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Find video protocols related to scientific articles indexed in Pubmed.
Medication misadventures in older adults: literature from 2013.
J Am Geriatr Soc
PUBLISHED: 10-22-2014
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The objective of this paper is to review articles published in 2013 examining drug-related problems in the elderly and comment on their potential impact on clinical practice. To identify articles, we did a systematic search of the English-language literature restricted to those aged 65 + from January 2013 to December 2013 using Medline and Google Scholar and a combination of the following search terms: drug-related problems, medication-related problems, medication errors, suboptimal prescribing, inappropriate prescribing, underutilization, polypharmacy, medication monitoring, medication dispensing, medication administration, medication adherence, adverse drug events, and adverse drug withdrawal events. A manual search of major general medicine and clinical pharmacology journals was also conducted to identify additional articles. A total of 51 articles were identified of which 20 were chosen to highlight. Three were annotated and critiqued and the additional 17 articles were summarized in an appendix. One article reported the results of a randomized controlled trial that showed that a pharmacist intervention successfully reduced suboptimal prescribing in older hospital patients. Another paper from this group previously reported data from the same study showing that the intervention also reduced medication related readmissions to the hospital. An observational study compared the use of two thiazide diuretics in older outpatients. They found that chlorthalidone was more likely to cause hypokalemia than hydrochlorothiazide. Finally, in a randomized controlled trial a pharmacist intervention resulted in the reduction of anticholinergic burden but did result in an improvement in cognition. These studies highlight that medication errors and adverse drug events continue to be important issues for health care professionals caring for older adults.
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Circulating CXCR5+PD-1+ response predicts influenza vaccine antibody responses in young adults but not elderly adults.
J. Immunol.
PUBLISHED: 08-29-2014
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Although influenza vaccination is recommended for all adults annually, the incidence of vaccine failure, defined as weak or absent increase in neutralizing Ab titers, is increased in the elderly compared with young adults. The T follicular helper cell (Tfh) subset of CD4 T cells provides B cell help in germinal centers and is necessary for class-switched Ab responses. Previous studies suggested a role for circulating Tfh cells (cTfh) following influenza vaccination in adults, but cTfh have not been studied in elderly adults in whom weak vaccine responses are often observed. In this study, we studied cTfh expressing CXCR5 and programmed death-1 (PD-1). cTfh from elderly adults were present at reduced frequency, had decreased in vitro B cell help ability, and had greater expression of ICOS compared with young adults. At 7 d after inactivated influenza vaccination, cTfh correlated with influenza vaccine-specific IgM and IgG responses in young adults but not in elderly adults. In sum, we have identified aging-related changes in cTfh that correlated with reduced influenza vaccine responses. Future rational vaccine design efforts should incorporate Tfh measurement as an immune correlate of protection, particularly in the setting of aging.
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Designing Therapeutic Clinical Trials for Older and Frail Adults With Cancer: U13 Conference Recommendations.
J. Clin. Oncol.
PUBLISHED: 07-30-2014
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A majority of cancer diagnoses and deaths occur in patients age ? 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.
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Diabetes and cardiovascular disease in older adults: current status and future directions.
Diabetes
PUBLISHED: 07-26-2014
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The prevalence of diabetes increases with age, driven in part by an absolute increase in incidence among adults aged 65 years and older. Individuals with diabetes are at higher risk for cardiovascular disease, and age strongly predicts cardiovascular complications. Inflammation and oxidative stress appear to play some role in the mechanisms underlying aging, diabetes, cardiovascular disease, and other complications of diabetes. However, the mechanisms underlying the age-associated increase in risk for diabetes and diabetes-related cardiovascular disease remain poorly understood. Moreover, because of the heterogeneity of the older population, a lack of understanding of the biology of aging, and inadequate study of the effects of treatments on traditional complications and geriatric conditions associated with diabetes, no consensus exists on the optimal interventions for older diabetic adults. The Association of Specialty Professors, along with the National Institute on Aging, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Heart, Lung, and Blood Institute, and the American Diabetes Association, held a workshop, summarized in this Perspective, to discuss current knowledge regarding diabetes and cardiovascular disease in older adults, identify gaps, and propose questions to guide future research.
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A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity.
J Gen Intern Med
PUBLISHED: 01-18-2014
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Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.
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Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults.
J Am Geriatr Soc
PUBLISHED: 01-17-2014
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To quantify the effect of nosocomial bloodstream infection (BSI) on older adults, including mortality, length of stay (LOS), and costs attributed to BSI.
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Bloodstream infections in community hospitals in the 21st century: a multicenter cohort study.
PLoS ONE
PUBLISHED: 01-01-2014
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While the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown.
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The medication appropriateness index at 20: where it started, where it has been, and where it may be going.
Drugs Aging
PUBLISHED: 09-25-2013
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Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAIs reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term medication appropriateness index. A manual search of the reference lists from identified articles and the authors article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.
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Health services use of older veterans treated and released from veterans affairs medical center emergency departments.
J Am Geriatr Soc
PUBLISHED: 09-04-2013
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To determine predictors of repeat health service use in older veterans treated and released from the emergency department (ED).
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Varicella-zoster virus-specific antibody responses in 50-59-year-old recipients of zoster vaccine.
J. Infect. Dis.
PUBLISHED: 08-01-2013
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Prevaccination and 6-week postvaccination samples from the immunogenicity substudy (n = 2269) of the zoster vaccine (ZV) efficacy trial (N = 22 439) in 50-59-year-old subjects were examined for varicella-zoster virus-specific antibody responses to vaccination. The varicella-zoster virus geometric mean titer (GMT) and geometric mean fold rise were higher in ZV recipients than in placebo recipients (GMT, 660.0 vs 293.1 glycoprotein enzyme-linked immunosorbent assay units/mL [P < .001], respectively; geometric mean fold rise, 2.31 vs 1.00 [P < .025]). In each group there was a strong inverse correlation between postvaccination GMT and risk of subsequent herpes zoster. Although these data provide strong evidence that relates ZV-induced antibody and the risk of herpes zoster, a protective threshold was not determined. Clinical Trials Registration. NCT00534248.
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B cell responses to the 2011/12-influenza vaccine in the aged.
Aging (Albany NY)
PUBLISHED: 05-16-2013
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Antibody and B cell responses to influenza A viruses were measured over a period of 2 months in 30 aged and 15 middle-aged individuals following vaccination with the 2011/12 trivalent inactivated influenza vaccine by micro-neutralization assays, ELISAs, ELISpot assays and cell surface staining with lineage-defining antibodies followed by multicolor flow cytometry. Both cohorts developed comparable antibody responses to the H3N2 virus of the vaccine while responses to the H1N1 virus were compromised in the aged. ELISpot assays of peripheral blood mononuclear cells (PBMCs) gave comparable results for the two cohorts. Analysis by flow cytometry upon staining of CD19+IgD-CD20- PBMCs with antibodies to CD27 and CD38 showed markedly reduced increases of such cells following vaccination in the aged. Additional analysis of cells from a subset of 10 younger and 10 aged individuals indicated that in the aged a portion of IgG producing cells lose expression of CD27 and reduce expression of CD38.
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Safety of zoster vaccine in elderly adults following documented herpes zoster.
J. Infect. Dis.
PUBLISHED: 04-30-2013
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After completion of the Shingles Prevention Study (SPS; Department of Veterans Affairs Cooperative Studies Program Number 403), SPS participants who had initially received placebo were offered investigational zoster vaccine without charge. This provided an opportunity to determine the relative safety of zoster vaccine in older adults following documented herpes zoster (HZ).
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Increased T-bet is associated with senescence of influenza virus-specific CD8 T cells in aged humans.
J. Leukoc. Biol.
PUBLISHED: 02-25-2013
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Aged individuals have increased morbidity and mortality following influenza and other viral infections, despite previous exposure or vaccination. Mouse and human studies suggest increased senescence and/or exhaustion of influenza virus-specific CD8 T cells with advanced age. However, neither the relationship between senescence and exhaustion nor the underlying transcriptional pathways leading to decreased function of influenza virus-specific cellular immunity in elderly humans are well-defined. Here, we demonstrate that increased percentages of CD8 T cells from aged individuals express CD57 and KLRG1, along with PD-1 and other inhibitory receptors, markers of senescence, or exhaustion, respectively. Expression of T-box transcription factors, T-bet and Eomes, were also increased in CD8 T cells from aged subjects and correlated closely with expression of CD57 and KLRG1. Influenza virus-specific CD8 T cells from aged individuals exhibited decreased functionality with corresponding increases in CD57, KLRG1, and T-bet, a molecular regulator of terminal differentiation. However, in contrast to total CD8 T cells, influenza virus-specific CD8 T cells had altered expression of inhibitory receptors, including lower PD-1, in aged compared with young subjects. Thus, our data suggest a prominent role for senescence and/or terminal differentiation for influenza virus-specific CD8 T cells in elderly subjects.
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Vaccination against herpes zoster in developed countries: state of the evidence.
Hum Vaccin Immunother
PUBLISHED: 01-16-2013
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Although progress has been made in the treatment of herpes zoster (HZ) and postherpetic neuralgia (PHN), available therapeutic options are only partially effective. Given evidence that a live-attenuated varicella-zoster-virus vaccine is effective at reducing the incidence of HZ, PHN and the burden of illness, policymakers and clinicians are being asked to make recommendations regarding the use of the zoster vaccine. In this report, we summarize the evidence regarding the: (1) burden of illness; (2) vaccine efficacy and safety; and (3) cost-effectiveness of vaccination, to assist evidence-based policy making and guide clinicians in their recommendations. First, there is general agreement that the overall burden of illness associated with HZ and PHN is substantial. Second, the safety and efficacy of the zoster vaccine at reducing the burden of illness due to HZ and the incidence of PHN have been clearly demonstrated in large placebo-controlled trials. However, uncertainty remains about the vaccines duration of protection. Third, vaccination against HZ is likely to be cost-effective when the vaccine is given at approximately 65 y of age, if vaccine duration is longer than 10 y.
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Vaccine-induced boosting of influenza virus-specific CD4 T cells in younger and aged humans.
PLoS ONE
PUBLISHED: 01-01-2013
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Current yearly influenza virus vaccines induce strain-specific neutralizing antibody (NAb) responses providing protective immunity to closely matched viruses. However, these vaccines are often poorly effective in high-risk groups such as the elderly and challenges exist in predicting yearly or emerging pandemic influenza virus strains to include in the vaccines. Thus, there has been considerable emphasis on understanding broadly protective immunological mechanisms for influenza virus. Recent studies have implicated memory CD4 T cells in heterotypic immunity in animal models and in human challenge studies. Here we examined how influenza virus vaccination boosted CD4 T cell responses in younger versus aged humans. Our results demonstrate that while the magnitude of the vaccine-induced CD4 T cell response and number of subjects responding on day 7 did not differ between younger and aged subjects, fewer aged subjects had peak responses on day 14. While CD4 T cell responses were inefficiently boosted against NA, both HA and especially nucleocaspid protein- and matrix-(NP+M) specific responses were robustly boosted. Pre-existing CD4 T cell responses were associated with more robust responses to influenza virus NP+M, but not H1 or H3. Finally pre-existing strain-specific NAb decreased the boosting of CD4 T cell responses. Thus, accumulation of pre-existing influenza virus-specific immunity in the form of NAb and cross-reactive T cells to conserved virus proteins (e.g. NP and M) over a lifetime of exposure to infection and vaccination may influence vaccine-induced CD4 T cell responses in the aged.
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Delays in appropriate antibiotic therapy for gram-negative bloodstream infections: a multicenter, community hospital study.
PLoS ONE
PUBLISHED: 01-01-2013
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Gram-negative bacterial bloodstream infection (BSI) is a serious condition with estimated 30% mortality. Clinical outcomes for patients with severe infections improve when antibiotics are appropriately chosen and given early. The objective of this study was to estimate the association of prior healthcare exposure on time to appropriate antibiotic therapy in patients with gram-negative BSI.
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Older patients understanding of emergency department discharge information and its relationship with adverse outcomes.
J Patient Saf
PUBLISHED: 09-17-2011
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To describe older patients understanding of emergency department (ED) discharge information and to explore the relationship between understanding of ED discharge information and adverse outcomes.
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Emergency department visits in Veterans Affairs medical facilities.
Am J Manag Care
PUBLISHED: 07-16-2011
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To identify the frequency of, and risk factors for, repeat emergency department (ED) visits and hospitalizations following a treat-andrelease ED visit in patients from Veterans Affairs Medical Centers (VAMCs).
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Association between prodromal pain and the severity of acute herpes zoster and utilization of health care resources.
Eur J Pain
PUBLISHED: 03-03-2011
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Herpes zoster results from the reactivation of the varicella-zoster virus, which is often accompanied by a prodrome of dermatomal pain. Little is known about the burden of prodromal pain.
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Predictors of nosocomial bloodstream infections in older adults.
J Am Geriatr Soc
PUBLISHED: 03-02-2011
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To identify predictors and construct a prediction model for nosocomial bloodstream infection (BSI) in older adults.
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Do geriatric conditions increase risk of adverse drug reactions in ambulatory elders? Results from the VA GEM Drug Study.
J. Gerontol. A Biol. Sci. Med. Sci.
PUBLISHED: 02-14-2011
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Many clinicians prescribe cautiously to older adults with common geriatric conditions for fear of causing adverse drug reactions (ADRs). However, little is known about the association between these conditions and risk of ADRs.
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Health care utilization before and after an outpatient ED visit in older people.
Am J Emerg Med
PUBLISHED: 01-08-2011
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Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population.
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Acute kidney injury in older adults.
J. Am. Soc. Nephrol.
PUBLISHED: 01-07-2011
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Aging kidneys undergo structural and functional changes that decrease autoregulatory capacity and increase susceptibility to acute injury. Acute kidney injury associates with duration and location of hospitalization, mortality risk, progression to chronic kidney disease, and functional status in daily living. Definition and diagnosis of acute kidney injury are based on changes in creatinine, which is an inadequate marker and might identify patients when it is too late. The incidence of acute kidney injury is rising and increases with advancing age, yet clinical studies have been slow to address geriatric issues or the heterogeneity in etiologies, outcomes, or patient preferences among the elderly. Here we examine some of the current literature, identify knowledge gaps, and suggest potential research questions regarding acute kidney injury in older adults. Answering these questions will facilitate the integration of geriatric issues into future mechanistic and clinical studies that affect management and care of acute kidney injury.
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Exploring patterns of health service use in older emergency department patients.
Acad Emerg Med
PUBLISHED: 11-03-2010
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Study objectives were to identify groups of older patients with similar patterns of health care use in the 12 months preceding an index outpatient emergency department (ED) visit and to identify patient-level predictors of group membership.
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Effect of a zoster vaccine on herpes zoster-related interference with functional status and health-related quality-of-life measures in older adults.
J Am Geriatr Soc
PUBLISHED: 09-25-2010
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To determine the efficacy of a zoster vaccine on herpes zoster (HR)-related interference with activities of daily living (ADLs) and health-related quality of life (HRQL).
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A prospective study of the herpes zoster severity of illness.
Clin J Pain
PUBLISHED: 09-16-2010
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MASTER, a multicenter prospective study, was conducted to provide a thorough understanding of the burden of herpes zoster (HZ) and postherpetic neuralgia (PHN). Objectives are to: (1) describe the herpes zoster severity-of-illness (HZSOI), a composite measure of pain duration and severity; and (2) to identify the characteristics at recruitment predictive of greater HZSOI at the different phases of HZ.
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Workshop on idiopathic pulmonary fibrosis in older adults.
Chest
PUBLISHED: 09-09-2010
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Idiopathic pulmonary fibrosis (IPF), a heterogeneous disease with respect to clinical presentation and rates of progression, disproportionately affects older adults. The diagnosis of IPF is descriptive, based on clinical, radiologic, and histopathologic examination, and definitive diagnosis is hampered by poor interobserver agreement and lack of a consensus definition. There are no effective treatments. Cellular, molecular, genetic, and environmental risk factors have been identified for IPF, but the initiating event and the characteristics of preclinical stages are not known. IPF is predominantly a disease of older adults, and the processes underlying normal aging might significantly influence the development of IPF. Yet, the biology of aging and the principles of medical care for this population have been typically ignored in basic, translational, or clinical IPF research. In August 2009, the Association of Specialty Professors, in collaboration with the American College of Chest Physicians, the American Geriatrics Society, the National Institute on Aging, and the National Heart, Lung, and Blood Institute, held a workshop, summarized herein, to review what is known, to identify research gaps at the interface of aging and IPF, and to suggest priority areas for future research. Efforts to answer the questions identified will require the integration of geriatrics, gerontology, and pulmonary research, but these efforts have great potential to improve care for patients with IPF.
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What types of inappropriate prescribing predict adverse drug reactions in older adults?
Ann Pharmacother
PUBLISHED: 05-12-2010
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Adverse drug events happen all too often in older adults, but we still do not have a clear understanding of potentially modifiable risk factors, with the exception of polypharmacy. This paper critiques the article in this issue of The Annals entitled, "Inappropriate Prescribing Predicts Adverse Drug Events in Older Adults." A validated measure for self-reported adverse drug events was used, along with a modified measure for inappropriate prescribing that we developed nearly 2 decades ago (ie, Medication Appropriateness Index). Besides discussing the strengths and weaknesses of this article, we also recommend future research directions in this area.
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Safety of herpes zoster vaccine in the shingles prevention study: a randomized trial.
Ann. Intern. Med.
PUBLISHED: 05-05-2010
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The herpes zoster vaccine is effective in preventing herpes zoster and postherpetic neuralgia in immunocompetent older adults. However, its safety has not been described in depth.
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Workshop on immunizations in older adults: identifying future research agendas.
J Am Geriatr Soc
PUBLISHED: 04-20-2010
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Goals for immunization in older adults may differ from those in young adults and children, in whom complete prevention of disease is the objective. Often, reduced hospitalization and death but also averting exacerbation of underlying chronic illness, functional decline, and frailty are important goals in the older age group. Because of the effect of age on dendritic cell function, T cell-mediated immune suppression, reduced proliferative capacity of T cells, and other immune responses, the efficacy of vaccines often wanes with advanced age. This article summarizes the discussion and proceedings of a workshop organized by the Association of Specialty Professors, the Infectious Diseases Society of America, the American Geriatrics Society, the National Institute on Aging, and the National Institute of Allergy and Infectious Diseases. Leading researchers and clinicians in the fields of immunology, epidemiology, infectious diseases, geriatrics, and gerontology reviewed the current status of vaccines in older adults, identified knowledge gaps, and suggest priority areas for future research. The goal of the workshop was to identify what is known about immunizations (efficacy, effect, and current schedule) in older adults and to recommend priorities for future research. Investigation in the areas identified has the potential to enhance understanding of the immune process in aging individuals, inform vaccine development, and lead to more-effective strategies to reduce the risk of vaccine-preventable illness in older adults.
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Ranolazine-related dyspnea on exertion.
Am J Geriatr Pharmacother
PUBLISHED: 03-16-2010
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Ranolazine is increasingly being prescribed for the treatment of chronic stable angina. This report describes an adverse effect that may be related to ranolazine.
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Economic burden of herpes zoster among skilled nursing facility residents in the United States.
J Am Med Dir Assoc
PUBLISHED: 03-12-2010
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To evaluate health care resource use and direct medical costs attributable to herpes zoster (HZ) among elderly residents of skilled nursing facilities (SNF).
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Recommendations for the pharmacological management of neuropathic pain: an overview and literature update.
Mayo Clin. Proc.
PUBLISHED: 03-03-2010
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The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain recently sponsored the development of evidence-based guidelines for the pharmacological treatment of neuropathic pain. Tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel alpha(2)-delta ligands (ie, gabapentin and pregabalin), and topical lidocaine were recommended as first-line treatment options on the basis of the results of randomized clinical trials. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in certain clinical circumstances. Results of several recent clinical trials have become available since the development of these guidelines. These studies have examined botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies in various neuropathic pain conditions. The increasing number of negative clinical trials of pharmacological treatments for neuropathic pain and ambiguities in the interpretation of these negative trials must also be considered in developing treatment guidelines. The objectives of the current article are to review the Neuropathic Pain Special Interest Group guidelines for the pharmacological management of neuropathic pain and to provide a brief overview of these recent studies.
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Treatment considerations for elderly and frail patients with neuropathic pain.
Mayo Clin. Proc.
PUBLISHED: 03-03-2010
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Currently, an estimated 38 million individuals 65 years or older live in the United States, and more than 11 million of these individuals are 80 years or older. Older people are at high risk of neuropathic pain because many diseases that cause neuropathic pain increase in incidence with age. Depending on their underlying health, older adults with neuropathic pain may have to cope with multiple coexisting diseases, polypharmacy, and impaired functional ability. The objective of this article is to review how aging and frailty affect the treatment of older adults with neuropathic pain. Specific topics reviewed include the complexity of treatment decisions in older patients due to aged heterogeneity, multimorbidity, and polypharmacy; selection of treatment in an effort to maximize patients functional abilities in addition to relieving their pain; more careful dosing (usually lower) and monitoring of pharmacotherapy relative to younger patients due to age-related changes in pharmacokinetics and pharmacodynamics; and underrepresentation of older adults in clinical trials of neuropathic pain treatments, which further compromises physicians ability to make informed treatment decisions.
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Treatment considerations for patients with neuropathic pain and other medical comorbidities.
Mayo Clin. Proc.
PUBLISHED: 03-03-2010
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The efficacy of drugs for neuropathic pain has been established in randomized controlled trials that have excluded patients with comorbid conditions and those taking complex medications. However, patients with neuropathic pain frequently present with complex histories, making direct application of this evidence problematic. Treatment of neuropathic pain needs to be individualized according to the cause of the pain, concomitant diseases, medications, and other individual factors. Tricyclic antidepressants (TCAs), gabapentinoids, selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line choices; if needed, combination therapy may be used. When a new drug is added, screening for potential drug interactions is recommended. The TCAs have anticholinergic adverse effects and may cause orthostatic hypotension. They should be avoided or used cautiously in patients with cardiac conduction disturbances or arrhythmias. Patients who lack cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine and have a weaker analgesic response to tramadol. A combination of several serotoninergic drugs may lead to serotonin syndrome. Risk of gastrointestinal tract bleeding is increased in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially when combined with nonsteroidal anti-inflammatory drugs. Dose adjustment may be needed in patients with renal or hepatic impairment. Depending on the drug, the dose is reduced or the dosage interval lengthened. Slow titration and careful follow-up are needed. No drug is absolutely safe during pregnancy and lactation. Particular care must be exercised during the first trimester when drug dose should be as low as possible. Individual weighing of benefits and risks should guide therapeutic decisions.
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Poor functional status is an independent predictor of surgical site infections due to methicillin-resistant Staphylococcus aureus in older adults.
J Am Geriatr Soc
PUBLISHED: 02-11-2010
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Methicillin-resistant Staphylococcus aureus (MRSA) has become a common surgical site infection (SSI) pathogen, particularly in older adults. Risk factors for MRSA SSI in elderly patients have not been described.
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The impact of herpes zoster and post-herpetic neuralgia on quality-of-life.
BMC Med
PUBLISHED: 01-29-2010
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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.
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Predictors of postherpetic neuralgia among patients with herpes zoster: a prospective study.
J Pain
PUBLISHED: 01-08-2010
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Postherpetic neuralgia (PHN) is the most common complication of herpes zoster (HZ). The main objectives of this study were to: 1) estimate the severity and duration of PHN; and 2) identify the predictors of PHN. From October, 2005 to July, 2006, 261 outpatients with HZ, aged ? 50, were recruited within 14 days of rash onset during the routine clinical practice of 83 physicians across Canada. Physicians documented HZ characteristics, treatments, general health, functional, and immune status. HZ pain was measured at recruitment and on days 7, 14, 21, 30, 60, 90, 120, 150, and 180 following recruitment. PHN was defined as a worst pain ? 3 persisting or appearing more than 90 days after rash onset. Predictors of PHN were obtained by hierarchical log-binomial regression. Twenty-two percent of 249 immunocompetent subjects with HZ developed PHN. Median duration of PHN was 77 days. Independent predictors of PHN included: older age, limitation in performing usual activities prior to HZ, and pain severity at recruitment. This study confirms that older age and greater acute pain severity are predictors of PHN, while functional status emerges as a novel independent predictor of PHN that deserves further exploration. These findings will contribute to optimal use of the HZ vaccine and testing of new therapies that might prevent PHN.
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Performance of diagnostic tests to detect respiratory viruses in older adults.
Diagn. Microbiol. Infect. Dis.
PUBLISHED: 01-05-2010
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The performance of 4 laboratory methods for diagnosis of viral respiratory tract infections (RTI) in older adults was evaluated. Seventy-four nasopharyngeal (NP) swab specimens were obtained from 60 patients with RTI at a long-term care facility over 2 respiratory seasons. Sixteen specimens were positive for a respiratory virus by at least 1 method. Multiplex reverse transcriptase polymerase chain reaction (RT-PCR) by the Luminex xTAG Respiratory Viral Panel (RVP) detected 16 (100%) of the positive specimens, RVP of 24-h culture supernatant detected 8 (50%), direct fluorescent antibody testing detected 4 (25%), rapid culture detected 2 (12.5%), and rapid antigen testing detected none. For a comparison group, RVP was performed on NP swabs from 20 outpatient children with RTI. The mean fluorescence intensity by RVP was significantly lower for positive adult patients than pediatric patients (P = 0.0373). Our data suggest that older adult patients shed lower titers of viruses, necessitating a highly sensitive assay such as RT-PCR to reliably detect respiratory viral pathogens.
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Underuse of indicated medications among physically frail older US veterans at the time of hospital discharge: results of a cross-sectional analysis of data from the Geriatric Evaluation and Management Drug Study.
Am J Geriatr Pharmacother
PUBLISHED: 10-26-2009
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Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood.
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Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study.
PLoS ONE
PUBLISHED: 09-22-2009
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The clinical and financial outcomes of SSIs directly attributable to MRSA and methicillin-resistance are largely uncharacterized. Previously published data have provided conflicting conclusions.
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Age and persistent use of cardiovascular medication after acute coronary syndrome: results from medication applied and sustained over time.
J Am Geriatr Soc
PUBLISHED: 09-15-2009
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To describe the persistent use of evidence-based cardiovascular medications (EBCMs) 3 months after discharge from an acute coronary syndrome (ACS) event and patient-reported reasons for nonpersistence across age groups.
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Varicella-zoster virus-specific immune responses to herpes zoster in elderly participants in a trial of a clinically effective zoster vaccine.
J. Infect. Dis.
PUBLISHED: 08-29-2009
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The objectives of this study were to evaluate the association between varicella-zoster virus (VZV)-specific humoral and cell-mediated immunity (CMI) to herpes zoster (HZ) and protection against HZ morbidity and to compare immune responses to HZ and zoster vaccine.
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Development and pilot testing of computerized order entry algorithms for geriatric problems in nursing homes.
J Am Geriatr Soc
PUBLISHED: 08-04-2009
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To develop order entry algorithms for five common nursing home problems and to test their acceptance, use, and preliminary effect on nine quality indicators and resource utilization.
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A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses.
J. Med. Virol.
PUBLISHED: 05-29-2009
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A real-time PCR assay was developed to identify varicella-zoster virus (VZV) and herpes simplex virus (HSV) DNA in clinical specimens from subjects with suspected herpes zoster (HZ; shingles). Three sets of primers and probes were used in separate PCR reactions to detect and discriminate among wild-type VZV (VZV-WT), Oka vaccine strain VZV (VZV-Oka), and HSV DNA, and the reaction for each virus DNA was multiplexed with primers and probe specific for the human beta-globin gene to assess specimen adequacy. Discrimination of all VZV-WT strains, including Japanese isolates and the Oka parent strain, from VZV-Oka was based upon a single nucleotide polymorphism at position 106262 in ORF 62, resulting in preferential amplification by the homologous primer pair. The assay was highly sensitive and specific for the target virus DNA, and no cross-reactions were detected with any other infectious agent. With the PCR assay as the gold standard, the sensitivity of virus culture was 53% for VZV and 77% for HSV. There was 92% agreement between the clinical diagnosis of HZ by the Clinical Evaluation Committee and the PCR assay results.
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Prediction, progression, and outcomes of chronic kidney disease in older adults.
J. Am. Soc. Nephrol.
PUBLISHED: 05-21-2009
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Chronic kidney disease is a large and growing problem among aging populations. Although progression of chronic kidney disease to end-stage renal disease (ESRD) is a costly and important clinical event with substantial morbidity, it appears less frequently in aging people compared with cardiovascular mortality. The measurement of kidney function and management of kidney disease in older individuals remain challenging, partly because the pathophysiologic mechanisms underlying age-related decline in kidney function, the interactions between age and other risk factors in renal progression, and the associations of chronic kidney disease with other comorbidities in older people are understudied and poorly understood. The Association of Specialty Professors, the American Society of Nephrology, the American Geriatrics Society, the National Institute on Aging, and the National Institute of Diabetes and Digestive and Kidney Diseases held a workshop, summarized in this article, to review what is known about chronic kidney disease, identify research gaps and resources available to address them, and identify priority areas for future research. Answers to emerging research questions will support the integration of geriatrics and nephrology and thus improve care for older patients at risk for chronic kidney disease.
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The effect of surgical site infection on older operative patients.
J Am Geriatr Soc
PUBLISHED: 03-07-2009
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To determine the effect of surgical site infection (SSI) on mortality, duration of hospitalization, and hospital cost in older operative patients.
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A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster.
Pain
PUBLISHED: 02-04-2009
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Although acute pain in patients with herpes zoster can be severe and has a substantial impact on health-related quality of life, there have been no randomized clinical trials of oral medications specifically for its ongoing treatment. A randomized clinical trial was conducted in which 87 subjects >or=50 years of age with herpes zoster within 6 calendar days of rash onset and with worst pain in the past 24h >or=3 on a 0-10 rating scale initiated 7 days of treatment with famciclovir in combination with 28 days of treatment with either controlled-release (CR) oxycodone, gabapentin, or placebo. Subjects were evaluated for adverse effects of treatment, acute pain, and health-related quality of life. The results showed that CR-oxycodone and gabapentin were generally safe and were associated with adverse events that reflect well-known effects of these medications. Discontinuing participation in the trial, primarily associated with constipation, occurred more frequently in subjects randomized to CR-oxycodone (27.6%) compared with placebo (6.9%). Treatment with CR-oxycodone reduced the mean worst pain over days 1-8 (p=0.01) and days 1-14 (p=0.02) relative to placebo but not throughout the entire 28-day treatment period as pain resolved in most subjects. Gabapentin did not provide significantly greater pain relief than placebo, although the data for the first week were consistent with a modest benefit. By demonstrating that CR-oxycodone is safe, generally adequately tolerated, and appears to have efficacy for relieving acute pain, the results of this clinical trial provide a foundation for evidence-based treatment for acute pain in herpes zoster.
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Respiratory syncytial virus outbreak in a long-term care facility detected using reverse transcriptase polymerase chain reaction: an argument for real-time detection methods.
J Am Geriatr Soc
PUBLISHED: 01-23-2009
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To report an outbreak of respiratory synctyial virus (RSV) in a long-term care facility (LTCF) during ongoing routine respiratory illness surveillance.
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Transitional Care Partners: a hospital-to-home support for older adults and their caregivers.
J Am Assoc Nurse Pract
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To describe the development, implementation, and preliminary results of the Transitional Care (TLC) Partners, a clinical demonstration program that supports the transition from hospital to home of older veterans.
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A randomized, controlled study to assess the effect of silk-like textiles and high-absorbency adult incontinence briefs on pressure ulcer prevention.
Ostomy Wound Manage
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Pressure ulcer prevention is an important aspect of nursing home care. A 20-week, unblinded, randomized, controlled trial was conducted to compare the rate of nursing home-acquired pressure ulcers and adverse events between residents managed using: 1) a silk-like textile for bedding paired with high-absorbency adult incontinence briefs or 2) usual-care, plain-weave cotton/polyester bed sheets and adult incontinence briefs. All residents with an expected length of stay 30 days or more who agreed to participate were enrolled in the study and assessed daily. A total of 46 residents (all men) was enrolled; 26 (median age 72.7 years, range 54 to 95 years) in the intervention group and 20 (median age 69.5 years, range 51 to 91 years) in the usual care group. At baseline, there were no significant differences in resident demographic variables, including Braden Scale risk scores. Fewer pressure ulcers developed in the intervention (six; average follow up 75.6 days/person) than in the standard care group (20; average follow up 95.6 days/person) (hazard ratio = 0.31, 95% confidence interval 0.12, 0.78) and the number of new non-Stage I ulcers was significantly lower in the intervention group (HR = .23, 95% CI .078, .69, P = 0.0084). The number of adverse events did not differ significantly between the two groups. Additional research is warranted on use of products with the silk-like fabric, alone or in combination with highabsorbencybriefs, in larger groups and different populations.
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Role of pain medications, consultants, and other services in improved pain control of elderly adults with cancer in geriatric evaluation and management units.
J Am Geriatr Soc
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To determine whether pain medication use and inpatient consultations and services were associated with significantly better pain control.
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Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics.
J Am Geriatr Soc
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Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the programs influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.
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Older veterans and emergency department discharge information.
BMJ Qual Saf
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Study goals were to assess older veterans understanding of their emergency department (ED) discharge information and to determine the association between understanding discharge information and patient assessment of overall quality of care.
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Biological, clinical, and psychosocial correlates at the interface of cancer and aging research.
J. Natl. Cancer Inst.
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In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: (1) improved standardized geriatric assessment of older oncology patients, (2) substantially enhanced biological assessment of older oncology patients, (3) specific trials for the most vulnerable and/or those older than 75 years, and (4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.
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Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years.
Clin. Infect. Dis.
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Herpes zoster (HZ) adversely affects individuals aged 50-59, but vaccine efficacy has not been assessed in this population. This study was designed to determine the efficacy, safety, and tolerability of zoster vaccine for preventing HZ in persons aged 50-59 years.
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Employment related productivity loss associated with herpes zoster and postherpetic neuralgia: a 6-month prospective study.
Vaccine
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We conducted a prospective multi-center study to assess productivity loss associated with herpes zoster (HZ) and postherpetic neuralgia (PHN). From 10/2005 to 07/2006, we recruited immunocompetent subjects aged ?50 years with HZ within 14 days of rash onset across Canada. Of the 249 patients recruited, 88 were employed. Data on employment status, absences from work, reasons for absence and effectiveness at work were documented at recruitment, 7-14-21-30-60-90-120-150 and 180 days later. The majority (64%) of employed subjects missed work because of HZ and 76% reported decreased effectiveness at work (i.e. presenteeism) because of HZ/PHN. Mean hours of absenteeism and presenteeism per working individual were 27 and 34 h, respectively. Pain severity and duration were associated with greater productivity loss. These results provide new information about the burden of HZ and PHN, which is useful for public health planning and cost-effectiveness analyses of HZ vaccination among individuals of working age.
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JoVE Visualize is a tool created to match the last 5 years of PubMed publications to methods in JoVE's video library.

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In developing our video relationships, we compare around 5 million PubMed articles to our library of over 4,500 methods videos. In some cases the language used in the PubMed abstracts makes matching that content to a JoVE video difficult. In other cases, there happens not to be any content in our video library that is relevant to the topic of a given abstract. In these cases, our algorithms are trying their best to display videos with relevant content, which can sometimes result in matched videos with only a slight relation.