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Importance: Bacteriuria plus pyuria is highly prevalent among older women living in nursing homes. Cranberry capsules are an understudied, nonantimicrobial prevention strategy used in this population. Objective: To test the effect of 2 oral cranberry capsules once a day on presence of bacteriuria plus pyuria among women residing in nursing homes. Design, Setting, and Participants: Double-blind, randomized, placebo-controlled efficacy trial with stratification by nursing home and involving 185 English-speaking women aged 65 years or older, with or without bacteriuria plus pyuria at baseline, residing in 21 nursing homes located within 50 miles (80 km) of New Haven, Connecticut (August 24, 2012-October 26, 2015). Interventions: Two oral cranberry capsules, each capsule containing 36 mg of the active ingredient proanthocyanidin (ie, 72 mg total, equivalent to 20 ounces of cranberry juice) vs placebo administered once a day in 92 treatment and 93 control group participants. Main Outcomes and Measures: Presence of bacteriuria (ie, at least 105 colony-forming units [CFUs] per milliliter of 1 or 2 microorganisms in urine culture) plus pyuria (ie, any number of white blood cells on urinalysis) assessed every 2 months over the 1-year study surveillance; any positive finding was considered to meet the primary outcome. Secondary outcomes were symptomatic urinary tract infection (UTI), all-cause death, all-cause hospitalization, all multidrug antibiotic-resistant organisms, antibiotics administered for suspected UTI, and total antimicrobial administration. Results: Of the 185 randomized study participants (mean age, 86.4 years [SD, 8.2], 90.3% white, 31.4% with bacteriuria plus pyuria at baseline), 147 completed the study. Overall adherence was 80.1%. Unadjusted results showed the presence of bacteriuria plus pyuria in 25.5% (95% CI, 18.6%-33.9%) of the treatment group and in 29.5% (95% CI, 22.2%-37.9%) of the control group. The adjusted generalized estimating equations model that accounted for missing data and covariates showed no significant difference in the presence of bacteriuria plus pyuria between the treatment group vs the control group (29.1% vs 29.0%; OR, 1.01; 95% CI, 0.61-1.66; P = .98). There were no significant differences in number of symptomatic UTIs (10 episodes in the treatment group vs 12 in the control group), rates of death (17 vs 16 deaths; 20.4 vs 19.1 deaths/100 person-years; rate ratio [RR], 1.07; 95% CI, 0.54-2.12), hospitalization (33 vs 50 admissions; 39.7 vs 59.6 hospitalizations/100 person-years; RR, 0.67; 95% CI, 0.32-1.40), bacteriuria associated with multidrug-resistant gram-negative bacilli (9 vs 24 episodes; 10.8 vs 28.6 episodes/100 person-years; RR, 0.38; 95% CI, 0.10-1.46), antibiotics administered for suspected UTIs (692 vs 909 antibiotic days; 8.3 vs 10.8 antibiotic days/person-year; RR, 0.77; 95% CI, 0.44-1.33), or total antimicrobial utilization (1415 vs 1883 antimicrobial days; 17.0 vs 22.4 antimicrobial days/person-year; RR, 0.76; 95% CI, 0.46-1.25). Conclusions and Relevance: Among older women residing in nursing homes, administration of cranberry capsules vs placebo resulted in no significant difference in presence of bacteriuria plus pyuria over 1 year. Trial Registration: clinicaltrials.gov Identifier: NCT01691430.
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Bacteriúria/tratamento farmacológico , Fitoterapia/métodos , Extratos Vegetais/uso terapêutico , Piúria/tratamento farmacológico , Vaccinium macrocarpon , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Bacteriúria/mortalidade , Cápsulas , Método Duplo-Cego , Farmacorresistência Bacteriana Múltipla , Feminino , Humanos , Casas de Saúde , Piúria/mortalidade , Resultado do Tratamento , Infecções Urinárias/tratamento farmacológicoRESUMO
We evaluated in vivo innate immune responses in monocyte populations from 67 young (aged 21-30 years) and older (aged ≥65 years) adults before and after influenza vaccination. CD14(+)CD16(+) inflammatory monocytes were induced after vaccination in both young and older adults. In classical CD14(+)CD16(-) and inflammatory monocytes, production of tumor necrosis factor α and interleukin 6, as measured by intracellular staining, was strongly induced after vaccination. Cytokine production was strongly associated with influenza vaccine antibody response; the highest levels were found as late as day 28 after vaccination in young subjects and were substantially diminished in older subjects. Notably, levels of the anti-inflammatory cytokine interleukin 10 (IL-10) were markedly elevated in monocytes from older subjects before and after vaccination. In purified monocytes, we found age-associated elevation in phosphorylated signal transducer and activator of transcription-3, and decreased serine 359 phosphorylation of the negative IL-10 regulator dual-specificity phosphatase 1. These findings for the first time implicate dysregulated IL-10 production in impaired vaccine responses in older adults.
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Citocinas/metabolismo , Vacinas contra Influenza/imunologia , Influenza Humana/prevenção & controle , Interleucina-10/metabolismo , Monócitos/metabolismo , Adulto , Fatores Etários , Idoso , Citocinas/imunologia , Fosfatase 1 de Especificidade Dupla/imunologia , Fosfatase 1 de Especificidade Dupla/metabolismo , Feminino , Proteínas Ligadas por GPI/imunologia , Proteínas Ligadas por GPI/metabolismo , Regulação da Expressão Gênica/imunologia , Humanos , Imunidade Inata , Influenza Humana/imunologia , Influenza Humana/virologia , Interleucina-10/imunologia , Interleucina-6/imunologia , Interleucina-6/metabolismo , Receptores de Lipopolissacarídeos/imunologia , Receptores de Lipopolissacarídeos/metabolismo , Masculino , Monócitos/imunologia , Fosforilação , Receptores de IgG/imunologia , Receptores de IgG/metabolismo , Fator de Transcrição STAT3/imunologia , Fator de Transcrição STAT3/metabolismo , Transdução de Sinais/imunologia , Fator de Necrose Tumoral alfa/imunologia , Fator de Necrose Tumoral alfa/metabolismo , Vacinação , Adulto JovemRESUMO
BACKGROUND: In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers. OBJECTIVES: To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP). RESEARCH DESIGN: Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures. SUBJECTS: The sample included 37,128 women Veterans aged 21 through 69 years. MEASURES: Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines. RESULTS: Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001). CONCLUSIONS: As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.
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Neoplasias da Mama/diagnóstico , Programas de Rastreamento/estatística & dados numéricos , Atenção Primária à Saúde , Neoplasias do Colo do Útero/diagnóstico , Saúde dos Veteranos , Saúde da Mulher , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Política Organizacional , Estudos Retrospectivos , Estados Unidos , United States Department of Veterans AffairsRESUMO
UNLABELLED: BACKGROUND/STUDY CONTEXT: The potential of cluster analysis (CA) as a baseline predictor of multivariate gerontologic outcomes over a long period of time has not been previously demonstrated. METHODS: Restricting candidate variables to a small group of established predictors of deleterious gerontologic outcomes, various CA methods were applied to baseline values from 754 nondisabled, community-living persons, aged 70 years or older. The best cluster solution yielded at baseline was subsequently used as a fixed explanatory variable in time-to-event models of the first occurrence of the following outcomes: any disability in four activities of daily living, any disability in four mobility measures, and death. Each outcome was recorded through a maximum of 129 months or death. Associations between baseline ordinal cluster level and first occurrence of all three outcomes were modeled over a 10-year period with proportional hazards regression and compared with the associations yielded by the analogous latent class analysis (LCA) solution. RESULTS: The final cluster-defining variables were continuous measures of cognitive status and depressive symptoms, and dichotomous indicators of slow gait and exhaustion. The best solution yielded by baseline values of these variables was obtained with a K-means algorithm and cosine similarity and consisted of three clusters representing increasing levels of impairment. After adjustment for age, sex, ethnic group, and number of chronic conditions, baseline ordinal cluster level demonstrated significantly positive associations with all three outcomes over a 10-year period that were equivalent to those from the corresponding LCA solution. CONCLUSION: These findings suggest that baseline clusters based on previously established explanatory variables have potential to predict multivariate gerontologic outcomes over a long period of time.
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Atividades Cotidianas , Envelhecimento/fisiologia , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Cognição , Depressão , Feminino , Marcha , Humanos , Masculino , CaminhadaRESUMO
This study examined the relationship between scores on the Hypnotic Induction Profile (HIP) and the trait of absorption in three different clinical groups: Smokers (n = 226), Phobics (n = 95), and patients with Chronic Pain (n = 65). Two hypotheses were investigated. The first predicted that both the Eye-Roll sign (ERS) and Induction Score (IND) of the HIP would correlate similarly (r = .30) with scores on the Tellegen Absorption Scale (TAS), as has been previously reported with other measures of hypnotic responsivity in student samples. The second was that using a combination of both ERS and IND scores to predict TAS scores would result in a significant increase in forecasting accuracy over using either HIP measure alone. Both hypotheses were supported in all three clinical groups. Correlations between HIP and Absorption scores ranged from .33 to .53. Clinical and theoretical implications of the findings are discussed.
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Dor Crônica/fisiopatologia , Hipnose , Transtornos Fóbicos/fisiopatologia , Fumar/fisiopatologia , Adulto , HumanosRESUMO
The pathogenesis of chronic obstructive pulmonary disease (COPD) remains poorly understood. Cellular senescence and apoptosis contribute to the development of COPD; however, crucial regulators of these underlying mechanisms remain unknown. Macrophage migration inhibitory factor (MIF) is a pleiotropic cytokine that antagonizes both apoptosis and premature senescence and may be important in the pathogenesis of COPD. This study examines the role of MIF in the pathogenesis of COPD. Mice deficient in MIF (Mif(-/-)) or the MIF receptor CD74 (Cd74(-/-)) and wild-type (WT) controls were aged for 6 mo. Both Mif(-/-) and Cd74(-/-) mice developed spontaneous emphysema by 6 mo of age compared with WT mice as measured by lung volume and chord length. This was associated with activation of the senescent pathway markers p53/21 and p16. Following exposure to cigarette smoke, Mif(-/-) mice were more susceptible to the development of COPD and apoptosis compared with WT mice. MIF plasma concentrations were measured in a cohort of 224 human participants. Within a subgroup of older current and former smokers (n = 72), MIF concentrations were significantly lower in those with COPD [8.8, 95%CI (6.7-11.0)] compared with those who did not exhibit COPD [12.7 ng/ml, 95%CI (10.6-14.8)]. Our results suggest that both MIF and the MIF receptor CD74 are required for maintenance of normal alveolar structure in mice and that decreases in MIF are associated with COPD in human subjects.
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Oxirredutases Intramoleculares/genética , Fatores Inibidores da Migração de Macrófagos/genética , Doença Pulmonar Obstrutiva Crônica/genética , Receptores Imunológicos/sangue , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Animais , Apoptose/efeitos dos fármacos , Senescência Celular , Inibidor p16 de Quinase Dependente de Ciclina/metabolismo , Inibidor de Quinase Dependente de Ciclina p21/metabolismo , Enfisema/genética , Feminino , Humanos , Oxirredutases Intramoleculares/deficiência , Pulmão/metabolismo , Fatores Inibidores da Migração de Macrófagos/deficiência , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Pessoa de Meia-Idade , Receptores Imunológicos/deficiência , Receptores Imunológicos/genética , Fumaça/efeitos adversos , Fumar/efeitos adversos , Nicotiana/efeitos adversos , Proteína Supressora de Tumor p53/metabolismo , Adulto JovemRESUMO
Sepsis is a systemic inflammatory response to infection and a major cause of death worldwide. Because specific therapies to treat sepsis are limited, and underlying pathogenesis is unclear, current medical care remains purely supportive. Therefore targeted therapies to treat sepsis need to be developed. Although an important mediator of sepsis is thought to be mitochondrial dysfunction, the underlying molecular mechanism is unclear. Modulation of mitochondrial processes may be an effective therapeutic strategy in sepsis. Here, we investigated the role of the kinase MKK3 in regulation of mitochondrial function in sepsis. Using clinically relevant animal models, we examined mitochondrial function in primary mouse lung endothelial cells exposed to LPS. MKK3 deficiency reduces lethality of sepsis in mice and by lowering levels of lung and mitochondrial injury as well as reactive oxygen species. Furthermore, MKK3 deficiency appeared to simultaneously increase mitochondrial biogenesis and mitophagy through the actions of Sirt1, Pink1, and Parkin. This led to a more robust mitochondrial network, which we propose provides protection against sepsis. We also detected higher MKK3 activation in isolated peripheral blood mononuclear cells from septic patients compared with nonseptic controls. Our findings demonstrate a critical role for mitochondria in the pathogenesis of sepsis that involves a previously unrecognized function of MKK3 in mitochondrial quality control. This mitochondrial pathway may help reveal new diagnostic markers and therapeutic targets against sepsis.
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Lesão Pulmonar/etiologia , MAP Quinase Quinase 3/sangue , MAP Quinase Quinase 3/deficiência , Mitocôndrias/fisiologia , Mitofagia , Sepse/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Animais , Células Endoteliais/metabolismo , Feminino , Humanos , Lipopolissacarídeos , Pulmão/metabolismo , MAP Quinase Quinase 3/fisiologia , Masculino , Camundongos , Pessoa de Meia-Idade , Mitocôndrias/efeitos dos fármacos , Mitofagia/efeitos dos fármacos , Proteínas Quinases/metabolismo , Sepse/complicações , Sirtuína 1/antagonistas & inibidores , Ubiquitina-Proteína Ligases/metabolismoAssuntos
Família , Procurador , Fatores Etários , Idoso , Distribuição de Qui-Quadrado , Connecticut , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Consentimento do Representante Legal , VeteranosRESUMO
Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.
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Analgésicos Opioides/uso terapêutico , Analgésicos/uso terapêutico , Osteoartrite/tratamento farmacológico , Dor/tratamento farmacológico , Acetaminofen/uso terapêutico , Idoso , Analgésicos não Narcóticos/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , VeteranosRESUMO
This study evaluated the effect of the alpha-2A-adrenoceptor agonist guanfacine on prefrontally mediated cognitive functions, as well as quality of life and global function in healthy older participants. One hundred twenty-three participants aged 75 years and older were randomly assigned to guanfacine 0.5 mg, 0.1 mg, or placebo daily for 12 weeks. The primary outcome measure was the change in z-score for 6 prefrontal executive function tasks over 12 weeks (PEF6). Neither dose of guanfacine improved PEF6 z-score relative to placebo. The rate of mean change (95% confidence interval) in PEF6 z-score over 12 weeks was 0.270 (0.159, 0.380) for placebo, compared with 0.121 (0.011, 0.232) for guanfacine 0.1 mg (p = 0.06, compared to placebo) and 0.213 (0.101, 0.324) for 0.5 mg (p = 0.47). Neither dose of guanfacine improved the quality of life or global function relative to placebo. Among common adverse events, only dry mouth was significantly more frequent on guanfacine compared to placebo. Guanfacine failed to ameliorate prefrontal cognitive function in older individuals, who were cognitively normal for age.
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Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Disfunção Cognitiva/tratamento farmacológico , Guanfacina/uso terapêutico , Córtex Pré-Frontal/fisiopatologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/fisiopatologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Testes Neuropsicológicos , Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: Clinical trials of older adults are increasingly common, but risks of serious adverse events (SAE) may vary. We describe the incidence of SAE in two randomized trials, one community-based and one nursing home-based. METHODS: We performed a secondary data analysis from two randomized clinical trials at one academic health center and 21 nursing homes involving 200 sedentary community dwellers aged 70-89 years and 185 female nursing home residents aged 65 years or older. Interventions included structured physical activity to reduce mobility disability in the Lifestyle Interventions and Independence for Elders (LIFE) study and oral cranberry capsules to reduce bacteriuria plus pyuria in nursing home residents (CRANNY) trial. We measured SAE incidence per 100 person-years and incidence of protocol-related unanticipated SAE per 100 person-years in LIFE and CRANNY trials. RESULTS: Mean age and proportion of patients with dementia in LIFE and CRANNY trials were 79.3 years and 86.4 years and 0% and 78%, respectively. There were 179 total SAE in LIFE including 8 (4%) deaths, and 116 total SAE in CRANNY including 33 (28%) deaths. SAE incidence was 33.7 (95% CI 27.2, 41.8) events per 100 person-years in LIFE and 69.4 (95% CI 49.1, 98.1) events per 100 person-years in CRANNY. No protocol-related unanticipated SAE occurred in either trial. CONCLUSIONS: The frequency and severity of SAE vary in older adults. While SAE are common in nursing home residents, protocol-related, unanticipated SAE are rare in nursing home residents and community dwellers. This finding can inform trial monitoring protocols. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT01072500 and NCT01691430.
RESUMO
Depot medroxyprogesterone acetate (DMPA) is a common medical treatment for endometriosis in NHP. Because DMPA reportedly impairs glucoregulatory function in humans and rhesus macaques, as well as predisposes humans to diabetes mellitus (DM), we performed a retrospective study to further investigate its potential long-term clinical effects in animals with and without DM. Using a cohort of 29 rhesus macaques, we explored the hypotheses that DMPA treatment accelerates the onset of DM and that its use in rhesus macaques with endometriosis worsens clinical outcome measures (lifespan, body weight and body condition score). For both body weight and body condition score, a declining and statistically significant trend in mean values was evident as macaques developed either DM, or endometriosis or both. The addition of DMPA did not significantly alter this pattern. The presence of DM, endometriosis, or DMPA treatment statistically but not clinically significantly increased risk of death. Similarly, the presence of the 2 highly correlated variables endometriosis and DMPA treatment statistically but not clinically significantly increased the risk of incident DM. These results indicate that DMPA treatment was associated with worsening trends in lifespan and incident DM, however these trends did not achieve clinical significance in this cohort.
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Complicações do Diabetes/veterinária , Endometriose/veterinária , Macaca mulatta , Acetato de Medroxiprogesterona/efeitos adversos , Doenças dos Macacos/tratamento farmacológico , Animais , Preparações de Ação Retardada , Complicações do Diabetes/tratamento farmacológico , Endometriose/complicações , Endometriose/tratamento farmacológico , Feminino , Acetato de Medroxiprogesterona/administração & dosagem , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The TAM receptors (Tyro3, Axl, and Mer) are a family of homologous receptor-tyrosine kinases that inhibit Toll-like receptor signaling to regulate downstream pathways and restore homeostasis. TAM triple mutant mice (Tyro3-/-, Axl-/-, Mer-/-) have elevated levels of pro-inflammatory cytokines and are prone to developing lymphoproliferative disorders and autoimmunity. Understanding differential expression of TAM receptors among human subjects is critical to harnessing this pathway for therapeutic interventions. We have quantified changes in TAM expression during the ontogeny of human macrophages using paired samples of monocytes and macrophages to take advantage of characteristic expression within an individual. No significant differences in levels of Tyro3 were found between monocytes and macrophages (flow cytometry: p=0.652, immunoblot: p=0.231, qPCR: p=0.389). Protein levels of Axl were reduced (flow cytometry: p=0.049, immunoblot: p<0.001) when monocytes matured to macrophages. No significant differences in the levels of Axl mRNA transcripts were found (qPCR: p=0.082), however, Tyro3 and Axl were proportionate. The most striking difference was upregulation of expression of Mer with both protein and mRNA being significantly increased when monocytes developed into macrophages (flow cytometry: p<0.001, immunoblot: p<0.001, qPCR: p=0.004). A fuller characterization of TAM receptor expression in macrophage ontogeny informs our understanding of their function and potential therapeutic interventions.
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BACKGROUND: Persons with multiple chronic conditions receive multiple guideline-recommended medications to improve outcomes such as mortality. Our objective was to estimate the longitudinal average attributable fraction for 3-year survival of medications for cardiovascular conditions in persons with multiple chronic conditions and to determine whether heterogeneity occurred by age. METHODS: Medicare Current Beneficiary Survey participants (N = 8,578) with two or more chronic conditions, enrolled from 2005 to 2009 with follow-up through 2011, were analyzed. We calculated the longitudinal extension of the average attributable fraction for oral medications (beta blockers, renin-angiotensin system blockers, and thiazide diuretics) indicated for cardiovascular conditions (atrial fibrillation, coronary artery disease, heart failure, and hypertension), on survival adjusted for 18 participant characteristics. Models stratified by age (≤80 and >80 years) were analyzed to determine heterogeneity of both cardiovascular conditions and medications. RESULTS: Heart failure had the greatest average attributable fraction (39%) for mortality. The fractional contributions of beta blockers, renin-angiotensin system blockers, and thiazides to improve survival were 10.4%, 9.3%, and 7.2% respectively. In age-stratified models, of these medications thiazides had a significant contribution to survival only for those aged 80 years or younger. The effects of the remaining medications were similar in both age strata. CONCLUSIONS: Most cardiovascular medications were attributed independently to survival. The two cardiovascular conditions contributing independently to death were heart failure and atrial fibrillation. The medication effects were similar by age except for thiazides that had a significant contribution to survival in persons younger than 80 years.
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Antagonistas Adrenérgicos beta/uso terapêutico , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/mortalidade , Múltiplas Afecções Crônicas/tratamento farmacológico , Múltiplas Afecções Crônicas/mortalidade , Tiazidas/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Prescrições de Medicamentos , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Medicare , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Inquéritos e Questionários , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
We postulated that associations between two specific provider characteristics, class (nurse practitioner relative to physician) and primary care providers who are proficient and interested in women's health (designated women's provider relative to nondesignated) and overall satisfaction with provider, were mediated through women veterans' perception of enough time spent with the provider. A national patient experience survey was administered to 7,620 women veterans. Multivariable models of overall patient satisfaction with provider were compared with and without the proposed mediator. A structural equation model (SEM) of the mediation of the two provider characteristics was also evaluated. Without the mediator, associations of provider class and designation with overall patient satisfaction were significant. With the proposed mediator, these associations became nonsignificant. An SEM showed that the majority (>80%) of the positive associations between provider class and designation and the outcome were exerted through patient perception of enough time spent with provider. Higher ratings of overall satisfaction with provider exhibited by nurse practitioners and designated women's health providers were exerted through patient perception of enough time spent with provider. Future research should examine what elements of provider training can be developed to improve provider-patient communication and patient satisfaction with their health care.
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Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/estatística & dados numéricos , Profissionais de Enfermagem/estatística & dados numéricos , Satisfação do Paciente , Médicos de Atenção Primária/estatística & dados numéricos , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Percepção , Fatores Socioeconômicos , Fatores de Tempo , Estados Unidos , United States Department of Veterans Affairs , Veteranos , Saúde da MulherRESUMO
Influenza A virus (IAV) causes up to half a million deaths worldwide annually, 90% of which occur in older adults. We show that IAV-infected monocytes from older humans have impaired antiviral interferon production but retain intact inflammasome responses. To understand the in vivo consequence, we used mice expressing a functional Mx gene encoding a major interferon-induced effector against IAV in humans. In Mx1-intact mice with weakened resistance due to deficiencies in Mavs and Tlr7, we found an elevated respiratory bacterial burden. Notably, mortality in the absence of Mavs and Tlr7 was independent of viral load or MyD88-dependent signaling but dependent on bacterial burden, caspase-1/11, and neutrophil-dependent tissue damage. Therefore, in the context of weakened antiviral resistance, vulnerability to IAV disease is a function of caspase-dependent pathology.
Assuntos
Infecções Bacterianas/imunologia , Imunidade Inata/imunologia , Vírus da Influenza A/imunologia , Influenza Humana/imunologia , Proteínas de Resistência a Myxovirus/fisiologia , Infecções por Orthomyxoviridae/imunologia , Infecções Respiratórias/imunologia , Proteínas Adaptadoras de Transdução de Sinal/genética , Proteínas Adaptadoras de Transdução de Sinal/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Infecções Bacterianas/etiologia , Caspase 1/metabolismo , Caspases/metabolismo , Caspases Iniciadoras , Feminino , Humanos , Imunidade Inata/genética , Influenza Humana/complicações , Interferon beta/imunologia , Masculino , Glicoproteínas de Membrana/genética , Glicoproteínas de Membrana/metabolismo , Camundongos , Monócitos/imunologia , Proteínas de Resistência a Myxovirus/genética , Neutrófilos/imunologia , Infecções Respiratórias/microbiologia , Receptor 7 Toll-Like/genética , Receptor 7 Toll-Like/metabolismo , Carga Viral , Adulto JovemRESUMO
PURPOSE: The objective is to modify the longitudinal extension of the average attributable fraction (LE-AAF) for recurrent outcomes with time-varying exposures and control for covariates. METHODS: We included Medicare Current Beneficiary Survey participants with two or more chronic conditions enrolled from 2005 to 2009 with follow-up through 2011. Nine time-varying medications indicated for nine time-varying common chronic conditions and 14 of 18 forward-selected participant characteristics were used as control variables in the generalized estimating equations step of the LE-AAF to estimate associations with the recurrent universal health outcome self-rated health (SRH). Modifications of the LE-AAF were made to accommodate these indicated medication-condition interactions and covariates. Variability was empirically estimated by bias-corrected and accelerated bootstrapping. RESULTS: In the adjusted LE-AAF, thiazide, warfarin, and clopidogrel had significant contributions of 1.2%, 0.4%, 0.2%, respectively, to low (poor or fair) SRH; whereas there were no significant contributions of the other medications to SRH. Hyperlipidemia significantly contributed 4.6% to high SRH. All the other conditions except atrial fibrillation contributed significantly to low SRH. CONCLUSIONS: Our modifications to the LE-AAF method apply to a recurrent binary outcome with time-varying factors accounting for covariates.
Assuntos
Doença Crônica/tratamento farmacológico , Nível de Saúde , Adesão à Medicação , Atividades Cotidianas , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Estudos Longitudinais , Masculino , Modelos Estatísticos , Autorrelato , Inquéritos e Questionários , Fatores de TempoRESUMO
Scholars argue about whether age stereotypes (beliefs about old people) are becoming more negative or positive over time. No previous study has systematically tested the trend of age stereotypes over more than 20 years, due to lack of suitable data. Our aim was to fill this gap by investigating whether age stereotypes have changed over the last two centuries and, if so, what may be associated with this change. We hypothesized that age stereotypes have increased in negativity due, in part, to the increasing medicalization of aging. This study applied computational linguistics to the recently compiled Corpus of Historical American English (COHA), a database of 400 million words that includes a range of printed sources from 1810 to 2009. After generating a comprehensive list of synonyms for the term elderly for these years from two historical thesauri, we identified 100 collocates (words that co-occurred most frequently with these synonyms) for each of the 20 decades. Inclusion criteria for the collocates were: (1) appeared within four words of the elderly synonym, (2) referred to an old person, and (3) had a stronger association with the elderly synonym than other words appearing in the database for that decade. This yielded 13,100 collocates that were rated for negativity and medicalization. We found that age stereotypes have become more negative in a linear way over 200 years. In 1880, age stereotypes switched from being positive to being negative. In addition, support was found for two potential explanations. Medicalization of aging and the growing proportion of the population over the age of 65 were both significantly associated with the increase in negative age stereotypes. The upward trajectory of age-stereotype negativity makes a case for remedial action on a societal level.
Assuntos
Modelos Teóricos , Fatores Etários , HumanosRESUMO
OBJECTIVE: To estimate the association between guideline recommended drugs and death in older adults with multiple chronic conditions. DESIGN: Population based cohort study. SETTING: Medicare Current Beneficiary Survey cohort, a nationally representative sample of Americans aged 65 years or more. PARTICIPANTS: 8578 older adults with two or more study chronic conditions (atrial fibrillation, coronary artery disease, chronic kidney disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, and thromboembolic disease), followed through 2011. EXPOSURES: Drugs included ß blockers, calcium channel blockers, clopidogrel, metformin, renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazides; and warfarin. MAIN OUTCOME MEASURE: Adjusted hazard ratios for death among participants with a condition and taking a guideline recommended drug relative to participants with the condition not taking the drug and among participants with the most common combinations of four conditions. RESULTS: Over 50% of participants with each condition received the recommended drugs regardless of coexisting conditions; 1287/8578 (15%) participants died during the three years of follow-up. Among cardiovascular drugs, ß blockers, calcium channel blockers, RAS blockers, and statins were associated with reduced mortality for indicated conditions. For example, the adjusted hazard ratio for ß blockers was 0.59 (95% confidence interval 0.48 to 0.72) for people with atrial fibrillation and 0.68 (0.57 to 0.81) for those with heart failure. The adjusted hazard ratios for cardiovascular drugs were similar to those with common combinations of four coexisting conditions, with trends toward variable effects for ß blockers. None of clopidogrel, metformin, or SSRIs/SNRIs was associated with reduced mortality. Warfarin was associated with a reduced risk of death among those with atrial fibrillation (adjusted hazard ratio 0.69, 95% confidence interval 0.56 to 0.85) and thromboembolic disease (0.44, 0.30 to 0.62). Attenuation in the association with reduced risk of death was found with warfarin in participants with some combinations of coexisting conditions. CONCLUSIONS: Average effects on survival, particularly for cardiovascular study drugs, were comparable to those reported in randomized controlled trials but varied for some drugs according to coexisting conditions. Determining treatment effects in combinations of conditions may guide prescribing in people with multiple chronic conditions.