. New approaches for understanding the potential role of microbes in Alzheimer's disease. Brain Behav Immun Health 2024; 36:100743. [PMID: 38435720 PMCID: PMC10906156 DOI: 10.1016/j.bbih.2024.100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Alzheimer's disease (AD) involves a complex pathological process that evolves over years, and its etiology is understood as a classic example of gene-environment interaction. The notion that exposure to microbial organisms may play some role in AD pathology has been proposed and debated for decades. New evidence from model organisms and -omic studies, as well as epidemiological data from the recent COVID-19 pandemic and widespread use of vaccines, offers new insights into the "germ hypothesis" of AD. To review new evidence and identify key research questions, the Duke/University of North Carolina (Duke/UNC) Alzheimer's Disease Research Center hosted a virtual symposium and workshop: "New Approaches for Understanding the Potential Role of Microbes in Alzheimer's disease." Discussion centered around the antimicrobial protection hypothesis of amyloid accumulation, and other mechanisms by which microbes could influence AD pathology including immune cell activation, changes in blood-brain barrier, or direct neurotoxicity. This summary of proceedings reviews the content presented in the symposium and provides a summary of major topics and key questions discussed in the workshop.
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Affiliation(s)
- Heather E. Whitson
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Busse Bldg Rm 3502, Durham, NC, 27710, USA
- Durham VA Medical Center, Geriatric Research Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA
| | - William A. Banks
- Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
| | - Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill, 170 Manning Dr, CB 7025, Chapel Hill, NC, 27599, USA
| | - Bess Frost
- Barshop Institute for Longevity & Aging Studies, 4939 Charles Katz Rm 1041, University of Texas Health San Antonio, San Antonio, TX, 78229, USA
| | - Manolis Kellis
- Computer Science and Artificial Intelligence Lab, Massachusetts Institute of Technology, 32 Vassar St., Cambridge, MA, 02139, USA
| | - Richard Lathe
- Division of Infection Medicine, University of Edinburgh Medical School, Edinburgh BioQuarter, Little France, Edinburgh, EH16 4SB, UK
| | - Kenneth E. Schmader
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Busse Bldg Rm 3502, Durham, NC, 27710, USA
- Durham VA Medical Center, Geriatric Research Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA
| | - Serena S. Spudich
- Department of Neurology, Yale University School of Medicine, 300 George Street, Room 8300, New Haven, CT, 06510, USA
| | - Rudolph Tanzi
- Genetics and Aging Research Unit, Massachusetts General Hospital, 114 16th Street, Charlestown, MA, 02129, USA
| | - Gwenn Garden
- University of North Carolina - Dept of Neurology, 170 Manning Drive, Campus Box 7025, Chapel Hill, NC, 27599-7025, USA
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Jackson LA, Stapleton JT, Walter EB, Chen WH, Rouphael NG, Anderson EJ, Neuzil KM, Winokur PL, Smith MJ, Schmader KE, Swamy GK, Thompson AB, Mulligan MJ, Rostad CA, Cross K, Tsong R, Wegel A, Roberts PC. Immunogenicity and safety of varying dosages of a fifth-wave influenza A/H7N9 inactivated vaccine given with and without AS03 adjuvant in healthy adults. Vaccine 2024; 42:295-309. [PMID: 38105137 PMCID: PMC10790638 DOI: 10.1016/j.vaccine.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/25/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Human infections with the avian influenza A(H7N9) virus were first reported in China in 2013 and continued to occur in annual waves. In the 2016/2017 fifth wave, Yangtze River Delta (YRD) lineage viruses, which differed antigenically from those of earlier waves, predominated. METHODS In this phase 2 double-blinded trial we randomized 720 adults ≥ 19 years of age to receive two injections of a YRD lineage inactivated A/Hong Kong/125/2017 fifth-wave H7N9 vaccine, given 21 days apart, at doses of 3.75, 7.5, and 15 µg of hemagglutinin (HA) with AS03A adjuvant and at doses of 15 and 45 µg of HA without adjuvant. RESULTS Two doses of adjuvanted vaccine were required to induce HA inhibition (HI) antibody titers ≥ 40 in most participants. After two doses of the 15 µg H7N9 formulation, given with or without AS03 adjuvant, the proportion achieving a HI titer ≥ 40 against the vaccine strain at 21 days after the second vaccination was 65 % (95 % CI, 57 %-73 %) and 0 % (95 % CI, 0 %-4%), respectively. Among those who received two doses of the 15 µg adjuvanted formulation the proportion with HI titer ≥ 40 at 21 days after the second vaccination was 76 % (95 % CI, 66 %-84 %) in those 19-64 years of age and 49 % (95 % CI, 37 %-62 %) in those ≥ 65 years of age. Responses to the adjuvanted vaccine formulations did not vary by HA content. Antibody responses declined over time and responses against drifted H7N9 strains were diminished. Overall, the vaccines were well tolerated but, as expected, adjuvanted vaccines were associated with more frequent solicited systemic and local adverse events. CONCLUSIONS AS03 adjuvant improved the immune responses to an inactivated fifth-wave H7N9 influenza vaccine, particularly in younger adults, but invoked lower responses to drifted H7N9 strains. These findings may inform future influenza pandemic preparedness strategies.
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Affiliation(s)
- Lisa A Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Jack T Stapleton
- Departments of Internal Medicine and Microbiology and Immunology, University of Iowa, Iowa City, IA, USA
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Wilbur H Chen
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nadine G Rouphael
- Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Evan J Anderson
- Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patricia L Winokur
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Michael J Smith
- Duke Human Vaccine Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine and GRECC, Durham VA Health Care System, Durham, NC, USA
| | - Geeta K Swamy
- Duke Human Vaccine Institute and Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Amelia B Thompson
- Duke Human Vaccine Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Mark J Mulligan
- Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Christina A Rostad
- Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | - Paul C Roberts
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
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5
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Hanlon JT, Schmader KE. Use of new STOPP/START criteria in the care of older adults. J Am Geriatr Soc 2024; 72:318-320. [PMID: 37795884 DOI: 10.1111/jgs.18613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 10/06/2023]
Abstract
This article comments on the article by Rochon et al. in this issue.
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Affiliation(s)
- Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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6
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Schmader KE, Liu CK, Flannery B, Rountree W, Auerbach H, Barnett ED, Schlaudecker EP, Todd CA, Poniewierski M, Staat MA, Harrington T, Li R, Broder KR, Walter EB. Immunogenicity of adjuvanted versus high-dose inactivated influenza vaccines in older adults: a randomized clinical trial. Immun Ageing 2023; 20:30. [PMID: 37393237 DOI: 10.1186/s12979-023-00355-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Adjuvanted inactivated influenza vaccine (aIIV) and high-dose inactivated influenza vaccine (HD-IIV) are U.S.-licensed for adults aged ≥ 65 years. This study compared serum hemagglutination inhibition (HAI) antibody titers for the A(H3N2) and A(H1N1)pdm09 and B strains after trivalent aIIV3 and trivalent HD-IIV3 in an older adult population. RESULTS The immunogenicity population included 342 participants who received aIIV3 and 338 participants who received HD-IIV3. The proportion of participants that seroconverted to A(H3N2) vaccine strains after allV3 (112 participants [32.8%]) was inferior to the proportion of participants that seroconverted after HD-IIV3 (130 participants [38.5%]) at day 29 after vaccination (difference, - 5.8%; 95%CI, - 12.9% to 1.4%). There were no significant differences between the vaccine groups in percent seroconversion to A(H1N1)pdm09 or B vaccine strains, in percent seropositivity for any of the strains, or in post-vaccination GMT for the A(H1N1)pdm09 strain. The GMTs for the post-vaccination A(H3N2) and B strains were higher after HD-IIV than after aIIV3. CONCLUSIONS Overall immune responses were similar after aIIV3 and HD-IIV3. For the primary outcome, the aIIV3 seroconversion rate for H3N2 did not meet noninferiority criteria compared with HD-IIV3, but the HD-IIV3 seroconversion rate was not statistically superior to the aIIV3 seroconversion rate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03183908.
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Affiliation(s)
- Kenneth E Schmader
- Division of Geriatrics, Department of Medicine and Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA.
- Geriatric Research Education and Clinical Center (GRECC), Durham VA Health Care System, Box 3003, Durham, NC, 27710, USA.
| | - Christine K Liu
- Section of Geriatrics, Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Geriatric Research and Education Clinical Center (GRECC), Palo Alto Veterans Affairs Health Care System, Palo Alto, CA, USA
- Geriatrics Section, Department of Medicine, School of Medicine and Boston Medical Center, Boston University, Chobanian & Avedisian, Boston, MA, USA
| | - Brendan Flannery
- Infuenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Wes Rountree
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Heidi Auerbach
- Geriatrics Section, Department of Medicine, School of Medicine and Boston Medical Center, Boston University, Chobanian & Avedisian, Boston, MA, USA
| | - Elizabeth D Barnett
- Department of Pediatrics, Section of Pediatric Infectious Diseases, School of Medicine and Boston Medical Center, Boston University, Chobanian & Avedisian, Boston, MD, USA
| | - Elizabeth P Schlaudecker
- Department of Pediatrics Division of Infectious Diseases, University of Cincinnati College of Medicine and Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | - Christopher A Todd
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Marek Poniewierski
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Mary A Staat
- Department of Pediatrics Division of Infectious Diseases, University of Cincinnati College of Medicine and Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | - Theresa Harrington
- Immunization Safety Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Rongxia Li
- Immunization Safety Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Karen R Broder
- Immunization Safety Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Joseph J, Pajewski NM, Dolor RJ, Ann Sellers M, Perdue LH, Peeples SR, Henrie AM, Woolard N, Jones WS, Benziger CP, Orkaby AR, Mixon AS, VanWormer JJ, Shapiro MD, Kistler CE, Polonsky TS, Chatterjee R, Chamberlain AM, Forman DE, Knowlton KU, Gill TM, Newby LK, Hammill BG, Cicek MS, Williams NA, Decker JE, Ou J, Rubinstein J, Choudhary G, Gazmuri RJ, Schmader KE, Roumie CL, Vaughan CP, Effron MB, Cooper-DeHoff RM, Supiano MA, Shah RC, Whittle JC, Hernandez AF, Ambrosius WT, Williamson JD, Alexander KP. Pragmatic evaluation of events and benefits of lipid lowering in older adults (PREVENTABLE): Trial design and rationale. J Am Geriatr Soc 2023; 71:1701-1713. [PMID: 37082807 PMCID: PMC10258159 DOI: 10.1111/jgs.18312] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 04/22/2023]
Abstract
Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double-blind, placebo-controlled randomized pragmatic clinical trial, will compare high-intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community-dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site-reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co-secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.
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Affiliation(s)
| | | | - Rowena J. Dolor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Mary Ann Sellers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Adam M. Henrie
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Albuquerque, NM
| | - Nancy Woolard
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Ariela R. Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, and Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
| | - Amanda S. Mixon
- Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
| | | | | | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC
| | | | - Ranee Chatterjee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Daniel E. Forman
- Department of Medicine, Sections of Geriatrics and Cardiology, University of Pittsburgh; Pittsburgh GRECC, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | | | - L. Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Bradley G. Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Jake E. Decker
- Section of Primary Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jiafu Ou
- Cardiology Division, John Cochran VA Medical Center and Cardiology Division, Washington University School of Medicine, St. Louis, MO
| | - Jack Rubinstein
- Division of Cardiology, Cincinnati VAMC and Division of Cardiovascular Diseases, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Gaurav Choudhary
- Providence VA Medical Center, and Lifespan Cardiovascular Institute, and Alpert Medical School of Brown University, Providence RI
| | - Raúl J. Gazmuri
- Captain James A. Lovell Federal Health Care Center and Rosalind Franklin University of Medicine and Science, Chicago, IL
| | | | - Christianne L. Roumie
- Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
| | - Camille P. Vaughan
- Birmingham/Atlanta Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs, and Division of Geriatrics & Gerontology, Department of Medicine, Emory University, Atlanta, GA
| | - Mark B. Effron
- John Ochsner Heart and Vascular Institute, The University of Queensland Ochsner Clinical School, New Orleans, LA
| | | | | | - Raj C. Shah
- Family & Preventive Medicine and the Rush Alzheimer’s Disease Center, Rush University, Chicago, IL
| | | | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Karen P. Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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8
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Advani SD, Turner NA, Schmader KE, Wrenn RH, Moehring RW, Polage CR, Vaughn VM, Anderson DJ. Optimizing reflex urine cultures: Using a population-specific approach to diagnostic stewardship. Infect Control Hosp Epidemiol 2023; 44:206-209. [PMID: 36625063 PMCID: PMC9931665 DOI: 10.1017/ice.2022.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Clinicians and laboratories routinely use urinalysis (UA) parameters to determine whether antimicrobial treatment and/or urine cultures are needed. Yet the performance of individual UA parameters and common thresholds for action are not well defined and may vary across different patient populations. METHODS In this retrospective cohort study, we included all encounters with UAs ordered 24 hours prior to a urine culture between 2015 and 2020 at 3 North Carolina hospitals. We evaluated the performance of relevant UA parameters as potential outcome predictors, including sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also combined 18 different UA criteria and used receiver operating curves to identify the 5 best-performing models for predicting significant bacteriuria (≥100,000 colony-forming units of bacteria/mL). RESULTS In 221,933 encounters during the 6-year study period, no single UA parameter had both high sensitivity and high specificity in predicting bacteriuria. Absence of leukocyte esterase and pyuria had a high NPV for significant bacteriuria. Combined UA parameters did not perform better than pyuria alone with regard to NPV. The high NPV ≥0.90 of pyuria was maintained among most patient subgroups except females aged ≥65 years and patients with indwelling catheters. CONCLUSION When used as a part of a diagnostic workup, UA parameters should be leveraged for their NPV instead of sensitivity. Because many laboratories and hospitals use reflex urine culture algorithms, their workflow should include clinical decision support and or education to target symptomatic patients and focus on populations where absence of pyuria has high NPV.
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Affiliation(s)
- Sonali D Advani
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nicholas A Turner
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke and Durham VA Medical Center, Durham, North Carolina
| | - Rebekah H Wrenn
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebekah W Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Polage
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Deverick J Anderson
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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9
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Neuzil KM, Anderson EJ, Frenck RW, Frey SE, Walter EB, Rupp R, Rotrosen ET, Rouphael NG, Brady RC, Graham I, Schmader KE, Porterfield L, Ortiz JR, Swamy GK, El Sahly HM, Jeevan T, Sitaula R, Wegel A, Webby RJ, Bryant C. Safety and Immunogenicity of Influenza A/H5N8 Virus Vaccine in Healthy Adults: Durability and Cross-reactivity of Antibody Responses. Clin Infect Dis 2023:ciac982. [PMID: 36610728 DOI: 10.1093/cid/ciac982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/14/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Influenza A/H5N8 viruses infect poultry and wild birds in many countries. In 2021, the first human A/H5N8 cases were reported. METHODS We conducted a phase I, cohort-randomized, double-blind, controlled trial of inactivated influenza A/H5N8 vaccine (clade 2.3.4.4c) administered with or without adjuvant. Cohort 1 subjects received either two doses of AS03-adjuvanted vaccine containing 3.75 μg or 15 μg hemagglutinin (HA); two doses of 15 μg HA unadjuvanted vaccine; or one dose of AS03-adjuvanted vaccine (3.75 μg or 15 μg HA), followed by one dose of non-adjuvanted vaccine (same HA content). Cohort 2 subjects received two doses of MF59-adjuvanted vaccine containing 3.75 μg or 15 μg HA, or 15 μg HA of non-adjuvanted vaccine. Subjects were followed for 13 months for safety and immunogenicity. RESULTS We enrolled 386 adult subjects in good health. Solicited adverse events were generally mild and more common among subjects who received adjuvanted vaccines. Antibody responses (hemagglutination inhibition or microneutralization assays) were highest in the two-dose AS03 group, followed by the one-dose AS03 group, the MF59 groups, and the non-adjuvanted groups. Antibody levels returned to baseline 12 months after the second vaccination in all groups except the 15 μg AS03-adjuvanted group. Cross-reactive antibodies to clade 2.3.4.4b strains isolated from recent human cases were demonstrated in a subset of both 15 μg adjuvanted groups. CONCLUSIONS Two doses of influenza A/H5N8 vaccine were well-tolerated. Immunogenicity improved with receipt of two doses of adjuvanted vaccine and higher antigen content. (Funded by the National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MD, USA
| | - Evan J Anderson
- Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sharon E Frey
- Center for Vaccine Development, Saint Louis University, St. Louis, MO, USA
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Richard Rupp
- Sealy Institute for Vaccine Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Elizabeth T Rotrosen
- Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MD, USA
| | - Nadine G Rouphael
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Irene Graham
- Center for Vaccine Development, Saint Louis University, St. Louis, MO, USA
| | - Kenneth E Schmader
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Laura Porterfield
- Sealy Institute for Vaccine Sciences, University of Texas Medical Branch, TX, USA
| | - Justin R Ortiz
- Center for Vaccine Development and Global Health, University of Maryland, Baltimore, MD, USA
| | - Geeta K Swamy
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Hana M El Sahly
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
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10
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Hemmersbach-Miller M, Balevic SJ, Winokur PL, Landersdorfer CB, Gu K, Chan AW, Cohen-Wolkowiez M, Conrad T, An G, Kirkpatrick CMJ, Swamy GK, Walter EB, Schmader KE. Population Pharmacokinetics of Piperacillin/Tazobactam Across the Adult Lifespan. Clin Pharmacokinet 2023; 62:127-139. [PMID: 36633812 PMCID: PMC9969806 DOI: 10.1007/s40262-022-01198-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Piperacillin/tazobactam is one of the most frequently used antimicrobials in older adults. Using an opportunistic study design, we evaluated the pharmacokinetics of piperacillin/tazobactam as a probe drug to evaluate changes in antibacterial drug exposure and dosing requirements, including in older adults. METHODS A total of 121 adult patients were included. The population pharmacokinetic models that best characterized the observed plasma concentrations of piperacillin and tazobactam were one-compartment structural models with zero-order input and linear elimination. RESULTS Among all potential covariates, estimated creatinine clearance had the most substantial impact on the elimination clearance for both piperacillin and tazobactam. After accounting for renal function and body size, there was no remaining impact of frailty on the pharmacokinetics of piperacillin and tazobactam. Monte Carlo simulations indicated that renal function had a greater impact on the therapeutic target attainment than age, although these covariates were highly correlated. Frailty, using the Canadian Study of Health and Aging Clinical Frailty Scale, was assessed in 60 patients who were ≥ 65 years of age. CONCLUSIONS The simulations suggested that adults ≤ 50 years of age infected with organisms with higher minimum inhibitory concentrations may benefit from continuous piperacillin/tazobactam infusions (12 g/day of piperacillin component) or extended infusions of 4 g every 8 hours. However, for a target of 50% fT + minimum inhibitory concentration, dosing based on renal function is generally preferable to dosing by age, and simulations suggested that patients with creatinine clearance ≥ 120 mL/min may benefit from infusions of 4 g every 8 hours for organisms with higher minimum inhibitory concentrations.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- ICON Plc, North Wales, PA, USA
| | - Stephen J Balevic
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Division of Rheumatology and Immunology, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Patricia L Winokur
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Kenan Gu
- Division of Microbiology and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Austin W Chan
- Division of Infectious Diseases, Department of Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Guohua An
- College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Carl M J Kirkpatrick
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Geeta K Swamy
- Department of Obstetrics and Gynecology, Obstetrics Clinical Research, Duke University Medical System, Durham, NC, USA
| | - Emmanuel B Walter
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Duke Box 3469, Durham, NC, 27710, USA.
- Geriatric Research Education and Clinical Center (GRECC), Durham Veterans Affairs Health Care System, Durham, NC, USA.
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11
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Advani SD, Turner NA, Schmader KE, Wrenn R, Moehring RW, Polage CR, Vaughn V, Anderson DJ. 190. Performance of urinalysis parameters in predicting significant bacteriuria: Making the case for a population-specific approach to diagnostic stewardship. Open Forum Infect Dis 2022. [PMCID: PMC9752402 DOI: 10.1093/ofid/ofac492.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Clinicians and laboratories routinely use urinalysis (UA) results to help determine if urine cultures and/or antimicrobials are indicated. Yet, the performance of individual UA parameters and common clinical thresholds for action are not well defined and may vary across different patient populations. Our objective was to compare the performance of different UA parameters in predicting significant bacteriuria irrespective of symptoms, and to assess performance of pyuria based on age, sex, and presence of indwelling catheter. Methods This retrospective review of UA and urine culture data from the Duke University Health System included all UAs ordered within 24 hours of a urine culture between 2015 and 2020 (no reflex urine cultures included). We defined significant bacteriuria as a urine culture with ≥1 uropathogen growing at ≥100,000 colony forming units/mL. Then, we used this definition to evaluate the performance of relevant UA parameters and result thresholds including sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). We also combined 18 different UA criteria (as shown in Figure) and used receiver operating characteristic (ROC) curves to identify the top 5 performing models for predicting significant bacteriuria (sensitivity and specificity). 18 Different Combinations of UA Parameters for Predicting Significant Bacteriuria on Urine Cultures
![]() Results Of 240,195 encounters during the 6-year study period, 38% were outpatient and 62% were inpatient. Twenty-nine percent had a urine culture with significant bacteriuria; 30.7% had a negative urine culture. No single UA parameter had both - high sensitivity and high specificity in predicting bacteriuria. Trace leukocyte esterase and low-level pyuria had a high NPV for significant bacteriuria (Table 1A). Combined UA parameters did not perform better than pyuria alone (Table 1B). The high NPV >=0.90 of pyuria was maintained among most patient age and sex subgroups with the exception of females ≥65 and patients with indwelling catheters (Table 2).
Performance of UA parameters in predicting significant bacteriuria, Table 1B: Best performing models by AUROC after testing 18 models ![]() ![]() Conclusion UA parameters should be leveraged for their NPV instead of sensitivity, when used as a part of diagnostic workup. Future reflex urine culture workflows and diagnostic stewardship algorithms should incorporate population-specific UA criteria and/or focus on populations where NPV of pyuria is high. Disclosures Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant Nicholas A. Turner, MD, MHSc, Aperio: Advisor/Consultant Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Valerie Vaughn, MD, MSc, Thermo Fisher Scientific: Honoraria.
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12
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Porter LS, Weiner DK, Ramos K, Barnes DE, Schmader KE, Gwyther L, Ritchie CS, Keefe FJ. Partnering to cope with pain: A pilot study of a caregiver-assisted pain coping skills intervention for patients with cognitive impairment and dementia. Palliat Support Care 2022; 20:785-793. [PMID: 36942584 PMCID: PMC10032330 DOI: 10.1017/s1478951521001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To develop a new caregiver-assisted pain coping skills training protocol specifically tailored for community-dwelling persons with cognitive impairment and pain, and assess its feasibility and acceptability. METHOD In Phase I, we conducted interviews with 10 patient-caregiver dyads to gather feedback about intervention content and delivery. Phase II was a single-arm pilot test to evaluate the intervention's feasibility and acceptability. Dyads in the pilot study (n = 11) completed baseline surveys, received five intervention sessions, and then completed post-intervention surveys. Analyses focused on feasibility and acceptability. RESULTS Dyads responded positively to the pain coping skills presented in the interviews; their feedback was used to refine the intervention. Findings from the pilot study suggested that the intervention was feasible and acceptable. 69% of eligible dyads consented, 82% completed all five intervention sessions, and 100% completed the post-treatment assessment. Caregivers reported high satisfaction ratings. They also reported using the pain coping skills on a regular basis, and that they found most of the skills helpful and easy to use. SIGNIFICANCE OF RESULTS These preliminary findings suggest that a caregiver-assisted pain coping skills intervention is feasible and acceptable, and that it may be a promising approach to managing pain in patients with cognitive impairment.
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Affiliation(s)
- Laura S Porter
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Debra K Weiner
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine Ramos
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Deborah E Barnes
- University of San Francisco, UCSF Weill Institute for Neurosciences, San Francisco, CA
| | - Kenneth E Schmader
- Department of Medicine, Duke University School of Medicine and GRECC, Durham VA Medical Center, Durham, NC
| | - Lisa Gwyther
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Christine S Ritchie
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Francis J Keefe
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC
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13
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Advani SD, Schmader KE, Mody L. Clin-Star corner: What's new at the interface of geriatrics, infectious diseases, and antimicrobial stewardship. J Am Geriatr Soc 2022; 70:2214-2218. [PMID: 35704918 PMCID: PMC9378540 DOI: 10.1111/jgs.17907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/01/2022] [Accepted: 03/29/2022] [Indexed: 12/18/2022]
Abstract
Antibiotics are among the leading causes of adverse drug events in older adults. Short-course antibiotic therapy has been shown to work as well as the traditional longer durations for many types of infections. Antibiotic stewardship interventions including deprescribing strategies have shown a reduction in patient readmissions and mortality among older adults. We identified practice-changing clinical trials focusing on three major domains of overprescribing antibiotics in older adults - community-acquired pneumonia, urinary tract infections, and gram-negative bacteremia. The selected articles underscore the safety and effectiveness of shorter durations of antibiotic treatment for infections in older adults, thus highlighting an opportunity for deprescribing in the aging population. By optimizing antibiotic use, we stand to reduce adverse events and enhance overall health outcomes in older adults.
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Affiliation(s)
- Sonali D Advani
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina, USA.,Geriatric Research and Education Clinical Center, Durham Veterans Administration Medical Center, Durham, North Carolina, USA
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Geriatric Research and Education Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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14
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Hanlon JT, Schmader KE. The Medication Appropriateness Index: A Clinimetric Measure. Psychother Psychosom 2022; 91:78-83. [PMID: 35158365 DOI: 10.1159/000521699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/24/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Joseph T Hanlon
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Kenneth E Schmader
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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15
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Eshetie TC, Marcum ZA, Schmader KE, Gray SL. Medication use quality and safety in older adults: 2020 update. J Am Geriatr Soc 2022; 70:389-397. [PMID: 34897654 PMCID: PMC8821136 DOI: 10.1111/jgs.17603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/03/2021] [Accepted: 11/13/2021] [Indexed: 02/03/2023]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12-week follow-up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population-based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Tesfahun C. Eshetie
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Zachary A. Marcum
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, NC
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shelly L. Gray
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
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16
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Jin W, Fang M, Sayin I, Smith C, Hunter JL, Richardson B, Golden JB, Haley C, Schmader KE, Betts MR, Tyring SK, Cameron CM, Cameron MJ, Canaday DH. Differential CD4+ T-Cell Cytokine and Cytotoxic Responses Between Reactivation and Latent Phases of Herpes Zoster Infection. Pathog Immun 2022; 7:171-188. [PMID: 36865570 PMCID: PMC9973729 DOI: 10.20411/pai.v7i2.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/17/2023] [Indexed: 02/19/2023] Open
Abstract
Background CD4+ T cells are a critical component of effective immune responses to varicella zoster virus (VZV), but their functional properties during the reactivation acute vs latent phase of infection remain poorly defined. Methods Here we assessed the functional and transcriptomic properties of peripheral blood CD4+ T cells in persons with acute herpes zoster (HZ) compared to those with a prior history of HZ infection using multicolor flow cytometry and RNA sequencing. Results We found significant differences between the polyfunctionality of VZV-specific total memory, effector memory, and central memory CD4+ T cells in acute vs prior HZ. VZV-specific CD4+ memory T-cell responses in acute HZ reactivation had higher frequencies of IFN-γ and IL-2 producing cells compared to those with prior HZ. In addition, cytotoxic markers were higher in VZV-specific CD4+ T cells than non-VZV-specific cells. Transcriptomic analysis of ex vivo total memory CD4+ T cells from these individuals showed differential regulation of T-cell survival and differentiation pathways, including TCR, cytotoxic T lymphocytes (CTL), T helper, inflammation, and MTOR signaling pathways. These gene signatures correlated with the frequency of IFN-γ and IL-2 producing cells responding to VZV. Conclusions In summary, VZV-specific CD4+ T cells from acute HZ individuals had unique functional and transcriptomic features, and VZV-specific CD4+ T cells as a group had a higher expression of cytotoxic molecules including Perforin, Granzyme-B, and CD107a.
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Affiliation(s)
- Wenjie Jin
- Division of Infectious Diseases Case Western Reserve University, Cleveland, OH.,Division of Infectious Diseases Case Western Reserve University, Cleveland, OH
| | - Mike Fang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Ismail Sayin
- Division of Infectious Diseases Case Western Reserve University, Cleveland, OH.,Division of Infectious Diseases and Geriatric Research, Education and Clinical Center (GRECC), Cleveland Veterans Administration Medical Center, Cleveland, OH
| | - Carson Smith
- Division of Infectious Diseases Case Western Reserve University, Cleveland, OH.,Division of Infectious Diseases and Geriatric Research, Education and Clinical Center (GRECC), Cleveland Veterans Administration Medical Center, Cleveland, OH
| | | | - Brian Richardson
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Jackelyn B Golden
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Christopher Haley
- Center for Clinical Studies and Department of Dermatology, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, NC
| | - Michael R Betts
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephen K Tyring
- Center for Clinical Studies and Department of Dermatology, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX
| | - Cheryl M Cameron
- Department of Nutrition, Case Western Reserve University, Cleveland, OH
| | - Mark J Cameron
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - David H Canaday
- Division of Infectious Diseases Case Western Reserve University, Cleveland, OH.,Division of Infectious Diseases and Geriatric Research, Education and Clinical Center (GRECC), Cleveland Veterans Administration Medical Center, Cleveland, OH
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17
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University, Durham, North Carolina
- Durham VA Health Care System, Durham, North Carolina
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18
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Herati RS, Silva LV, Vella LA, Muselman A, Alanio C, Bengsch B, Kurupati RK, Kannan S, Manne S, Kossenkov AV, Canaday DH, Doyle SA, Ertl HC, Schmader KE, Wherry EJ. Vaccine-induced ICOS +CD38 + circulating Tfh are sensitive biosensors of age-related changes in inflammatory pathways. Cell Rep Med 2021; 2:100262. [PMID: 34095875 PMCID: PMC8149371 DOI: 10.1016/j.xcrm.2021.100262] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 12/31/2020] [Accepted: 04/06/2021] [Indexed: 12/23/2022]
Abstract
Humoral immune responses are dysregulated with aging, but the cellular and molecular pathways involved remain incompletely understood. In particular, little is known about the effects of aging on T follicular helper (Tfh) CD4 cells, the key cells that provide help to B cells for effective humoral immunity. We performed transcriptional profiling and cellular analysis on circulating Tfh before and after influenza vaccination in young and elderly adults. First, whole-blood transcriptional profiling shows that ICOS+CD38+ cTfh following vaccination preferentially enriches in gene sets associated with youth versus aging compared to other circulating T cell types. Second, vaccine-induced ICOS+CD38+ cTfh from the elderly had increased the expression of genes associated with inflammation, including tumor necrosis factor-nuclear factor κB (TNF-NF-κB) pathway activation. Finally, vaccine-induced ICOS+CD38+ cTfh display strong enrichment for signatures of underlying age-associated biological changes. These data highlight the ability to use vaccine-induced cTfh as cellular “biosensors” of underlying inflammatory and/or overall immune health. Vaccine-induced ICOS+CD38+ cTfh show increased TNF-NF-κB signaling with aging TNF-NF-κB signaling is beneficial for cTfh survival in the elderly Vaccine-induced cTfh are sensors of background changes in immune environment
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Affiliation(s)
- Ramin Sedaghat Herati
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
- Department of Microbiology, New York University School of Medicine, New York, NY, USA
- Corresponding author
| | - Luisa Victoria Silva
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura A. Vella
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Cecile Alanio
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Bertram Bengsch
- Department of Internal Medicine II, University Medical Center Freiburg, and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany
| | | | | | - Sasikanth Manne
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | | | - David H. Canaday
- Division of Infectious Disease, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research, Education, and Clinical Center, Cleveland VA Medical Center, Cleveland, OH, 44195, USA
| | - Susan A. Doyle
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC 27710, USA
| | | | - Kenneth E. Schmader
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC 27710, USA
| | - E. John Wherry
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- Corresponding author
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19
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Andrew MK, Schmader KE, Rockwood K, Clarke B, McElhaney JE. Considering Frailty in SARS-CoV-2 Vaccine Development: How Geriatricians Can Assist. Clin Interv Aging 2021; 16:731-738. [PMID: 33953551 PMCID: PMC8088982 DOI: 10.2147/cia.s295522] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has disproportionately impacted frail older adults, especially residents of long-term care (LTC) facilities. This has appropriately led to prioritization of frail older adults and LTC residents, and those who care for them, in the vaccination effort against COVID-19. Older adults have distinct immunological, clinical, and practical complexity, which can be understood through a lens of frailty. Even so, frailty has not been considered in studies of COVID-19 vaccines to date, leading to concerns that the vaccines have not been optimally tailored for and evaluated in this population even as vaccination programs are being implemented. This is an example of how vaccines are often not tested in Phase 1/2/3 clinical trials in the people most in need of protection. We argue that geriatricians, as frailty specialists, have much to contribute to the development, testing and implementation of COVID-19 vaccines in older adults. We discuss roles for geriatricians in ten stages of the vaccine development process, covering vaccine design, trial design, trial recruitment, establishment and interpretation of illness definitions, safety monitoring, consideration of relevant health measures such as frailty and function, analysis methods to account for frailty and differential vulnerability, contributions in regulatory and advisory roles, post-marketing surveillance, and program implementation and public health messaging. In presenting key recommendations pertinent to each stage, we hope to contribute to a dialogue on how to push the field of vaccinology to embrace the complexity of frailty. Making vaccines that can benefit frail older adults will benefit everyone in the fight against COVID-19.
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Affiliation(s)
- Melissa K Andrew
- Department of Medicine, Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Halifax, Nova Scotia, Canada
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Kenneth Rockwood
- Department of Medicine, Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barry Clarke
- Department of Family Medicine, Dalhousie University, Halifax, Canada
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20
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Schmader KE, Levin MJ, Chen M, Matthews S, Riley ME, Woo W, Hervé C, Grupping K, Schuind AE, Oostvogels L, Curran D. Impact of Reactogenicity After Two Doses of Recombinant Zoster Vaccine Upon Physical Functioning and Quality of Life: An Open Phase III Trial in Older Adults. J Gerontol A Biol Sci Med Sci 2021; 76:485-490. [PMID: 32530462 PMCID: PMC7907492 DOI: 10.1093/gerona/glaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Herpes zoster may significantly impact quality of life (QoL) in older adults. The recombinant zoster vaccine (RZV) is efficacious in adults aged ≥50 and older and is associated with increased reactogenicity compared to placebo. We report here on the impact of reactogenicity of the second RZV dose on the QoL and physical functioning (PF) of vaccine recipients, and summarize findings following both doses. METHOD In this single-arm study, 401 adults aged ≥50 and older were enrolled to receive two RZV doses 2 months apart. Change in mean Short Form Survey-36 (SF-36) PF and EuroQol-5 Dimension (EQ-5D) scores, reactogenicity, safety, productivity loss, and healthcare resource utilization were evaluated. RESULTS In total, 391 (97.5%) participants received dose 2. Post-dose 2, the most common solicited local symptoms were injection site pain (75.1%), erythema (22.4%), and swelling (13.9%), and the most common systemic symptoms were fatigue (46.3%), headache (37.5%), and myalgia (32.9%). Grade 3 solicited (local and systemic) adverse events were reported by 61 (15.6%) participants and were associated with a transient clinically significant decrease in SF-36 PF score on Days 1-2 post-dose 2 that recovered by Day 3. Overall, no clinically important reduction in mean SF-36 PF scores was observed from baseline to post-dose 2 (mean change -0.4), and no quality-adjusted-life-year loss was recorded. CONCLUSIONS Overall, QoL and PF of RZV vaccinees were not affected by vaccine-related reactogenicity. A transient reduction was observed in the first 2 days after RZV vaccination in individuals with Grade 3 adverse events. No safety concerns were identified.
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Affiliation(s)
- Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, North Carolina
| | - Myron J Levin
- Departments of Pediatrics and Medicine, University of Colorado Anschutz Medical Campus, Aurora
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21
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2019 Update. J Am Geriatr Soc 2021; 69:336-341. [PMID: 33438206 PMCID: PMC11057223 DOI: 10.1111/jgs.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Nagham J. Ailabouni
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Zachary A. Marcum
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L. Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
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22
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Schmader KE, Liu CK, Harrington T, Rountree W, Auerbach H, Walter EB, Barnett ED, Schlaudecker EP, Todd CA, Poniewierski M, Staat MA, Wodi P, Broder KR. Safety, Reactogenicity, and Health-Related Quality of Life After Trivalent Adjuvanted vs Trivalent High-Dose Inactivated Influenza Vaccines in Older Adults: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2031266. [PMID: 33443580 PMCID: PMC7809592 DOI: 10.1001/jamanetworkopen.2020.31266] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Trivalent adjuvanted inactivated influenza vaccine (aIIV3) and trivalent high-dose inactivated influenza vaccine (HD-IIV3) are US-licensed for adults aged 65 years and older. Data are needed on the comparative safety, reactogenicity, and health-related quality of life (HRQOL) effects of these vaccines. OBJECTIVE To compare safety, reactogenicity, and changes in HRQOL scores after aIIV3 vs HD-IIV3. DESIGN, SETTING, AND PARTICIPANTS This randomized blinded clinical trial was a multicenter US study conducted during the 2017 to 2018 and 2018 to 2019 influenza seasons. Among 778 community-dwelling adults aged at least 65 years and assessed for eligibility, 13 were ineligible and 8 withdrew before randomization. Statistical analysis was performed from August 2019 to August 2020. INTERVENTIONS Intramuscular administration of aIIV3 or HD-IIV3 after age-stratification (65-79 years; ≥80 years) and randomization. MAIN OUTCOMES AND MEASURES Proportions of participants with moderate-to-severe injection-site pain and 14 other solicited reactions during days 1 to 8, using a noninferiority test (5% noninferiority margin), and serious adverse events (SAE) and adverse events of clinical interest (AECI), including new-onset immune-mediated conditions, during days 1 to 43. Changes in HRQOL scores before and after vaccination (days 1, 3) were also compared between study groups. RESULTS A total of 757 adults were randomized, 378 to receive aIIV3 and 379 to receive HD-IIV3. Of these participants, there were 420 women (55%) and 589 White individuals (78%) with a median (range) age of 72 (65-97) years. The proportion reporting moderate-to-severe injection-site pain, limiting or preventing activity, after aIIV3 (12 participants [3.2%]) (primary outcome) was noninferior compared with HD-IIV3 (22 participants [5.8%]) (difference -2.7%; 95% CI, -5.8 to 0.4). Ten reactions met noninferiority criteria for aIIV3; 4 (moderate-to-severe injection-site tenderness, arthralgia, fatigue, malaise) did not. It was inconclusive whether these 4 reactions occurred in higher proportions of participants after aIIV3. No participant sought medical care for a vaccine reaction. No AECI was observed. Nine participants had at least SAE after aIIV3 (2.4%; 95% CI,1.1% to 4.5%); 3 had at least 1 SAE after HD-IIV3 (0.8%; 95% CI, 0.2% to 2.2%). No SAE was associated with vaccination. Changes in prevaccination and postvaccination HRQOL scores were not clinically meaningful and not different between the groups. CONCLUSIONS AND RELEVANCE Overall safety and HRQOL findings were similar after aIIV3 and HD-IIV3, and consistent with prelicensure data. From a safety standpoint, this study's results support using either vaccine to prevent influenza in older adults. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03183908.
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Affiliation(s)
- Kenneth E. Schmader
- Center for the Study of Aging, Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | - Christine K. Liu
- Section of Geriatrics, Division of Primary Care and Population Health, Stanford University, Stanford, California
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Theresa Harrington
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wes Rountree
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi Auerbach
- Geriatrics Section, Boston Medical Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Emmanuel B. Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth D. Barnett
- Section of Pediatric Infectious Diseases, Boston Medical Center, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Elizabeth P. Schlaudecker
- Cincinnati Children’s Hospital and Medical Center, Department of Pediatrics Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chris A. Todd
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina
| | - Marek Poniewierski
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina
| | - Mary A. Staat
- Cincinnati Children’s Hospital and Medical Center, Department of Pediatrics Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patricia Wodi
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karen R. Broder
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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Curran D, Kim JH, Matthews S, Dessart C, Levin MJ, Oostvogels L, Riley ME, Schmader KE, Cunningham AL, McNeil SA, Schuind AE, Andrew MK. Recombinant Zoster Vaccine Is Efficacious and Safe in Frail Individuals. J Am Geriatr Soc 2020; 69:744-752. [PMID: 33197294 PMCID: PMC7984267 DOI: 10.1111/jgs.16917] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Frail participants are often under-represented in randomized trials, raising questions about outcomes of interventions in real-world settings. Frailty is strongly associated with vulnerability to illness and adverse health outcomes. We studied the impact of frailty on recombinant zoster vaccine (RZV) clinical outcomes. DESIGN/SETTING Data from two previously conducted phase III randomized trials of RZV were pooled. These two parent trials were conducted concurrently at the same study sites using the same methods. PARTICIPANTS/INTERVENTION In the two parent studies, participants aged ≥50 years (ZOE-50 study) and ≥70 years (ZOE-70 study), respectively, were randomized 1:1 to receive two doses of RZV or placebo. MEASUREMENTS In the current ZOE-Frailty study (NCT03563183), a frailty index was created using previously validated methods. Clinical outcomes assessed by frailty status included vaccine efficacy, immunogenicity, reactogenicity, and safety. RESULTS Of 29,305 participants from the pooled ZOE-50 and ZOE-70 total vaccinated cohort, 92% were included in this study. Mean age was 68.8 years; 58.1% were women; 45.6% were pre-frail and 11.3% frail. The percentage of frail participants increased with age from 5.7% aged 50-59 years to 22.7% aged ≥80 years. RZV vaccine efficacy against herpes zoster was >90% for all frailty subgroups (non-frail: 95.8% (95% confidence interval = 91.6-98.2), pre-frail: 90.4% (84.4-94.4), frail: 90.2% (75.4-97.0)). The RZV group demonstrated robust anti-gE antibody and gE-specific CD42+ responses, with mean concentrations remaining above pre-vaccination levels at least 3 years post-dose two, in all frailty subgroups. In the RZV group, the percentage of participants reporting solicited adverse events tended to decrease with increasing frailty. CONCLUSION The relatively nonrestrictive inclusion/exclusion criteria in the parent ZOE studies resulted in a range of participants that included frail and pre-frail older adults. RZV significantly reduced the risk of herpes zoster across all frailty subgroups.
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Affiliation(s)
| | | | | | | | - Myron J Levin
- Departments of Pediatrics and Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Anthony L Cunningham
- The Westmead Institute for Medical Research, Westmead, University of Sydney, Sydney, Australia
| | - Shelly A McNeil
- Canadian Center for Vaccinology, IWK Health Centre and Nova Scotia Health Authority, Dalhousie University, Halifax, Canada
| | | | - Melissa K Andrew
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Canada
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24
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Callahan KE, Boustani M, Ferrante L, Forman DE, Gurwitz J, High KP, McFarland F, Robinson T, Studenski S, Yang M, Schmader KE. Embedding and Sustaining a Focus on Function in Specialty Research and Care. J Am Geriatr Soc 2020; 69:225-233. [PMID: 33064303 DOI: 10.1111/jgs.16860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/12/2022]
Abstract
Function and the independent performance of daily activities are of critical importance to older adults. Although function was once a domain of interest primarily limited to geriatricians, transdisciplinary research has demonstrated its value across the spectrum of medical and surgical care. Nonetheless, integrating a functional perspective into medical and surgical therapeutics has yet to be implemented consistently into clinical practice. This article summarizes the presentations and discussions from a workshop, "Embedding/Sustaining a Focus on Function in Specialty Research and Care," held on January 31 to February 1, 2019. The third in a series supported by the National Institute on Aging and the John A. Hartford Foundation, the workshop aimed to identify scientific gaps and recommend research strategies to advance the implementation of function in care of older adults. Transdisciplinary leaders discussed implementation of mobility programs and functional assessments, including comprehensive geriatric assessment; integrating cognitive and sensory functional assessments; the role of culture, environment, and community in incorporating function into research; innovative methods to better identify functional limitations, techniques, and interventions to facilitate functional gains; and the role of the health system in fostering integration of function. Workshop participants emphasized the importance of aligning goals and assessments and adopting a team science approach that includes clinicians and frontline staff in the planning, development, testing, and implementation of tools and initiatives. This article summarizes those discussions.
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Affiliation(s)
- Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Malaz Boustani
- Center for Aging Research and Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jerry Gurwitz
- Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kevin P High
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA.,Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Frances McFarland
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Thomas Robinson
- Department of Surgery, University of Colorado School of Medicine and the Denver Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Stephanie Studenski
- Section of Geriatric Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,National Institute on Aging, Bethesda, Maryland, USA
| | - Mia Yang
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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25
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Pepin MJ, Valencia WM, Bettger JP, Pearson M, Manning KM, Sloane R, Schmader KE, Morey MC. Impact of Supervised Exercise on One-Year Medication Use in Older Veterans with Multiple Morbidities. Gerontol Geriatr Med 2020; 6:2333721420956751. [PMID: 32995368 PMCID: PMC7503003 DOI: 10.1177/2333721420956751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022] Open
Abstract
Exercise is touted as the ideal prescription to treat and prevent many chronic diseases. We examined changes in utilization and cost of medication classes commonly prescribed in the management of chronic conditions following participation in 12-months of supervised exercise within the Veterans Affairs Gerofit program. Gerofit enrolled 480 veterans between 1999 and 2017 with 12-months participation, with 453 having one or more active prescriptions on enrollment. Active prescriptions overall and for five classes of medications were examined. Changes from enrollment to 12 months were calculated, and cost associated with prescriptions filled were used to estimate net cost changes. Active prescriptions were reduced for opioids (77 of 164, 47%), mental health (93 of 221, 42%), cardiac (175 of 391, 45%), diabetes (41 of 166, 25%), and lipid lowering (56 of 253, 22%) agents. Cost estimates resulted in a net savings of $38,400. These findings support the role of supervised exercise as a favorable therapeutic intervention that has impact across chronic conditions.
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Affiliation(s)
| | - Willy M Valencia
- Miami Healthcare System, FL, USA.,University of Miami, Miami, FL, USA
| | | | | | | | - Richard Sloane
- Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
| | - Kenneth E Schmader
- VA Health Care System, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
| | - Miriam C Morey
- VA Health Care System, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
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26
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Messina JA, Moehring RW, Schmader KE, Anderson DJ. Impact of Location of Acquisition of Gram-Positive Bloodstream Infections on Clinical Outcomes Among Patients Admitted to Community Hospitals. Infect Drug Resist 2020; 13:3023-3031. [PMID: 32922048 PMCID: PMC7457735 DOI: 10.2147/idr.s259185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/07/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We investigated the association between location of acquisition (LOA) of gram-positive (GP) bloodstream infections (BSI) in community hospitals and clinical outcomes. Methods We performed a multicenter cohort study of adult inpatients with GP BSI in nine community hospitals from 2003 to 2006. LOA was defined by CDC criteria: 1) community-acquired (CA), 2) healthcare-associated (HCA) such as BSI <48 hours after admission plus hospitalization, surgery, dialysis, invasive device, or residence in a long-term care facility in the prior 12 months, and 3) hospital-acquired (HA) as BSI ≥48 hours after hospital admission. Results A total of 750 patients were included. Patients with HCA or HA GP BSI were significantly more likely to require assistance with ≥1 activity of daily living, have higher Charlson scores, and die during the hospitalization. Patients with HCA or HA GP BSI were more likely to have BSI due to a multidrug-resistant GP organism, but less likely to receive appropriate antibiotics within 24 hours of BSI presentation. Those with CA BSI were more likely to have a streptococcal BSI and to be discharged home following hospitalization. HA BSI was a risk factor for requiring a procedure for BSI and receiving inappropriate antibiotics within 24 hours of BSI. Both HA and HCA GP BSI were risk factors for in-hospital mortality. Conclusion LOA for patients with GP BSI in community hospitals was significantly associated with differences in clinical outcomes including receiving inappropriate antibiotics and in-hospital mortality. Distinguishing LOA in a patient presenting with suspected GP BSI is a critical assessment that should influence empiric treatment patterns.
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Affiliation(s)
- Julia A Messina
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
| | - Rebekah W Moehring
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
| | - Kenneth E Schmader
- Duke University Medical Center, Department of Medicine, Division of Geriatrics and GRECC, Durham VA Health Care System, Durham, NC, USA
| | - Deverick J Anderson
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
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27
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Colón-Emeric C, Pieper CF, Schmader KE, Sloane R, Bloom A, McClain M, Magaziner J, Huffman KM, Orwig D, Crabtree DM, Whitson HE. Two Approaches to Classifying and Quantifying Physical Resilience in Longitudinal Data. J Gerontol A Biol Sci Med Sci 2020; 75:731-738. [PMID: 30993327 PMCID: PMC7328208 DOI: 10.1093/gerona/glz097] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Approaches for quantifying physical resilience in older adults have not been described. METHODS We apply two conceptual approaches to defining physical resilience to existing longitudinal data sets in which outcomes are measured after an acute physical stressor. A "recovery phenotype" approach uses statistical methods to describe how quickly and completely a patient recovers. Statistical methods using a recovery phenotype approach can consider multiple outcomes simultaneously in a composite score (eg, factor analysis and principal components analysis) or identify groups of patients with similar recovery trajectories across multiple outcomes (eg, latent class profile analysis). An "expected recovery differential" approach quantifies how patients' actual outcomes are compared to their predicted outcome based on a population-derived model and their individual clinical characteristics at the time of the stressor. RESULTS Application of the approaches identified different participants as being the most or least physically resilient. In the viral respiratory cohort (n = 186) weighted kappa for agreement across resilience quartiles was 0.37 (0.27-0.47). The expected recovery differential approach identified a group with more comorbidities and lower baseline function as highly resilient. In the hip fracture cohort (n = 541), comparison of the expected recovery differentials across 10 outcome measures within individuals provided preliminary support for the hypothesis that there is a latent resilience trait at the whole-person level. CONCLUSIONS We posit that recovery phenotypes may be useful in clinical applications such as prediction models because they summarize the observed outcomes across multiple measures. Expected recovery differentials offer insight into mechanisms behind physical resilience not captured by age and other comorbidities.
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Affiliation(s)
- Cathleen Colón-Emeric
- Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, North Carolina
- Duke Claude D. Pepper Older American Independence Center, Duke University, Durham, North Carolina
| | - Carl F Pieper
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, North Carolina
- Duke Claude D. Pepper Older American Independence Center, Duke University, Durham, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, North Carolina
- Duke Claude D. Pepper Older American Independence Center, Duke University, Durham, North Carolina
| | - Richard Sloane
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, North Carolina
- Duke Claude D. Pepper Older American Independence Center, Duke University, Durham, North Carolina
| | - Allison Bloom
- Center for Applied Genomics and Precision Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Micah McClain
- Center for Applied Genomics and Precision Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Jay Magaziner
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore
| | - Kim M Huffman
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina
| | - Denise Orwig
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore
| | - Donna M Crabtree
- Duke Office of Clinical Research, School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Heather E Whitson
- Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Medical Center, North Carolina
- Duke Claude D. Pepper Older American Independence Center, Duke University, Durham, North Carolina
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Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, Schmader KE, Hendrix CC, Kessler C, Hughes JM, Ramos K, Wieland GD, Weiner M, Robinson K, Oddone E. Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. J Gen Intern Med 2020; 35:79-86. [PMID: 31489559 PMCID: PMC6957582 DOI: 10.1007/s11606-019-05319-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/10/2019] [Accepted: 08/08/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. OBJECTIVE To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES The primary outcome was repeat ED use within 30 days. KEY RESULTS Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. CONCLUSIONS A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION ClinicalTrials.gov NCT01717976.
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Affiliation(s)
- Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA. .,Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA. .,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Morris Weinberger
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kenneth E Schmader
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Cristina C Hendrix
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Duke University School of Nursing, Durham, NC, USA
| | - Chad Kessler
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jaime M Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine Ramos
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.,Department of Psychiatry, Duke University School of Medicine, Durham, NC, USA
| | - G Darryl Wieland
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA.,Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Madeline Weiner
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Katina Robinson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA
| | - Eugene Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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29
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Kritchevsky SB, Forman DE, Callahan KE, Ely EW, High KP, McFarland F, Pérez-Stable EJ, Schmader KE, Studenski SA, Williams J, Zieman S, Guralnik JM. Pathways, Contributors, and Correlates of Functional Limitation Across Specialties: Workshop Summary. J Gerontol A Biol Sci Med Sci 2019; 74:534-543. [PMID: 29697758 DOI: 10.1093/gerona/gly093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/25/2022] Open
Abstract
Traditional clinical care models focus on the measurement and normalization of individual organ systems and de-emphasize aspects of health related to the integration of physiologic systems. Measures of physical, cognitive and sensory, and psychosocial or emotional function predict important health outcomes like death and disability independently from the severity of a specific disease, cumulative co-morbidity, or disease severity measures. A growing number of clinical scientists in several subspecialties are exploring the utility of functional assessment to predict complication risk, indicate stress resistance, inform disease screening approaches and risk factor interpretation, and evaluate care. Because a substantial number of older adults in the community have some form of functional limitation, integrating functional assessment into clinical medicine could have a large impact. Although interest in functional implications for health and disease management is growing, the science underlying functional capacity, functional limitation, physical frailty, and functional metrics is often siloed among different clinicians and researchers, with fragmented concepts and methods. On August 25-26, 2016, participants at a trans-disciplinary workshop, supported by the National Institute on Aging and the John A. Hartford Foundation, explored what is known about the pathways, contributors, and correlates of physical, cognitive, and sensory functional measures across conditions and disease states; considered social determinants and health disparities; identified knowledge gaps, and suggested priorities for future research. This article summarizes those discussions.
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Affiliation(s)
- Stephen B Kritchevsky
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Kathryn E Callahan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - E Wesley Ely
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC) and Department of Medicine, Vanderbilt University, Nashville
| | - Kevin P High
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Frances McFarland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | | | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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30
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2018 Update. J Am Geriatr Soc 2019; 67:2458-2462. [PMID: 31765004 DOI: 10.1111/jgs.16243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/20/2019] [Accepted: 10/04/2019] [Indexed: 01/04/2023]
Abstract
Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative-hypnotics, first-generation antihistamines, selective nonsteroidal anti-inflammatory drugs, and glyburide). The second study, a nested case-control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double-blind, placebo-controlled trial that investigated the effect of daily low-dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community-dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458-2462, 2019.
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Affiliation(s)
| | - Zachary A Marcum
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
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31
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Hemmersbach-Miller M, Alexander BD, Pieper CF, Schmader KE. Age matters: older age as a risk factor for CMV reactivation in the CMV serostatus-positive kidney transplant recipient. Eur J Clin Microbiol Infect Dis 2019; 39:455-463. [PMID: 31758441 DOI: 10.1007/s10096-019-03744-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/17/2019] [Indexed: 12/29/2022]
Abstract
Evaluate risk factors for cytomegalovirus (CMV) reactivation during the first year after kidney transplantation in the CMV-seropositive older recipient. Retrospective single-center study. Between 2011 and 2015, 91 patients ≥ 65 years received a kidney transplant; these were matched with 91 controls, aged 40-60. Risk of CMV reactivation in the CMV-seropositive recipients was analyzed. Sixty-three older and 54 younger recipients were included; 50% had received CMV-directed prophylaxis. CMV reactivation was significantly more frequent in the older group (71.4% vs 44.4%, p = 0.003) and occurred earlier (p = 0.003). A multivariate model showed that only age was associated with CMV reactivation (OR 2.48, p = 0.03). After excluding patients that received thymoglobulin, older age group remained the only risk factor of CMV reactivation (OR 3.81, p = 0.014). Recurrent event analysis showed that the older cohort had an HR of 1.94 (p = 0.01) of CMV viremia; there was significant episode-cohort interaction (p < 0.01). While the older group had a higher risk of infection (HR = 2.43), after the initial episode the relative hazards were approximately equal (HR = 1.08, at period 2). This suggests that it is key to specifically avoid the first episode of reactivation. Universal prophylaxis or a hybrid prophylaxis model should be considered in the CMV-seropositive kidney transplant recipient aged ≥ 65 years.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham, NC, USA.,GRECC, Durham VA, Durham, NC, USA
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32
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Weinberg A, Popmihajlov Z, Schmader KE, Johnson MJ, Caldas Y, Salazar AT, Canniff J, McCarson BJ, Martin J, Pang L, Levin MJ. Persistence of Varicella-Zoster Virus Cell-Mediated Immunity After the Administration of a Second Dose of Live Herpes Zoster Vaccine. J Infect Dis 2019; 219:335-338. [PMID: 30165651 DOI: 10.1093/infdis/jiy514] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Abstract
Protection against zoster conferred by zoster vaccine live (ZVL; Zostavax) wanes over time. We compared varicella-zoster virus cell-mediated immunity (VZV-CMI) of adults ≥70 years who received a second dose of ZVL ≥10 years after the initial dose with de novo-immunized age-matched controls. Before and during the first year after vaccination, VZV-CMI was significantly higher in reimmunized compared with de novo vaccinees. At 3 years, VZV-CMI differences between groups decreased and only memory responses remained marginally higher in reimmunized participants. In conclusion, the increase in VZV-CMI generated by reimmunization with ZVL is at least equally persistent compared with de novo immunization.
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Affiliation(s)
| | | | - Kenneth E Schmader
- Duke University and Geriatric Research Education and Clinical Centers, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | | | - Yupanqui Caldas
- University of Colorado Denver Anschutz Medical Campus, Aurora
| | | | | | | | | | - Lei Pang
- Merck & Co., Inc., Kenilworth, New Jersey
| | - Myron J Levin
- University of Colorado Denver Anschutz Medical Campus, Aurora
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33
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Cobey S, Gouma S, Parkhouse K, Chambers BS, Ertl HC, Schmader KE, Halpin RA, Lin X, Stockwell TB, Das SR, Landon E, Tesic V, Youngster I, Pinsky BA, Wentworth DE, Hensley SE, Grad YH. Poor Immunogenicity, Not Vaccine Strain Egg Adaptation, May Explain the Low H3N2 Influenza Vaccine Effectiveness in 2012-2013. Clin Infect Dis 2019; 67:327-333. [PMID: 29471464 PMCID: PMC6051447 DOI: 10.1093/cid/ciy097] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/03/2018] [Indexed: 12/28/2022] Open
Abstract
Background Influenza vaccination aims to prevent infection by influenza virus and reduce associated morbidity and mortality; however, vaccine effectiveness (VE) can be modest, especially for subtype A(H3N2). Low VE has been attributed to mismatches between the vaccine and circulating influenza strains and to the vaccine’s elicitation of protective immunity in only a subset of the population. The low H3N2 VE in the 2012–2013 season was attributed to egg-adaptive mutations that created antigenic mismatch between the actual vaccine strain (IVR-165) and both the intended vaccine strain (A/Victoria/361/2011) and the predominant circulating strains (clades 3C.2 and 3C.3). Methods We investigated the basis of low VE in 2012–2013 by determining whether vaccinated and unvaccinated individuals were infected by different viral strains and by assessing the serologic responses to IVR-165, A/Victoria/361/2011, and 3C.2 and 3C.3 strains in an adult cohort before and after vaccination. Results We found no significant genetic differences between the strains that infected vaccinated and unvaccinated individuals. Vaccination increased titers to A/Victoria/361/2011 and 3C.2 and 3C.3 representative strains as much as to IVR-165. These results are consistent with the hypothesis that vaccination boosted cross-reactive immune responses instead of specific responses against unique vaccine epitopes. Only approximately one-third of the cohort achieved a ≥4-fold increase in titer. Conclusions In contrast to analyses based on ferret studies, low H3N2 VE in 2012–2013 in adults does not appear to be due to egg adaptation of the vaccine strain. Instead, low VE might have been caused by low vaccine immunogenicity in a subset of the population.
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Affiliation(s)
- Sarah Cobey
- Department of Ecology & Evolution, University of Chicago, Illinois
| | - Sigrid Gouma
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kaela Parkhouse
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Benjamin S Chambers
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Hildegund C Ertl
- Division of Geriatrics, Duke University Medical Center, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, North Carolina
| | - Rebecca A Halpin
- Department of Infectious Disease, J. Craig Venter Institute, Rockville, Maryland
| | - Xudong Lin
- Department of Infectious Disease, J. Craig Venter Institute, Rockville, Maryland
| | - Timothy B Stockwell
- Department of Infectious Disease, J. Craig Venter Institute, Rockville, Maryland
| | - Suman R Das
- Department of Infectious Disease, J. Craig Venter Institute, Rockville, Maryland
| | - Emily Landon
- Department of Medicine, University of Chicago, Illinois
| | - Vera Tesic
- Department of Pathology, University of Chicago, Illinois
| | - Ilan Youngster
- Division of Pediatrics and the Center for Microbiome Research, Assaf Harofeh Medical Center, Tel Aviv University, Israel.,Division of Infectious Diseases, Boston Children's Hospital, Massachusetts
| | - Benjamin A Pinsky
- Department of Pathology, Stanford University School of Medicine, California.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, California
| | - David E Wentworth
- Department of Infectious Disease, J. Craig Venter Institute, Rockville, Maryland
| | - Scott E Hensley
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yonatan H Grad
- Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, Massachusetts.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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34
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Elias AM, Ogunwale AN, Pepin MJ, Bailey JC, Adams AD, Colón-Emeric CS, Vognsen JD, Schmader KE, Pavon JM. High Prevalence of Fall-Related Medication Use in Older Veterans at Risk for Falls. J Am Geriatr Soc 2019; 68:438-439. [PMID: 31657005 DOI: 10.1111/jgs.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 09/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Allison M Elias
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Abayomi N Ogunwale
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
| | - Marc J Pepin
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Janine C Bailey
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Aaron D Adams
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Cathleen S Colón-Emeric
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
| | - Julie D Vognsen
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Kenneth E Schmader
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
| | - Juliessa M Pavon
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
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Schmader KE, Levin MJ, Chen M, Matthews S, Riley M, Woo W, Hervé C, Grupping K, Schuind A, Oostvogels L, Curran D. 2778. Impact of Reactogenicity on Quality of Life and Physical Functioning in Adults ≥50 Years Receiving Both Doses of the Adjuvanted Recombinant Zoster Vaccine. Open Forum Infect Dis 2019. [PMCID: PMC6810498 DOI: 10.1093/ofid/ofz360.2455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The adjuvanted recombinant zoster vaccine (RZV) is efficacious in preventing herpes zoster in adults ≥ 50 years. The current study investigates whether the vaccinees’ quality of life (QoL) and physical functioning (PF) are impacted by local and systemic reactions due to RZV. In a previous report of this phase III, open-label, multicenter study (NCT02979639), overall PF and QoL were not significantly affected by a first RZV dose. [1] Here we report the results from the same study after a second RZV dose and safety results from dose 1 up to study end. Methods Adults aged ≥ 50 years were to receive 2 doses of RZV 2 months apart. Changes in mean Short Form health survey (SF-36) PF score between pre- and post-each RZV dose for 7 days, QoL, reactogenicity and safety were assessed. Results 401 adults received dose 1 and 391 received dose 2 of RZV. Post-second RZV dose, the reported solicited local symptoms were pain (75.1%), erythema (22.4%) and swelling (13.9%), and the most frequent solicited systemic symptoms were fatigue (46.3%), headache (37.5%) and myalgia (32.9%). Grade 3 solicited symptoms were reported by 7.2% (local) and 11.1% (general) of participants, and 5 (1.2%) participants reported reactogenicity triggering medical attention post-second RZV dose. From first dose up to study end, 14 (3.5%) participants reported 21 serious adverse events, none related to RZV. In days 1–2, post-second RZV dose, a transient, clinically-important decrease in SF-36 PF score (table) was seen in those reporting grade 3 solicited symptoms, which impacted activities such as walking and climbing stairs. Overall, during the 7 days post-second RZV dose, a mean change of −0.4 points was observed from the mean baseline score, indicating the PF was not clinically meaningfully impacted. No overall quality-adjusted-life-year loss was recorded. Conclusion Overall, the QoL and PF of adults ≥ 50 years were not affected post-second RZV dose; a transient impact was observed in adults with grade 3 reactogenicity. These results and the observed reactogenicity and safety profile are consistent with first RZV dose results, as well as that of previous studies with the RZV vaccine in adults of similar age. Funding: GlaxoSmithKline Biologicals SA. 1. Schmader et al., Abstract 2488, IDWeek 2018 ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Myron J Levin
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
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36
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Hanlon JT, Schmader KE. Measuring Underuse and Overuse of Medications. J Am Geriatr Soc 2019; 67:2428. [PMID: 31390044 DOI: 10.1111/jgs.16111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Joseph T Hanlon
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Kenneth E Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
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37
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Carpenter CR, Mody L, Lundebjerg NE, Walter LC, Schmader KE, High K. Do what you love. Love what you do. Dr. Arti Hurria's trailblazing transdisciplinary legacy. J Geriatr Oncol 2019; 11:158-159. [PMID: 31378641 DOI: 10.1016/j.jgo.2019.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/25/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher R Carpenter
- Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus Box 8072, Saint Louis, MO 63110, USA.
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Geriatrics Research Education and Clinical Center, VA Ann Arbor Healthcare System, 300 North Ingalls Building, Rm 905, Ann Arbor, MI 48109, USA.
| | - Nancy E Lundebjerg
- American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco VA Medical Center, 4150 Clement Street, 181-G, San Francisco, CA 94121, USA.
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center Durham, NC, USA; Durham VA Health Care System, 182 GRECC, 508 Fulton St., Durham, NC 27705, USA.
| | - Kevin High
- Health System, Wake Forest Baptist Health, USA; Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA; Sections on Infectious Diseases, Wake Forest School of Medicine, Winston Salem, NC, USA; Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA.
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38
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Schmader KE, Levin MJ, Grupping K, Matthews S, Butuk D, Chen M, Idrissi ME, Fissette LA, Fogarty C, Hartley P, Klein NP, Nevarez M, Uusinarkaus K, Oostvogels L, Curran D. The Impact of Reactogenicity After the First Dose of Recombinant Zoster Vaccine on the Physical Functioning and Quality of Life of Older Adults: An Open-Label, Phase III Trial. J Gerontol A Biol Sci Med Sci 2019; 74:1217-1224. [PMID: 30256905 PMCID: PMC6625580 DOI: 10.1093/gerona/gly218] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Herpes zoster and its related complications are associated with significant medical burden, which negatively affects quality of life and daily functioning of the patients. The recently licensed recombinant zoster vaccine (RZV) offers high efficacy but is associated with local and systemic reactions. This study assessed the impact of RZV on the quality of life and daily functioning of participants and implications for caregivers. METHODS Four hundred and one adults aged 50 years or older received single RZV doses at 0 and 2 months in this open-label, single-arm, multicenter study (NCT02979639). Change in mean SF-36 Physical Functioning score following first-dose administration, quality of life, reactogenicity, safety, productivity loss, and health care resource utilization was assessed. The current analysis was performed post-vaccine dose-1; safety follow-up will continue until 1 year post-dose-2. RESULTS The most common solicited local symptoms were injection-site pain (77.5%), redness (23.0%), and swelling (13.3%); the most frequent solicited systemic reactions were fatigue (33.5%), headache (28.3%), and myalgia (26.8%). Grade 3 reactogenicity occurred in 9.5% of participants and was associated with a transient clinically important decrease in SF-36 Physical Functioning score (affecting activities such as walking, carrying groceries, climbing stairs) on Days 1 and 2 post-first vaccination. No clinically meaningful reductions in mean SF-36 Physical Functioning scale scores from pre- to post-RZV dose-1 were observed (mean +1.9 points, primary end point), and no overall quality-adjusted-life-year loss was recorded post-dose-1. Five participants reported lost workdays; caregiver workload was not increased. CONCLUSIONS Overall, the physical functioning and quality of life of older adults were not affected by a first RZV dose. The observed reactogenicity was consistent with previous studies.
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Affiliation(s)
- Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, North Carolina
| | - Myron J Levin
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | | | | | | | | | | | | | | | - Paul Hartley
- Preferred Primary Care Physicians, Uniontown, Pennsylvania
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California
| | - Max Nevarez
- DaVita Medical Group, Colorado Springs, Colorado
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Abstract
Antibody responses to vaccinations or infections decline upon aging. In this study we tested if metabolic changes in B cells may contribute to attenuation of responses to influenza vaccination in aged humans. Our data show that aging affects mitochondrial functions in B cells leading to increases in mitochondrial reactive oxygen species (MROS) and mitochondrial mass (MM) in some aged B cell subsets and decreases in expression levels of Sirtuin 1 (SIRT1), Forkhead box protein (FOX)O1 and carnitine palmitoyltransferase 1 (CPT-1). Seahorse analyses showed minor defects in glycolysis in the aged B cells after activation but a strong reduction in oxidative phosphorylation. The analyses of the transcriptome revealed further pronounced defects in one-carbon metabolism, a pathway that is essential for amino acid and nucleotide metabolism. Overall our data support the notion that the declining ability of aged B cells to increase their metabolism following activation contributes to the weakened antibody responses of the elderly.
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Affiliation(s)
| | | | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Curran D, Andrew MK, Levin MJ, Turriani E, Matthews S, Fogarty C, Klein NP, Grupping K, Oostvogels L, Schmader KE. Evaluation of two frailty indices, with practical application in a vaccine clinical trial. Hum Vaccin Immunother 2019; 15:2960-2968. [PMID: 31157595 PMCID: PMC6930102 DOI: 10.1080/21645515.2019.1622974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Frail older adults are at increased risk of poor clinical outcomes. Frailty assessment is therefore important in clinical trials to understand the benefits and harms of interventions. However, consensus is lacking on how frailty should be assessed.We developed a prospectively specified index using a battery of formal tests and instruments and a retrospectively generated index using medical comorbidities and patient reported outcomes (PROs) within an adjuvanted recombinant zoster vaccine (RZV) trial (NCT02979639). For both frailty indices (FIs), a total deficit score was calculated as the accumulation of deficits and participants were categorized as non-frail, pre-frail and frail. We assessed (1) the feasibility and validity of both FIs; (2) the impact of RZV vaccine reactogenicity by frailty status on Short Form-36 [SF-36] physical functioning (PF) scores.Of 401 participants, aged ≥50 years, 236 (58.9%) were categorized non-frail, 143 (35.7%), pre-frail, and 22 (5.5%) frail using the prospective FI. Corresponding numbers for the retrospective FI were 192 (47.9%), 169 (42.1%) and 40 (10.0%), respectively. Strong concordance was observed between the frailty status assessments (P < .001). The proportion defined as frail increased from 1.5%, to 10.4% in participants aged 50-59, and ≥70 years, respectively, for the prospective FI. Corresponding numbers for the retrospective FI were 3.7%, and 17.2%, respectively. RZV vaccination was associated with a transient, non-clinically meaningful, decrease on the SF-36 PF score in frail participants.Both frailty indices provided similar results. The retrospectively generated FI offers the advantage of being easier to incorporate into vaccine clinical trials of older adults.
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Affiliation(s)
| | - Melissa K Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Myron J Levin
- Departments of Pediatrics and Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, CA, USA
| | | | | | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, NC, USA
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Hemmersbach-Miller M, Alexander BD, Sudan DL, Pieper C, Schmader KE. Infections after kidney transplantation. Does age matter? Clin Transplant 2019; 33:e13516. [PMID: 30849194 DOI: 10.1111/ctr.13516] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
Infections threaten successful outcomes after kidney transplantation. Our aim was to determine if the number, types of infections and the risk factors for common infections differed between older compared to younger kidney transplant (KT) recipients in the first year after surgery. We performed a single-center retrospective cohort study. Between 2011 and 2015, 91 KTs were performed in patients ≥65 years of age; these were matched 1:1 (by year of transplantation, sex and race) to controls aged 40-60 years. Over 90% of both groups had an infectious complication. Urinary tract infections (UTIs) and cytomegalovirus (CMV) viremia were significantly more frequent in older recipients. Older adults had more late onset UTIs, including after stent removal. CMV viremia was more frequent in older adults in the 1-6 months post-transplant period. Due to our center-specific protocol utilizing pre-emptive monitoring in the CMV recipient-seropositive population, the higher CMV incidence in the aged recipient was driven by this subpopulation of older adults. No difference in pneumonias or bloodstream infections were found, nor in surgical complications, rejection or graft loss. Mortality was higher at 1-year post-transplant in the older recipients (9.9% vs 1.1%; P = 0.018). Prophylactic and immunosuppressive strategies may need to be altered for older KT recipients.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Barbara D Alexander
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina
| | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center (GRECC), Durham VA, Durham, North Carolina
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42
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Abstract
In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham NC, USA.,GRECC, Durham VA, Durham NC. USA
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Schwartz JB, Schmader KE, Hanlon JT, Abernethy DR, Gray S, Dunbar-Jacob J, Holmes HM, Murray MD, Roberts R, Joyner M, Peterson J, Lindeman D, Tai-Seale M, Downey L, Rich MW. Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop. J Am Geriatr Soc 2018; 67:371-380. [PMID: 30536694 DOI: 10.1111/jgs.15634] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD). DESIGN Consensus meeting. SETTING Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017. PARTICIPANTS Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology. MEASUREMENTS Summary of workshop proceedings and recommendations. RESULTS To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority. CONCLUSION The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.
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Affiliation(s)
- Janice B Schwartz
- Divisions of Geriatrics and Clinical Pharmacology, Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Darrell R Abernethy
- Office of Clinical Pharmacology, U.S. Food & Drug Administration, Silver Spings, Maryland
| | - Shelly Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
| | | | - Holly M Holmes
- Geriatric and Palliative Medicine, Department of Medicine, McGovern Medical School, Houston, Texas
| | - Michael D Murray
- Department of Pharmacy Practice, Regenstrief Institute, Purdue University, West Lafayette, Indiana
| | - Robert Roberts
- Department of Medicine, College of Medicine, University of Arizona, Phoenix, Arizona
| | - Michael Joyner
- Departments of Anesthesiology and Perioperative Medicine and Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Josh Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Lindeman
- CITRIS and the Banatao Institute, University of California, Berkeley, California
| | - Ming Tai-Seale
- Division of Health Policy, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Laura Downey
- Concordance Health Solutions, West Lafayette, Indiana.,Krannert School of Management, Purdue University, West Lafayette, Indiana
| | - Michael W Rich
- Cardiovascular Division, Department of Internal Medicine, Washington University, St. Louis, Missouri
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Schmader KE, Levin MJ, Grupping K, Matthews S, Butuk D, Chen M, Idrissi ME, Fissette LA, Fogarty C, Hartley P, Klein NP, Nevarez M, Uusinarkaus K, Oostvogels L, Curran D. 2488. The Impact of Reactogenicity After Administration of the Recombinant Zoster Vaccine Upon the Physical Functioning and Quality of Life of Older Adults. Open Forum Infect Dis 2018. [PMCID: PMC6255533 DOI: 10.1093/ofid/ofy210.2141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Herpes zoster (HZ) and its related complications are associated with a significant burden of illness in older adults, which negatively impacts patients’ physical functioning and quality-of-life (QoL). The recombinant zoster vaccine (RZV) shows high efficacy for the prevention of HZ in older adults but is associated with local and systemic reactions. Therefore, this study assessed the impact of RZV reactogenicity upon the physical functioning and QoL of participants. Methods 401 adults aged ≥50 years received a dose of RZV at 0 and 2 months in this open-label, single-arm, multicenter study (NCT02979639). Changes in mean SF-36 Physical Functioning score were assessed between pre-dose-1 vaccination and post-dose-1 vaccination for 7 days (primary endpoint). Decreased scores are associated with decreased physical functioning. QoL, reactogenicity and safety were also assessed. The current analysis was performed post-dose-1 vaccination of the 2-dose RZV schedule. Results No clinically meaningful reductions in overall mean SF-36 Physical Functioning scores from pre- to post-RZV dose-1 were observed (mean +1.9 points) and no overall quality-adjusted-life-year loss was recorded post-dose-1. However, grade 3 reactogenicity occurred in 9.5% of participants, and was associated with a transient, clinically-important decrease in SF-36 Physical Functioning score (impacting activities such as walking, carrying groceries, climbing stairs) on Days 1–2 post-first-vaccination (Table 1). The solicited local symptoms were pain (77.5%), redness (23.0%) and swelling (13.3%); the most frequent solicited systemic reactions were fatigue (33.5%), headache (28.3%) and myalgia (26.8%). Conclusion Overall, the physical functioning and QoL of older adults were not significantly affected by a first RZV dose. Grade 3 reactogenicity was associated with a small transient decrease in physical functioning 1–2 days post-dose-1 that resolved by Day 3 post-vaccination. Funding: GlaxoSmithKline Biologicals SA ![]()
Disclosures K. E. Schmader, GSK group of companies: Investigator, Research grant. M. J. Levin, GSK group of companies: Grant Investigator and Scientific Advisor, Consulting fee and Research grant. K. Grupping, GSK group of companies: Employee, Salary. S. Matthews, GSK group of companies: Consultant, Consulting fee. M. El Idrissi, GSK group of companies: Employee and Shareholder, Salary. L. A. Fissette, GSK group of companies: Employee, Salary. C. Fogarty, Medical Research: Investigator, Research grant. N. P. Klein, GSK group of companies: Investigator, Research support. M. Nevarez, GSK group of companies: Investigator, Investigator stipend. K. Uusinarkaus, GSK group of companies: Investigator, Research grant. L. Oostvogels, GSK group of companies: Employee, Salary. D. Curran, GSK group of companies: Employee and Shareholder, GSK shares and Salary.
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Affiliation(s)
- Kenneth E Schmader
- Duke University Medical Center and Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Myron J Levin
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | | | | | | | | | - Paul Hartley
- Preferred Primary Care Physicians, Uniontown, Pennsylvania
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California
| | - Max Nevarez
- DaVita Medical Group, Colorado Springs, Colorado
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Gray SL, Marcum ZA, Schmader KE, Hanlon JT. Update on Medication Use Quality and Safety in Older Adults, 2017. J Am Geriatr Soc 2018; 66:2254-2258. [PMID: 30423194 DOI: 10.1111/jgs.15665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/10/2023]
Abstract
Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system-active medication polypharmacy in older adults and how this has changed over a 9-year period (2004-2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long-term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta-analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254-2258, 2018.
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Affiliation(s)
- Shelly L Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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46
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Cone EB, Hammill BG, Routh JC, Lipkin ME, Preminger GM, Schmader KE, Scales CD. Disproportionate Use of Inpatient Care by Older Adults With Kidney Stones. Urology 2018; 120:103-108. [PMID: 29940233 PMCID: PMC6689223 DOI: 10.1016/j.urology.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe variation in utilization and costs of inpatient care for patients with kidney stones, examining associations with older age. MATERIALS AND METHODS Using the Nationwide Inpatient Sample we examined inpatient discharges with stone diagnoses from 2007 to 2011. We examined length of stay, hospitalization cost, and postdischarge care utilization using multivariable regression to identify associations between patient/hospital characteristics and resource. RESULTS An estimated 1.7 million hospital discharges for stone disease occurred during the study period. Median length of stay was 2.1 days with a median cost of $6300. Hospital use was substantially higher among persons ≥65 years old (older adults) as compared to those aged 18-64 (younger adults): median length of stay was 3.1 days, with 25% staying more than 5.9 days. Older adults were significantly more likely to utilize home health (odds ratio [OR] 3.6) or skilled nursing (OR 5.0) after discharge. Older adults accounted for 1 in 3 hospital discharges, 40% of costs, and half of postdischarge care utilization. They were more likely to be septic during hospitalization (OR 1.8) which doubled costs per episode, but less likely to receive surgery (OR 0.93). CONCLUSION While historically at lower risk for kidney stones compared to younger adults, older adults utilizing inpatient care account for a disproportionate share of the economic burden of disease. Utilization is higher for older adults across multiple dimensions, including hospital costs, length of stay, and postdischarge care. These findings suggest that efforts to understand and mitigate the impact of kidney stones on this vulnerable population are required.
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Affiliation(s)
- Eugene B Cone
- Duke Clinical Research Institute, Durham, NC; Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC.
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, NC; Duke University Medical Center, Department of Medicine, Durham, NC
| | - Jonathan C Routh
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC; Duke University Medical Center, Department of Pediatrics, Durham, NC
| | - Michael E Lipkin
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC
| | - Glenn M Preminger
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC
| | - Kenneth E Schmader
- Duke University Medical Center, Department of Medicine, Durham, NC; Duke University School of Medicine, Durham, NC; Durham VA Medical Center, Geriatric Research Education and Clinical Center, Durham, NC
| | - Charles D Scales
- Duke Clinical Research Institute, Durham, NC; Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC
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Agarwal D, Schmader KE, Kossenkov AV, Doyle S, Kurupati R, Ertl HCJ. Immune response to influenza vaccination in the elderly is altered by chronic medication use. Immun Ageing 2018; 15:19. [PMID: 30186359 PMCID: PMC6119322 DOI: 10.1186/s12979-018-0124-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The elderly patient population is the most susceptible to influenza virus infection and its associated complications. Polypharmacy is common in the aged, who often have multiple co-morbidities. Previous studies have demonstrated that commonly used prescription drugs can have extensive impact on immune defenses and responses to vaccination. In this study, we examined how the dynamics of immune responses to the two influenza A virus strains of the trivalent inactivated influenza vaccine (TIV) can be affected by patient's history of using the prescription drugs Metformin, NSAIDs or Statins. RESULTS We provide evidence for differential antibody (Ab) production, B-cell phenotypic changes, alteration in immune cell proportions and transcriptome-wide perturbation in individuals with a history of long-term medication use, compared with non-users. We noted a diminished response to TIV in the elderly on Metformin, whereas those on NSAIDs or Statins had higher baseline responses but reduced relative increases in virus-neutralizing Abs (VNAs) or Abs detected by an enzyme-linked immunosorbent assay (ELISA) following vaccination. CONCLUSION Collectively, our findings suggest novel pathways that might underlie how long-term medication use impacts immune response to influenza vaccination in the elderly. They provide a strong rationale for targeting the medication-immunity interaction in the aged population to improve vaccination responses.
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Affiliation(s)
- Divyansh Agarwal
- Genomics and Computational Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Kenneth E. Schmader
- Division of Geriatrics, Duke University Medical Center; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC 27705 USA
| | | | - Susan Doyle
- Division of Geriatrics, Duke University Medical Center; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC 27705 USA
| | - Raj Kurupati
- The Wistar Institute, Philadelphia, PA 19104 USA
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Hadley EC, Kuchel GA, Newman AB, Allore HG, Bartley JM, Bergeman CS, Blinov ML, Colon-Emeric CS, Dabhar FS, Dugan LL, Dutta C, Eldadah BA, Ferrucci L, Kirkland JL, Kritchevsky SB, Lipsitz LA, Nadkarni NK, Reed MJ, Schmader KE, Sierra F, Studenski SA, Varadhan R, Walston JD, Whitson HE, Yung R. Corrigendum to: Report: NIA Workshop on Measures of Physiologic Resiliencies in Human Aging. J Gerontol A Biol Sci Med Sci 2018; 73:995. [PMID: 29788088 DOI: 10.1093/gerona/glx172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Evan C Hadley
- Division of Geriatrics and Clinical Gerontology, National Institutes of Health, National Institute on Aging, Bethesda, Maryland
| | - George A Kuchel
- Department of Medicine, Center on Aging, University of Connecticut Health Center, Farmington
| | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health.,Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Heather G Allore
- Department of Internal Medicine, Section of Geriatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Jenna M Bartley
- Department of Immunology, Center on Aging, University of Connecticut Health Center, University of Connecticut, Farmington
| | | | - Michael L Blinov
- R. D. Berlin Center for Cell Analysis and Modeling, University of Connecticut School of Medicine, University of Connecticut, Farmington
| | - Cathleen S Colon-Emeric
- Duke University School of Medicine, Duke University Medical Center.,Durham VA Geriatric Research Education and Clinical Center, North Carolina
| | - Firdaus S Dabhar
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, California
| | - Laura L Dugan
- Department of Medicine, Division of Geriatric Medicine, Vanderbilt University School of Medicine, Vanderbilt University Nashville, Tennessee
| | - Chhanda Dutta
- Division of Geriatrics and Clinical Gerontology, National Institutes of Health, National Institute on Aging, Bethesda, Maryland
| | - Basil A Eldadah
- Division of Geriatrics and Clinical Gerontology, National Institutes of Health, National Institute on Aging, Bethesda, Maryland
| | - Luigi Ferrucci
- Office of the Scientific Director, National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephen B Kritchevsky
- Department of Gerontology and Geriatrics, Sticht Center on Aging, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.,Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Neelesh K Nadkarni
- Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - May J Reed
- Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, University of Washington, Seattle
| | - Kenneth E Schmader
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, Duke University.,Department of Veterans Affairs Medical Center, Durham, North Carolina
| | - Felipe Sierra
- Division of Aging Biology, National Institute on Aging, National Institutes of Health, Bethesda
| | - Stephanie A Studenski
- Longitudinal Studies Section, National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - Ravi Varadhan
- Center on Aging and Health, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Division of Biostatistics and Bioinformatics, Department of Oncology, School of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy D Walston
- Division of Geriatrics Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Heather E Whitson
- Duke University Aging Center, North Carolina.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, North Carolina
| | - Raymond Yung
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, School of Medicine, University of Michigan.,Graduate Program in Immunology, University of Michigan.,Geriatric Research, Education and Clinical Care Center (GRECC), VA Ann Arbor Health System, Michigan
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49
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Whitson HE, Cohen HJ, Schmader KE, Morey MC, Kuchel G, Colon-Emeric CS. Physical Resilience: Not Simply the Opposite of Frailty. J Am Geriatr Soc 2018; 66:1459-1461. [PMID: 29577234 DOI: 10.1111/jgs.15233] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Heather E Whitson
- Center for the Study of Aging and Human Development, School of Medicine, Duke University, Durham, North Carolina.,Departments of Medicine, School of Medicine, Duke University, Durham, North Carolina.,Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development, School of Medicine, Duke University, Durham, North Carolina.,Departments of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Kenneth E Schmader
- Center for the Study of Aging and Human Development, School of Medicine, Duke University, Durham, North Carolina.,Departments of Medicine, School of Medicine, Duke University, Durham, North Carolina.,Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Miriam C Morey
- Center for the Study of Aging and Human Development, School of Medicine, Duke University, Durham, North Carolina.,Departments of Medicine, School of Medicine, Duke University, Durham, North Carolina.,Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - George Kuchel
- Center on Aging, University of Connecticut, Farmington, Connecticut
| | - Cathleen S Colon-Emeric
- Center for the Study of Aging and Human Development, School of Medicine, Duke University, Durham, North Carolina.,Departments of Medicine, School of Medicine, Duke University, Durham, North Carolina.,Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
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50
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Gray SL, Hart LA, Perera S, Semla TP, Schmader KE, Hanlon JT. Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults. J Am Geriatr Soc 2017; 66:282-288. [PMID: 29265170 DOI: 10.1111/jgs.15195] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine the effect of interventions to optimize medication use on adverse drug reactions (ADRs) in older adults. DESIGN Systematic review and meta-analysis. EMBASE, PubMed, OVID, Cochrane Library, Clinicaltrials.gov, and Google Scholar were searched through April 30, 2017. SETTING Randomized controlled trials. PARTICIPANTS Older adults (mean age ≥65) taking medications. MEASUREMENTS Two authors independently extracted relevant information and assessed studies for risk of bias. Discrepancies were resolved in consensus meetings. The outcomes were any and serious ADRs. Random-effects models were used to combine the results of multiple studies and create summary estimates. RESULTS Thirteen randomized controlled trials involving 6,198 older adults were included. The studies employed a number of different interventions that were categorized as pharmacist-led interventions (8 studies), other health professional-led interventions (3 studies), a brief educational session (1 study), and a technology intervention (1 study). The intervention group was 21% less likely than the control group to experience any ADR (odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.62-0.99). In the six studies that examined serious ADRs, the intervention group was 36% less likely than the control group to experience a serious ADR (OR = 0.64, 95% CI = 0.42-0.98). CONCLUSION Interventions designed to optimize medication use reduced the risk of any and serious ADRs in older adults. Implementation of these successful interventions in healthcare systems may improve medication safety in older adults.
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Affiliation(s)
- Shelly L Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Laura A Hart
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Subashan Perera
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd P Semla
- Pharmacy Benefits Management, Department of Veterans Affairs, Hines, Illinois.,Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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