Immunogenicity and safety of routine vaccines in children and adolescents with rheumatic diseases on immunosuppressive treatment - a systematic review.

The immunogenicity of vaccines in children with juvenile autoimmune rheumatic diseases (JARDs) can be reduced, there are additional safety concerns around vaccination, and there is a potential for worsening in disease activity. In this systematic review, we summarise studies that investigated the immunogenicity and safety of routine vaccines in children and adolescents with JARD on immunosuppressive treatment. We identified 37 studies investigating 2571 children and adolescents with JARD on immunosuppressive treatment and 4895 control children. Of the 56 geometric mean antibody titres measured, 19 (34%) were lower, six (11%) higher, and 31 (55%) similar; of the 39 seroprotection rates measured, 10 (26%) were lower, two (5%) higher, and 27 (69%) similar; and of the 27 seroconversion rates measured, nine (33%) were lower, two (8%) higher, and 16 (59%) similar in children with JARD on immunosuppressive treatment compared with control children. However, many of the studies were underpowered, and not designed to show non-inferiority between children with JARD and controls. Subgroup analysis for different types of immunosuppressive treatments was not feasible, as most studies did not report results by treatment. Severe adverse events were reported in 38 children (33 with juvenile idiopathic arthritis, four with systemic lupus erythematosus, and one in a healthy child); most of them were likely not related to the vaccination (e.g. elective hospitalisation or surgery). A worsening in disease activity was reported in 44 (2%) children with JARD; again, many of them were likely not related to the vaccination. There were no safety concerns with live attenuated vaccines; however, only few studies reported results for this. CONCLUSION: Vaccination in children with JARD on immunosuppressive treatment is safe and should be promoted, especially since these children are at increased risk for infection. The importance for the completion of vaccination schedules should be stressed. Strategies to compensate for the lower vaccine responses, which are found in approximately one-third of these children, include measuring antibody levels to determine the optimal timing for the administration of additional booster doses. WHAT IS KNOWN: • Children with juvenile autoimmune rheumatic diseases (JARDs) are at higher risk for infections, due to their underlying disease and their immunosuppressive treatment. • In children with JARD, the immunogenicity of vaccines might be reduced, and concerns about safety or the potential for worsening in disease activity after vaccination exist. WHAT IS NEW: • Our systematic review shows that vaccines in children with JARDs on immunosuppressive treatment are safe and immunogenic. • There are several limitations of the currently published studies, including random timing of measuring vaccine responses and age differences between children with JARD and control groups. Many of the studies were underpowered, and not designed to show non-inferiority between children with JARD and controls.

Drip irrigation uptake in traditional irrigated fields: The edaphological impact.

Historical and traditional flood-irrigated (FI) schemes are progressively being upgraded by means of drip irrigation (DI) to tackle current water and demographic challenges. This modernization process is likely to foster several changes of environmental relevance at the system level. In this paper we assess the effects derived from DI uptake on soil health and structure in ancient FI systems through the case study of Ricote, SE Spain, first established in the 10-13th centuries CE. We approach the topic by means of physico-chemical analyses (pH, electrical conductivity, available P, carbon analyses, bulk density, soil water content and particle size distribution), Electrical Resistivity Measurements (ERT) and robust statistics. We reach a power of 1-ß = 77 aiming at detecting a large effect size (f ≥ 0.4). Results indicate that, compared to FI, DI soils present significantly higher water content, a higher proportion of coarse particles relative to fines due to clay translocation, and less dispersion in salt contents. The soils away from the emitters, which were formerly FI and comparatively account for larger extensions, appear significantly depleted in organic matter, available P and N. These results are not affected by departures from statistical model assumptions and suggest that DI uptake in formerly FI systems might have relevant implications in terms of soil degradation and emission of greenhouse gases. A proper assessment of the edaphological trade-offs derived from this modernization process is mandatory in order to tackle undesired environmental consequences.

Looking Ahead to 2030: Survey of Evolving Needs in Pharmacy Education.

In order to keep pharmacy education relevant to a rapidly-evolving future, this study sought to identify key insights from leaders from a broad array of pharmacy and non-pharmacy industries on the future of the pharmacy profession, pharmaceutical sciences, and pharmacy education. Thought leaders representing a variety of industries were surveyed regarding their perspectives on the future of pharmacy practice, pharmaceutical science disciplines, and pharmacy education in seven domains. From 46 completed surveys, top challenges/threats were barriers that limit clinical practice opportunities, excessive supply of pharmacists, and high drug costs. Major changes in the drug distribution system, automation/robotics, and new therapeutic approaches were identified as the top technological disrupters. Key drivers of pharmacy education included the primary care provider shortage, growing use of technology and data, and rising drug costs. The most significant sources of job growth outside of retail and hospital settings were managed care organizations, technology/biotech/pharmaceutical companies, and ambulatory care practices. Needs in the industry included clinical management of complex patients, leadership and management, pharmaceutical scientists, and implementation science. Knowledge gaps were pharmacists not recognizing their value on the health care team, preparation to embrace and lead change, and expertise in data science and analytics. Pharmacy schools will need to address several disruptive trends to future-proof their curricula, including expanding patient management skills, leadership and management training, technology, and data analytics.

Personalized implementation of video telehealth for rural veterans (PIVOT-R).

BACKGROUND: A national shortage of mental health (MH) professionals leaves more than 90% of rural individuals without adequate access to services each year, troubling because 33% of Veterans Health Administration (VHA) enrollees live in rural areas and rural Veterans have a greater risk of suicide than urban Veterans. Additional barriers such as travel distance and cost, stigma and extreme weather or geography add to challenges of rural Veterans seeking treatment. Although the VHA has addressed this disparity by providing telemental health services, provision of services via traditional hub-and-spoke and/or establishment of regional centers has not fully addressed barriers or resource limitations. Video telehealth to home (VTH) has assisted in better addressing geographic, attitudinal and systematic barriers to in-person care; however, its uptake and implementation have been problematic. This article describes the Personalized Implementation of Video Telehealth for Rural Veterans (PIVOT-R) approach, developed in response to the unique needs of rural veterans. METHODS: We developed PIVOT, a flexible implementation strategy that is adaptive to site-specific contexts and different digital innovations and relies on a collaborative relationship between external facilitators, internal facilitators and clinical champions. We used formative evaluation (FE) to gather ongoing information about our quality improvement (QI) implementation approach of VTH. Our FE of PIVOT at rural sites provided insight into adaptations to improve rural implementation. This led to development of PIVOT-R, which explicitly focuses on rural implementation. PIVOT-R, developed from provider and patient feedback plus lessons learned during implementation, focuses on rurality as an important diversity factor and addresses relationship building, engaging the site, assessing context and infrastructure and balancing national expectations with site-level goals. During fiscal year 2018 we partnered with a VHA healthcare system in a Western mountain state to pilot the PIVOT-R approach, again using FE which included quantitative and qualitative data collection to evaluate its impact. RESULTS: PIVOT-R effectively increased uptake of VTH for MH care at the healthcare system evaluated. In fiscal year 2019 the percentage of Veterans receiving MH care via VTH at the site was 10 times greater than in fiscal year 2018, matching the mean VHA nationwide percentage and increasing by 43.24% by the end of 2019. Veteran feedback supported a positive experience by users. CONCLUSIONS: Inclusion of a comprehensive assessment of the rural system, including infrastructure and resources, greatly improves understanding of a system's specific needs and enables a tailored approach targeting relevant barriers. Our FE suggests the potential of PIVOT-R to increase VTH uptake at other rural locations and reinforces the value of telehealth technology as an important resource for rural sites.