Search

A study was conducted to test the hypothesis that vaccination against varicellazoster virus (VZV) would decrease the incidence, severity, or both of herpes zoster and postherpetic neuralgia among older adults. The result showed that the zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.

Melissa K Andrew,1,2 Kenneth E Schmader,3 Kenneth Rockwood,1 Barry Clarke,4 Janet E McElhaney5 1Department of Medicine, Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; 2Canadian Center for Vaccinology, Halifax, Nova Scotia, Canada; 3Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA; 4Department of Family Medicine, Dalhousie University, Halifax, Canada; 5Health Sciences North Research Institute, Sudbury, Ontario, CanadaCorrespondence: Melissa K AndrewDepartment of Medicine, Division of Geriatric Medicine, Dalhousie University, Veterans Memorial Building, 5955, Veterans Memorial Lane, Halifax, NS, B3H 2E1, CanadaTel +1 902 473-4995Email mandrew@dal.caAbstract: 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.Keywords: SARS-CoV-2, COVID-19, vaccine, frailty, frail elderly, geriatrics

Julia A Messina,1 Rebekah W Moehring,1,2 Kenneth E Schmader,3 Deverick J Anderson1,2 1Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA; 2Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA; 3Duke University Medical Center, Department of Medicine, Division of Geriatrics and GRECC, Durham VA Health Care System, Durham, NC, USACorrespondence: Julia A Messina Tel +1 919-684-2660Fax +1 919-681-7494Email Julia.messina@duke.eduPurpose: 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.Keywords: community hospital, bloodstream infection, bacteremia, Staphylococcus aureus

The purpose of this study was to determine if there are racial differences in the occurrence of herpes zoster (shingles). The study population was the Duke Established Populations for Epidemiologic Studies of the Elderly, a probability sample of community-dwelling persons > 64 years old in North Carolina. Interviewers administered a comprehensive health survey to the participants that included questions about lifetime occurrence of shingles. Of the 3206 subjects, 316 (9.9%) had had zoster: 81 (4.5%) of 1754 blacks and 235 (16.1%) of 1452 whites had had shingles (P < .0001). After controlling for age, cancer, and demographic factors, blacks remained one-fourth as likely as whites (adjusted odds ratio 0.25, 95% confidence interval 0.18-0.35; P = .0001) to have experienced zoster. In summary, blacks had a significantly lower risk of developing herpes zoster than whites, a new finding in herpes zoster epidemiology. [ABSTRACT FROM AUTHOR]

The Short-Term Persistence Substudy (STPS) of the Shingles Prevention Study (SPS) assessed persistence of zoster vaccine efficacy. Vaccine efficacy was lower in the STPS than in SPS, but there was evidence of persistence of vaccine efficacy for at least 5 years.Background. The Shingles Prevention Study (SPS; Department of Veterans Affairs Cooperative Study 403) demonstrated that zoster vaccine was efficacious through 4 years after vaccination. The Short-Term Persistence Substudy (STPS) was initiated after the SPS to further assess the persistence of vaccine efficacy.Methods. The STPS re-enrolled 7320 vaccine and 6950 placebo recipients from the 38 546–subject SPS population. Methods of surveillance, case determination, and follow-up were analogous to those in the SPS. Vaccine efficacy for herpes zoster (HZ) burden of illness, incidence of postherpetic neuralgia (PHN), and incidence of HZ were assessed for the STPS population, for the combined SPS and STPS populations, and for each year through year 7 after vaccination.Results. In the STPS as compared to the SPS, vaccine efficacy for HZ burden of illness decreased from 61.1% to 50.1%, vaccine efficacy for the incidence of PHN decreased from 66.5% to 60.1%, and vaccine efficacy for the incidence of HZ decreased from 51.3% to 39.6%, although the differences were not statistically significant. Analysis of vaccine efficacy in each year after vaccination for all 3 outcomes showed a decrease in vaccine efficacy after year 1, with a further decline thereafter. Vaccine efficacy was statistically significant for the incidence of HZ and the HZ burden of illness through year 5.Conclusions. Vaccine efficacy for each study outcome was lower in the STPS than in the SPS. There is evidence of the persistence of vaccine efficacy through year 5 after vaccination but, vaccine efficacy is uncertain beyond that point. [ABSTRACT FROM AUTHOR]

Background: Risk factor and outcomes data pertaining to surgical site infection in the elderly following orthopaedic operations are lacking. The aim of this study was to identify risk factors for surgical site infections and to quantify the impact of these infections on health outcomes in elderly patients following orthopaedic surgery.Methods: A risk factor and outcomes study was performed at Duke University Medical Center, a tertiary care center, and seven community hospitals in North Carolina and Virginia between 1991 and 2002. The study included elderly patients in whom a surgical site infection had developed following orthopaedic surgery and elderly patients in whom a surgical site infection had not developed following orthopaedic surgery (controls). Outcome measures included mortality during the one-year postoperative period and the total length of the hospital stay (including readmissions during the ninety-day postoperative period).Results: One hundred and sixty-nine patients with a surgical site infection were identified, and 171 controls were selected. The mean age of the patients was 74.7 years. The most frequent procedures were hip arthroplasty (n = 74, 22%) and open reduction of fractures (n = 55, 16%). The most common pathogen was Staphylococcus aureus (n = 95, 56%). A risk factor for surgical site infection, identified in the multivariate analysis, was admission from a health-care facility (odds ratio = 4.35; 95% confidence interval = 1.64, 11.11). Multivariate analysis also indicated that surgical site infection was a strong predictor of mortality (odds ratio = 3.80; 95% confidence interval = 1.49, 9.70) and an increased length of stay in the hospital (multiplicative effect = 2.49; 95% confidence interval = 2.10, 2.94; 9.31 mean attributable days per infection, 95% confidence interval = 6.88, 12.13).Conclusions: Measures for prevention of surgical site infection in elderly patients should target individuals who reside in health-care facilities prior to surgery. Future studies should be done to examine the effectiveness of such interventions in preventing infection and improving outcomes in elderly patients who undergo orthopaedic surgery. [ABSTRACT FROM AUTHOR]

Objective: To determine if a visual intervention (medication grid) delivered to physicians can reduce medication regimen complexity.Design: Nonrandomized, controlled trial.Setting: Veterans Affairs medical center.Patients/participants: Eight hundred thirty-six patients taking at least 5 medications at the time of admission and the 48 teams of physicians and students on the general medicine inpatient service.Intervention: For intervention patients, a medication grid was created that displayed all of the patients' medicines and the times of administration for 1 week. This grid was delivered to the admitting resident soon after admission.Measurements and Main Results: For the patients of each team of physicians, we calculated the change in the average number of medications and doses from admission to discharge. The number of medications in the intervention group decreased by 0.92 per patient, and increased by 1.65 in the control group (P <.001). The mean number of doses per day in the intervention group decreased by 2.47 per patient and increased by 3.83 in the control group (P <.001).Conclusions: This simple intervention had a significant impact on medication regimen complexity in this population. Apparently, physicians were able to address polypharmacy when the issue was brought to their attention. [ABSTRACT FROM AUTHOR]

Study Objective: To determine whether current therapies are useful in preventing postherpetic neuralgia (PHN) by analysis of study designs and pooled results.Design: Meta-analysis of all controlled studies investigating PHN prevention in the immunocompetent host. Articles were identified through MEDLINE, Index Medicus and bibliographic reviews of major texts and review articles. Studies meeting eligibility criteria were independently assessed using explicit methodologic criteria for validity and generalizability in clinical trials. Pooled analysis was also performed where appropriate.Measurements and Main Results: Twenty-one investigations met eligibility criteria and primarily addressed the use of antiviral agents and corticosteroids. Among studies with strong designs, no evidence of benefit was found for acyclovir or corticosteroids. Pooled results showed no significant effect of acyclovir on the prevention of PHN (odds ratio 0.81, 95% confidence interval 0.56, 1.11). The strongest studies that found potential efficacy in PHN prevention involved adenosine monophosphate and idoxuridine in dimethyl sulfoxide, but problems with clinical application limit the use of these compounds. Outcome definition, compliance assessment, power estimation, and method of randomization were infrequently addressed aspects of design.Conclusion: Currently there is no proven useful therapy for the prevention of PHN. The benefits of acyclovir and corticosteroids are limited but key questions remain regarding these medications. A clear consensus definition of PHN is needed to improve future investigations. [ABSTRACT FROM AUTHOR]

Abstract Background The potentially serious nature of herpes zoster (HZ) and the long-term complication post-herpetic neuralgia (PHN) are often underestimated. One in four people will contract herpes zoster in their lifetime, with this risk rising markedly after the age of 50 years, and affecting one in two in elderly individuals. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. In the acute phase, pain is usually moderate or severe, with patients ranking HZ pain as more intense than post-surgical or labour pains. Up to 20% of patients with HZ develop PHN, which is moderate-to-severe chronic pain persisting for months or years after the acute phase. We review the available data on the effect of HZ and PHN on patients' quality-of-life. Discussion Findings show that HZ, and particularly PHN, have a major impact on patients' lives across all four health domains - physical, psychological, functional and social. There is a clear correlation between increasing severity of pain and greater interference with daily activities. Non-pain complications such as HZ ophthalmicus can increase the risk of permanent physical impairment. Some elderly individuals may experience a permanent loss of independence after an acute episode of HZ. Current challenges in the management of HZ and PHN are highlighted, including the difficulty in administering antiviral agents before pain becomes established and the limited efficacy of pain treatments in many patients. We discuss the clinical rationale for the HZ vaccine and evidence demonstrating that the vaccine reduces the burden of the disease. The Shingles Prevention Study, conducted among >38,000 people aged ≥60 years old, showed that the HZ vaccine significantly reduces the burden of illness and the incidence of both HZ and PHN. In the entire study population, zoster vaccination reduced the severity of interference of HZ and PHN with activities of daily living by two-thirds, as measured by two questionnaires specific to HZ. Summary A vaccination scheme may positively impact the incidence and course of HZ disease, thereby improving patients' quality-of-life.

Examines epsilon4 frequencies in four distinct, normal, elderly control groups and in patients with amyloid-forming diseases whose epsilon4 distributions were not previously known. Increase in the frequency of the allele for apolipoprotein E4 in Alzheimer's disease; Composition of the control groups; Evidence in the association of apoE with amyloid plaques; Conclusion of the report.

Abstract: Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Introduction: Suboptimal nutrition promotes unfavorable outcomes in trauma patients, particularly among those aged 60 and over. While many institutions employ predictive energy equations to determine patients' energy requirements, mounting evidence shows these equations inaccurately estimate caloric needs. In this pilot randomized controlled trial, we sought to quantify the discrepancy between predictive equations and indirect calorimetry (IC)-the gold standard for determining energy requirements-in the older adult trauma population., Methods: This is a nested cohort study within a pilot randomized control trial in which 32 older adult trauma patients were randomized 3:1 to receive IC-guided nutrition delivery versus standard of care. IC requirements of patients in the intervention arm were compared to Mifflin St. Jeor (MSJ), Harris-Benedict (HB), and the American Society for Parenteral and Enteral Nutrition-Society of Critical Care Medicine (ASPEN-SCCM) predictive energy equations., Results: Twenty patients underwent IC to assess measured resting energy expenditure (mREE), yielding a mean (standard deviation) mREE of 23.1 ± 4.8 kcal/kg/d. MSJ and HB gave mean predictive resting energy expenditures of 17.5 ± 2.0 and 18.5 ± 2.0 kcal/kg/d in these patients, demonstrating that IC-derived values were 32.1% and 25.0% higher, respectively. When patients were stratified by body mass index (BMI), MSJ, and HB more severely underestimated caloric requirements in individuals with BMI <30 versus BMI 30-50. While the mean mREE fell within the mean predictive resting energy expenditure range prescribed by ASPEN-SCCM equations (21.4 ± 4.1 to 26.2 ± 4.3 kcal/kg/d), individuals' IC-derived values fell within their personal range in 8 of 20 cases., Conclusions: The MSJ and HB predictive energy equations consistently and significantly underpredict metabolic demands of older adult trauma patients compared to IC and perform worse in lower BMI individuals. ASPEN-SCCM equations frequently overpredict or underpredict resting energy expenditure. While these findings should be confirmed in a larger randomized control trial, this study suggests that institutions should prioritize IC to accurately identify the metabolic demands of older trauma patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)