Immune resilience despite inflammatory stress promotes longevity and favorable health outcomes including resistance to infection.

Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve and/or rapidly restore immune functions that promote disease resistance (immunocompetence) and control inflammation in infectious diseases as well as other causes of inflammatory stress. We gauge IR levels with two distinct peripheral blood metrics that quantify the balance between (i) CD8+ and CD4+ T-cell levels and (ii) gene expression signatures tracking longevity-associated immunocompetence and mortality-associated inflammation. Profiles of IR metrics in ~48,500 individuals collectively indicate that some persons resist degradation of IR both during aging and when challenged with varied inflammatory stressors. With this resistance, preservation of optimal IR tracked (i) a lower risk of HIV acquisition, AIDS development, symptomatic influenza infection, and recurrent skin cancer; (ii) survival during COVID-19 and sepsis; and (iii) longevity. IR degradation is potentially reversible by decreasing inflammatory stress. Overall, we show that optimal IR is a trait observed across the age spectrum, more common in females, and aligned with a specific immunocompetence-inflammation balance linked to favorable immunity-dependent health outcomes. IR metrics and mechanisms have utility both as biomarkers for measuring immune health and for improving health outcomes.

Immunologic resilience and COVID-19 survival advantage.

BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE: We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS: IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS: IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS: Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.

Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study.

BACKGROUND: Modifiable risks for coronary heart disease (CHD) in type 2 diabetes include glucose, blood pressure, lipid control, and smoking. The chronic care model (CCM) provides an organizational framework for improving these outcomes. OBJECTIVE: To examine the relationship between CHD risk attributable to modifiable risk factors among patients with type 2 diabetes and whether care delivered in primary care settings is consistent with the CCM. SUBJECTS/METHODS: Approximately 30 patients in each of 20 primary care clinics. CHD risk factors were assessed by patient survey and chart abstraction. Absolute 10-year CHD risk was calculated using the UK Prospective Diabetes Study risk engine. Attributable risk was calculated by setting all 4 modifiable risk factors to guideline indicated values, recalculating the risk, and subtracting it from the absolute risk. In each clinic, the consistency of care with the CCM was evaluated using the Assessment of Chronic Illness Care (ACIC) survey. RESULTS: Only 15.4% had guideline-recommended control of A1c, blood pressure, and lipids. The absolute 10-year risk CHD was 16.2% (SD 16.6). One-third of this risk, 5.0% (SD 7.4), was attributable to poor risk factor control. After controlling for patient and clinic characteristics, the ACIC score was inversely associated with attributable risk: a 1 point increase in the ACIC score was associated with a 16% (95% CI, 5-26%) relative decrease in attributable risk. DISCUSSION: The degree to which care delivered in a primary care clinic conforms to the CCM is an important predictor of the 10-year risk of CHD among patients with type 2 diabetes.

Characteristics associated with sustained abstinence from smoking among patients with COPD.

PURPOSE: Smoking cessation is the mainstay of recommended treatment for chronic obstructive pulmonary disease (COPD), yet many continue smoking. This study seeks to understand the characteristics of patients with COPD who have quit and those who have not quit to identify important factors to evaluate in smoking-cessation interventions. SUBJECTS/METHODS: A cross-sectional survey of a random sample of 1.5 million, predominantly male Veterans Administration enrollees. Of the respondents (63% [n = 887,775]), those with at least 1 COPD visit, a smoking history, and aged more than 34 years were included in this analysis (n = 89 337). Differences in demographics, functional status, comorbidities, and provider-patient interactions were evaluated for current and former smokers. RESULTS: Ninety-seven percent of the cohort with COPD was male. Former smokers (n = 58 482) were older (mean age of 69.6 vs 62.8, P<.001) and had more cardiac comorbidities, but better mental health (Mean Mental Component Summary score from the Veterans Short Form-36 +/- standard deviation of 43.4 +/- 13.2 vs 39.9 +/- 13.7, P<.001) than current smokers (n = 25 595), respectively. In addition, former smokers more actively participated in their health care and had a better relationship with their provider than current smokers. CONCLUSION: Former smokers with COPD were older, had more cardiac comorbidities, better mental health, and better perceived provider-patient interactions than active smokers. This study highlights the importance of screening participants with COPD who are enrolling in forthcoming smoking cessation trials for mental illnesses. In addition, developing interventions that address psychiatric comorbidities and potentially improve provider-patient communication may be other key areas to evaluate in future smoking cessation trials in patients with COPD.

Mexican American elders have similar severities of COPD despite less tobacco exposure than European American elders.

INTRODUCTION: Hispanics are the fastest growing ethnicity of the US population and the largest subset includes those of Mexican origin. Hispanics, including Mexican Americans (MAs), consistently report less tobacco exposure than European Americans (EAs), but limited data are available regarding differences in the clinical characteristics, severity of airflow obstruction, and functional status between MAs and EAs with chronic obstructive pulmonary disease (COPD). METHODS: Participants in a community-based study of aging and frailty among MAs and EAs, San Antonio Longitudinal Study of Aging, underwent spirometry. Participants with spirometry values consistent with COPD by Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria are described here. RESULTS: Thirty-four percent (248/721) of the participants who underwent spirometry had evidence of GOLD Stages 1-4 COPD. Significantly more MAs with COPD reported being never smokers compared to EAs with COPD. Among those with COPD who also smoked, MAs reported significantly less tobacco exposure than EAs (15.7 vs. 32.4 pack-years, respectively), but both groups had surprisingly similar severities of airflow obstruction. Additionally, MAs had worse functional status and perceived health than did EAs. CONCLUSIONS: Despite significantly less exposure to tobacco smoke, MAs with COPD had a similar degree of obstruction to airflow compared with EAs with COPD. Healthcare providers should have a high index of suspicion for COPD in MAs who are exposed to even small amounts of cigarette smoke.

Self-care communication during medical encounters: implications for future electronic medical records.

OBJECTIVE: The growing importance of electronic medical records (EMRs) to healthcare systems is evident, yet the debate concerning their impact on patient-provider communication during encounters remains unresolved. For this study, we hypothesize that providers' use of the EMR will improve patient-provider communication concerning self-care during the medical encounter. DESIGN: Cross-sectional, observational study. SETTING: A primary-care outpatient clinic of the South Texas Veterans Health Care System in San Antonio, TX, USA. METHODS: A convenience sample of 50 patient/physician encounters was videotaped, transcribed verbatim, and analyzed to determine the time that the physician spent using the EMR and self-care topics discussed. Self-care topics included medication use, recognition of disease symptoms, diet, exercise, management of physical and emotional distress, self-monitoring activities, cigarette smoking, alcohol consumption, and family support/community resources. Two observers independently coded for the kind of self-care topics (kappa = 0.91) using the Atlas.ti software package. RESULTS: Encounters averaged 22.6 minutes (range: 5-47, SD = 8.9). We identified two encounter types based on EMR usage: low use (n = 13), with EMR use of two minutes or less, and moderate to high EMR use (n = 37), with EMR use of five minutes or more. Average time for encounters was 25 minutes for moderate to high EMR use encounters and 16 minutes for low EMR use encounters (t test, p < 0.001). Issues pertaining to facets of self-care management were discussed in every physician-patient interaction (100 percent). The most frequently discussed self-care topics were medication use (100 percent), physical distress (76 percent), and disease symptoms (76 percent). Self-monitoring activities, exercise, and diet were discussed in 62 percent, 60 percent, and 46 percent of the 50 encounters respectively. Emotional distress (26 percent), smoking (30 percent), family support/community resources (26 percent), and alcohol consumption (20 percent) were the least discussed issues. Encounters were similar with respect to the kinds of self-care elements discussed. However, EMR use encounters were more likely to include a higher number of self-care topics raised by physicians than low EMR use encounters, particularly on disease symptoms (odds ratio = 4.4, p = 0.05), and physical distress (odds ratio = 7.4, p = 0.006). A significant correlation was observed between the number of self-care elements discussed and time spent on the EMR (r = 0.6, p < 0.05), but no correlation was observed between the length of the encounter and self-care discussion (r = 0.009, p = 0.90). CONCLUSIONS: The use of an EMR during encounters is associated with an increase in the number of self-care topics raised by physicians. EMRs offer the opportunity to involve patients and physicians in discussion of self-care during patients' visits. Given the current emphasis on the widespread implementation of EMRs, future EMRs should be designed to systematically facilitate the integration of EMRs into clinical exchanges about self-care.

Collaborative care needs and preferences of primary care patients with multimorbidity.

OBJECTIVE To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses. DESIGN Focus groups utilizing a series of open-ended questions elicited self-identified problems, experiences in communicating with providers, self-management needs, and preferences for monitoring and follow-up. Responses were organized and interpreted in light of the essential elements of collaborative care for chronic illness. SETTING AND PARTICIPANTS Sixty patients having two or more chronic illnesses at eight geographically dispersed primary care clinics within the Veterans Health Administration in the United States. RESULTS Identified problems included poor functioning, negative psychological reactions, negative effects on relationships and interference with work or leisure. Polypharmacy was a major concern. Problematic interactions with providers and the health care system were also mentioned, often in relation to specialty care and included incidents in which providers had ignored concerns or provided conflicting advice. Most participants, however, expressed overall satisfaction with their care and appreciation of their primary care physicians. Knowledge and skills deficits interfered with self-management. Participants were willing to use technology for monitoring or educational purposes if it did not preclude human contact, and were receptive to non-physician providers as long as they were used to augment, not eliminate, a physician's care. CONCLUSIONS Findings are consistent with the basic tenets of patient-centred, collaborative care, and suggested that health care can be organized and delivered to meet the complex needs of patients with multimorbidity.