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IMPORTANCE: Uptake of COVID-19 vaccines among pregnant individuals was hampered by safety concerns around potential risks to unborn children. Data clarifying early neurodevelopmental outcomes of offspring exposed to COVID-19 vaccination in utero are lacking. OBJECTIVE: To determine whether in utero exposure to maternal COVID-19 vaccination was associated with differences in scores on the Ages and Stages Questionnaire, third edition (ASQ-3), at 12 and 18 months of age. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study, Assessing the Safety of Pregnancy During the Coronavirus Pandemic (ASPIRE), enrolled pregnant participants from May 2020 to August 2021; follow-up of children from these pregnancies is ongoing. Participants, which included pregnant individuals and their offspring from all 50 states, self-enrolled online. Study activities were performed remotely. EXPOSURE: In utero exposure of the fetus to maternal COVID-19 vaccination during pregnancy was compared with those unexposed. MAIN OUTCOMES AND MEASURES: Neurodevelopmental scores on validated ASQ-3, completed by birth mothers at 12 and 18 months. A score below the established cutoff in any of 5 subdomains (communication, gross motor, fine motor, problem solving, social skills) constituted an abnormal screen for developmental delay. RESULTS: A total of 2487 pregnant individuals (mean [SD] age, 33.3 [4.2] years) enrolled at less than 10 weeks’ gestation and completed research activities, yielding a total of 2261 and 1940 infants aged 12 and 18 months, respectively, with neurodevelopmental assessments. In crude analyses, 471 of 1541 exposed infants (30.6%) screened abnormally for developmental delay at 12 months vs 203 of 720 unexposed infants (28.2%; χ2 = 1.32; P = .25); the corresponding prevalences at 18 months were 262 of 1301 (20.1%) vs 148 of 639 (23.2%), respectively (χ2 = 2.35; P = .13). In multivariable mixed-effects logistic regression models adjusting for maternal age, race, ethnicity, education, income, maternal depression, and anxiety, no difference in risk for abnormal ASQ-3 screens was observed at either time point (12 months: adjusted risk ratio [aRR], 1.14; 95% CI, 0.97-1.33; 18 months: aRR, 0.88; 95% CI, 0.72-1.07). Further adjustment for preterm birth and infant sex did not affect results (12 months: aRR, 1.16; 95% CI, 0.98-1.36; 18 months: aRR, 0.87; 95% CI, 0.71-1.07). CONCLUSIONS AND RELEVANCE: Results of this cohort study suggest that COVID-19 vaccination was safe during pregnancy from the perspective of infant neurodevelopment to 18 months of age. Additional longer-term research should be conducted to corroborate these findings and buttress clinical guidance with a strong evidence base.

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2010.02723.x Byline: Kenneth E. Covinsky (*[dagger]#), Kristine Yaffe (#[parallel]), Karla Lindquist (*[dagger]#), Elena Cherkasova (*[dagger]#), Edward Yelin (*[double dagger]s.), Dan G. Blazer (**) Keywords: depression; functional status; outcomes; aging; disability Abstract: OBJECTIVES: To determine whether middle-aged persons with depressive symptoms are at higher risk for developing activity of daily living (ADL) and mobility limitations as they advance into older age than those without. DESIGN: Prospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative sample of people aged 50 to 61. PARTICIPANTS: Seven thousand two hundred seven community living participants in the 1992 wave of the HRS. MEASUREMENTS: Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale (CES-D 11), with scores of 9 or more (out of 33) classified as significant depressive symptoms. Difficulty with five ADLs and basic mobility tasks (walking several blocks or up one flight of stairs) was measured every 2 years through 2006. The primary outcome was persistent difficulty with ADLs or mobility, defined as difficulty in two consecutive waves. RESULTS: Eight hundred eighty-seven (12%) subjects scored 9 or higher on the CES-D 11 and were classified as having significant depressive symptoms. Over 12 years of follow-up, subjects with depressive symptoms were more likely to reach the primary outcome measure of persistent difficulty with mobility or difficulty with ADL function (45% vs 23%, Cox hazard ratio (HR)=2.33, 95% confidence interval (CI)=2.06-2.63). After adjusting for age, sex, measures of socioeconomic status, comorbid conditions, high body mass index, smoking, exercise, difficulty jogging 1 mile, and difficulty climbing several flights of stairs, the risk was attenuated but still statistically significant (Cox HR=1.44, 95% CI=1.25-1.66). CONCLUSION: Depressive symptoms independently predict the development of persistent limitations in ADLs and mobility as middle-aged persons advance into later life. Middle-aged persons with depressive symptoms may be at greater risk for losing their functional independence as they age. Author Affiliation: (*)Department of Medicine ([dagger])Divisions of Geriatrics ([double dagger])Rheumatology (s.)Institute For Health Policy Studies ([parallel])Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics, University of California, San Francisco, California (#)San Francisco Veterans Affairs Medical Center, San Francisco, California (**)Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina Article note: Address correspondence to Kenneth Covinsky, University of California, San Francisco, San Francisco VA Medical Center (181G), 4150 Clement, San Francisco, CA 94121. E-mail: ken.covinsky@ucsf.edu

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02388.x Byline: Kenneth E. Covinsky (*[dagger][double dagger]s.), Karla Lindquist (*[dagger][double dagger]s.), Dorothy D. Dunlop ([paragraph][parallel]), Edward Yelin (***[dagger][dagger]) Keywords: pain; functional limitations; activities of daily living; quality of life; disability Abstract: OBJECTIVES: To examine the relationship between functional limitations and pain across a spectrum of age, ranging from mid life to advanced old age. DESIGN: Cross-sectional study. SETTING: The 2004 Health and Retirement Study (HRS), a nationally representative study of community-living persons aged 50 and older. PARTICIPANTS: Eighteen thousand five hundred thirty-one participants in the 2004 HRS. MEASUREMENTS: Participants who reported that they were often troubled by pain that was moderate or severe most of the time were defined as having significant pain. For each of four functional domains, subjects were classified according to their degree of functional limitation: mobility (able to jog 1 mile, able to walk several blocks, able to walk one block, unable to walk one block), stair climbing (able to climb several flights, able to climb one flight, not able to climb a flight), upper extremity tasks (able to do 3, 2, 1, or 0), and activity of daily living (ADL) function (able to do without difficulty, had difficulty but able to do without help, need help). RESULTS: Twenty-four percent of participants had significant pain. Across all four domains, participants with pain had much higher rates of functional limitations than subjects without pain. Participants with pain were similar in terms of their degree of functional limitation to participants 2 to 3 decades older. For example, for mobility, of subjects aged 50 to 59 without pain, 37% were able to jog 1 mile, 91% were able to walk several blocks, and 96% were able to walk one block without difficulty. In contrast, of subjects aged 50 to 59 with pain, 9% were able to jog 1 mile, 50% were able to walk several blocks, and 69% were able to walk one block without difficulty. Subjects aged 50 to 59 with pain were similar in terms of mobility limitations to subjects aged 80 to 89 without pain, of whom 4% were able to jog 1 mile, 55% were able to walk several blocks, and 72% were able to walk one block without difficulty. After adjustment for demographic characteristics, socioeconomic status, comorbid conditions, depression, obesity, and health habits, across all four measures, participants with significant pain were at much higher risk for having functional limitations (adjusted odds ratio (AOR)=2.85, 95% confidence interval (CI)=2.20-3.69, for mobility; AOR=2.84, 95% CI=2.48-3.26, for stair climbing; AOR=3.96, 95% CI=3.43-4.58, for upper extremity tasks; and AOR=4.33; 95% CI=3.71-5.06, for ADL function). CONCLUSION: Subjects with pain develop the functional limitations classically associated with aging at much earlier ages. Author Affiliation: (*)Department of Medicine ([dagger])Division of Geriatrics ([double dagger])University of California at San Francisco, San Francisco, California (s.)San Francisco Veterans Affairs Medical Center, San Francisco, California ([paragraph])Department of Medicine ([parallel])Institute for Healthcare Studies, Northwestern University, Chicago, Illinois (**)Division of Rheumatology ([dagger][dagger])Institute for Health Policy Studies. Article note: Address correspondence to Kenneth E. Covinsky, University of California, San Francisco, 4150 Clement, San Francisco, CA 94121.E-mail: covinsky@medicine.ucsf.edu

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02286.x Byline: Brie A. Williams (*[dagger]), Karla Lindquist (*), Terry Hill ([double dagger]), Jacques Baillargeon (s.), Jeff Mellow ([parallel]), Robert Greifinger (**), Louise C. Walter (*[dagger]) Keywords: prisoners; disability; geriatric Abstract: Despite increasing numbers of geriatric prisoners, little is known about geriatric disability or health care in prison. Although correctional officers often act as a liaison between prisoners and the healthcare system, the role of officers in recognizing geriatric disability has not been characterized. The goals of this study were to assess officers' assessment of disability in their assigned geriatric prisoners and to contrast their views with reports from the California Department of Corrections and Rehabilitation (CDCR). Questionnaires were given to 71 officers assigned to 618 randomly selected geriatric prisoners in 11 prisons. Information about 41 additional prisoners identified by correctional officers as 'high risk' was also analyzed. Prisoner disability and health were determined through correctional officer questionnaires (activity of daily living (ADL) impairment, geriatric syndromes, level of care), chart review (medical diagnoses), and CDCR data (demographics, disability designation). Overall, 211 (34.1%) geriatric prisoners were unknown to their officer. Of the 407 known prisoners, officers reported that 5.0% had ADL impairment and 3.1% were unsafe. Discordance between officer and CDCR reports of disability was common, with officers reporting higher disability rates. The 41 high-risk prisoners were more likely to have ADL impairment (22.0% vs 5.2%, P Author Affiliation: (*)Division of Geriatrics, University of California, San Francisco, California ([dagger])San Francisco Veterans Affairs Medical Center, San Francisco, California ([double dagger])California Prison Receivership, Sacramento, California (s.)Department of Preventive Medicine and Community Health, Correctional Managed Care, University of Texas Medical Branch, Galveston, Texas ([parallel])Department of Law, Police Science and Criminal Justice Administration (**)Criminal Justice Research and Evaluation Center, John Jay College of Criminal Justice, City University of New York, New York, New York. Article note: Address correspondence to Brie A. Williams, 4150 Clement Street Box 181-G, San Francisco, CA 94121. E-mail: brie.williams@ucsf.edu

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02184.x Byline: Sei J. Lee (*[dagger]), Rebecca L. Sudore (*[dagger]), Brie A. Williams (*[dagger]), Karla Lindquist ([dagger]), Helen L. Chen (*[dagger]), Kenneth E. Covinsky (*[dagger]) Keywords: alcohol; function; socioeconomic status; risk adjustment Abstract: OBJECTIVES: To determine whether the survival benefit associated with moderate alcohol use remains after accounting for nontraditional risk factors such as socioeconomic status (SES) and functional limitations. DESIGN: Prospective cohort. SETTING: The Health and Retirement Study (HRS), a nationally representative study of U.S. adults aged 55 and older. PARTICIPANTS: Twelve thousand five hundred nineteen participants were enrolled in the 2002 wave of the HRS. MEASUREMENTS: Participants were asked about their alcohol use, functional limitations (activities of daily living, instrumental activities of daily living, and mobility), SES (education, income, and wealth), psychosocial factors (depressive symptoms, social support, and the importance of religion), age, sex, race and ethnicity, smoking, obesity, and comorbidities. Death by December 31, 2006, was the outcome measure. RESULTS: Moderate drinkers (1 drink/d) had a markedly more-favorable risk factor profile, with higher SES and fewer functional limitations. After adjusting for demographic factors, moderate drinking (vs no drinking) was strongly associated with less mortality (odds ratio (OR)=0.50, 95% confidence interval (CI)=0.40-0.62). When traditional risk factors (smoking, obesity, and comorbidities) were also adjusted for, the protective effect was slightly attenuated (OR=0.57, 95% CI=0.46-0.72). When all risk factors including functional status and SES were adjusted for, the protective effect was markedly attenuated but still statistically significant (OR=0.72, 95% CI=0.57-0.91). CONCLUSION: Moderate drinkers have better risk factor profiles than nondrinkers, including higher SES and fewer functional limitations. Although these factors explain much of the survival advantage associated with moderate alcohol use, moderate drinkers maintain their survival advantage even after adjustment for these factors. Author Affiliation: (*)San Francisco Veterans Affairs Medical Center, San Francisco, California; and ([dagger])Division of Geriatrics, University of California at San Francisco, San Francisco, California. Article note: Address correspondence to Sei J. Lee, San Francisco VA Medical Center, Division of Geriatrics, Bldg 1, Room 306, Box 181G, 4150 Clement Street, San Francisco, CA 94121. E-mail: seijlee@gmail.com

Background: The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment. Objective: To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less. Design: Cohort study. Setting: Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims. Patients: 27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening. Measurements: The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson-Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score [greater than or equal to] 4), and 5-year mortality was determined for each group. Results: 46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits. Limitations: Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain. Conclusion: Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. Primary Funding Source: VA Health Services Research and Development.

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2007.01511.x Byline: Kenneth E. Covinsky (*[dagger][double dagger]), Karla Lindquist (*[dagger][double dagger]), Dorothy D. Dunlop (s.), Thomas M. Gill ([parallel]), Edward Yelin (*#**) Keywords: arthritis; ADL; mobility Abstract: OBJECTIVES: To examine whether symptomatic arthritis in middle age predicts the earlier onset of functional difficulties (difficulty with activities of daily living (ADLs) and walking) that are associated with loss of independence in older persons. DESIGN: Prospective longitudinal study. SETTING: The Health and Retirement Study, a nationally representative sample of persons aged 50 to 62 at baseline who were followed for 10 years. PARTICIPANTS: Seven thousand five hundred forty-three subjects with no difficulty in mobility or ADL function at baseline. MEASUREMENTS: Arthritis was measured at baseline according to self-report. The primary outcome was time to persistent difficulty in one of five ADLs or mobility (walking several blocks or up a flight of stairs). Difficulty with ADLs or mobility was assessed according to subject interview every 2 years. Analyses were adjusted for other comorbid conditions, body mass index, exercise, and demographic characteristics. RESULTS: Twenty-nine percent of subjects reported arthritis at baseline. Subjects with arthritis were more likely to develop persistent difficulty in mobility or ADL function over 10 years of follow-up (34% vs 18%, adjusted hazard ratio (HR)=1.63, 95% confidence interval (CI)=1.43-1.86). When each component of the primary outcome was assessed separately, arthritis was also associated with persistent difficulty in mobility (30% vs 16%, adjusted HR=1.55, 95% CI=1.41-1.71) and persistent difficulty in ADL function (13% vs 5%, adjusted HR=1.85, 95% CI=1.58-2.16). CONCLUSION: Middle-aged persons who report a history of arthritis are more likely to develop mobility and ADL difficulties as they enter old age. This finding highlights the need to develop interventions and treatments that take a life-course approach to preventing the disabling effect of arthritis. Author Affiliation: (*)Department of Medicine ([dagger])Division of Geriatrics (#)Division of Rheumatology, School of Medicine and (**)Institute for Health Policy Studies, University of California, San Francisco, California ([double dagger])San Francisco Veterans Affairs Medical Center, San Francisco, California (s.)Institute for Healthcare Studies, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois ([parallel])Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut. Article note: Address correspondence to Kenneth Covinsky, MD, MPH, University of California, San Francisco, San Francisco VA Medical Center (181G), 4150 Clement, San Francisco, CA 94121. E-mail: ken.covinsky@ucsf.edu

Background: Older women whose life expectancy is less than 5 years are unlikely to benefit from screening mammography of Papanicolaou (Pap) smears. Since life expectancy is better predicted by health status than by age alone, guidelines recommend considering an older woman's general health when making screening decisions. Objective: To determine whether screening mammography and Pap smears are targeted to healthy older women and are avoided in women with limited life expectancies. Design: Cross-sectional population-based study. Setting: California. Patients: 4792 women 70 years of age or older who participated in the California Health Interview Survey between November 2000 and October 2001. Measurements: Predictor variables included age and health status. Health status was measured by using the Medical Outcomes Study 12-item Short Form Physical Summary Scale. The main outcome was self-reported receipt of screening mammography within the previous 2 years and a screening Pap smear within 3 years. Results: Seventy-eight percent of women reported recent screening mammography, and 77% reported a recent Pap smear. Screening rates decreased with advancing age. However, within each age group, the percentage of women reporting screening did not significantly decrease with worsening health status (P > 0.1 for all comparisons). More than hall of women 80 years of age or older in the worst health quartile reported recent screening, representing approximately 81 000 mammograms and 35 000 Pap smears. Limitations: This study relied on self-report, and the interview response rate was 63.7%. Conclusions: Rates of recent screening mammography and Pap smears are high among older women in California. Although screening rates drop with advancing age, women in poor health do not avoid screening. Screening should be better targeted to healthy older women and should be avoided in women with limited life expectancies for whom risks of screening outweigh potential benefits.

A study investigating the death anticipation levels of physically immobile adults by family members, is presented. The influence of race on the attitude of family members is analyzed.

OBJECTIVES To investigate whether total and/or regional adiposity measured by anthropometry and radiographic studies influences cognitive decline in older adults and whether this association is explained by hormones and inflammatory factors known to be secreted by adipose tissue. DESIGN Prospective cohort study. SETTING Two clinical centers. PARTICIPANTS Three thousand fifty-four elderly individuals enrolled in the Health ABC Study. Adiposity measures included body mass index, waist circumference, sagittal diameter, total fat mass by dual-energy x-ray absorptiometry, and subcutaneous and visceral fat by abdominal computed tomography. We examined the association between baseline body fat measures and change in Modified Mini-Mental State Examination (3MS) score, sequentially adjusting for confounding and mediating variables, including comorbid diseases, adipocytokines, and sex hormones. MAIN OUTCOME MEASURE Scores from the 3MS, administered at the first, third, fifth, and eighth annual clinical examinations. RESULTS All baseline adiposity measures varied significantly by sex. In mixed-effects models, the association between total and regional adiposity and change in 3MS score varied significantly by sex, with the highest adiposity tertile being associated with greater cognitive declines in men (for each adiposity measure, P < .05) but not in women (for interaction, P < .05). Total fat mass was significantly associated with greater change in 3MS scores among men (lowest tertile, −1.6; middle tertile, −2.2; highest tertile, −2.7; P = .006), even after adjusting for mediators. CONCLUSIONS Higher levels of all adiposity measures were associated with worsening cognitive function in men after controlling for metabolic disorders, adipocytokines, and sex hormone levels. Conversely, there was no association between adiposity and cognitive change in women.Arch Neurol. 2009;66(3):329-335--

Maintaining independence in daily functioning is an important health outcome in older adults. A key measure of functional independence in elders is the ability to do activities of daily living (ADL) without the assistance of another person. However, few prognostic indices have been developed that stratify elders into groups at variable risk for developing ADL dependence.

Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies.

The authors investigated 499 patients that were found to be cognitively normal at the Alzheimer’s Disease Research Centers of California between 1988 and 1999. Patients reported high rates of depression (39) and family history of dementia (51). Thirty-six percent returned for follow-up, and of those, 65 received a diagnosis of dementia or mild cognitive impairment. Patients evaluated at memory clinics who are considered cognitively normal may merit periodic re-evaluation.