Publications

Vδ2 γδ T cells are semi-innate T cells that expand markedly following P. falciparum (Pf) infection in naïve adults, but are lost and become dysfunctional among children repeatedly exposed to malaria. The role of these cells in mediating clinical immunity (i.e. protection against symptoms) to malaria remains unclear. We measured Vδ2 T cell absolute counts at acute and convalescent malaria timepoints (n = 43), and Vδ2 counts, cellular phenotype, and cytokine production following in vitro stimulation at asymptomatic visits (n = 377), among children aged 6 months to 10 years living in Uganda. Increasing age was associated with diminished in vivo expansion following malaria, and lower Vδ2 absolute counts overall, among children living in a high transmission setting. Microscopic parasitemia and expression of the immunoregulatory markers Tim-3 and CD57 were associated with diminished Vδ2 T cell pro-inflammatory cytokine production. Higher Vδ2 pro-inflammatory cytokine production was associated with protection from subsequent Pf infection, but also with an increased odds of symptoms once infected. Vδ2 T cells may play a role in preventing malaria infection in children living in endemic settings; progressive loss and dysfunction of these cells may represent a disease tolerance mechanism that contributes to the development of clinical immunity to malaria.

CONTEXT

Older adults with advanced illness and associated symptoms may benefit from primary palliative care, but limited data exist to identify older adults in U.S. primary care to benefit from this care.

OBJECTIVES

To describe U.S. primary care visits among adults aged 65 years and older with advanced illness.

METHODS

Cross-sectional analysis of the National Ambulatory and Hospital Ambulatory Medical Care Surveys (2009-2011) was conducted using Chi-squared tests to compare visits without and with advanced illness with U.S. primary care defined by National Committee for Quality Assurance Palliative and End-of-Life Care Physician Performance Measurement Set International Classification of Diseases, Ninth Revision (ICD-9) codes for end-stage illness.

RESULTS

Among visits by older adults to primary care, 7.9% visits were related to advanced illness. A higher proportion of advanced illness visits was among men vs. women (8.9% vs. 7.2%; P = 0.03) and adults aged 75 years and older, non-Hispanic whites (8.3%) and blacks (8.2%) vs. Hispanic (6.7%) and non-Hispanic other (2.5%) (P = 0.02), dually eligible for Medicare and Medicaid, and from patient ZIP Codes with lower median household incomes (below $32,793). A higher percentage of visits with advanced illness conditions to primary care was chronic obstructive pulmonary disease, congestive heart failure, dementia, and cancer, and symptoms reported with these visits were mostly pain, depression, anxiety, fatigue, and insomnia.

CONCLUSION

In the U.S., approximately 8% primary care visits among older adults was related to advanced illness conditions. Advanced illness visits were most common among those most likely to be socioeconomically vulnerable and highlight the need to focus efforts for high-quality palliative care for these populations.

Achieving minimal residual mitral regurgitation (MR) after percutaneous MitraClip repair is limited by iatrogenic mitral stenosis. It is unknown whether allowing moderately elevated postprocedural mean mitral gradients (MMGs) to achieve < moderate residual MR is preferable to moderate residual regurgitation. Patients with less-than-moderate residual MR but a MMG of ≥5 mm Hg (Group 1) were compared with patients with moderate residual MR (Group 2). The primary end point was heart failure hospitalization. Secondary end points included mortality, subsequent mitral valve surgery, and MR at 1 year. Seventy-eight patients were included in the study. Group 1 included 48 patients (median MMG 6, interquartile range 5-6 mm Hg). Group 2 included 30 patients (median MMG 3.5, interquartile range 2-5 mm Hg). Age, baseline MR severity, and type of MR were not different between groups. Freedom from heart failure hospitalization at 1 year was 91.2 ± 4.2% in Group 1 versus 70.8 ± 8.7% in Group 2 (p = 0.021). Achieved differences in MR reduction between groups persisted at 1 year (p = 0.007). Survival was not different (p = 0.402), and subsequent mitral valve surgery occurred in 4 of 48 (8%) and in 4 of 30 patients (13%) in Group 1 and Group 2, respectively (p = 0.476). By multivariate Cox regression analysis, less-than-moderate residual MR, despite moderately elevated mitral gradients, was associated with a hazard ratio of 0.21 (95% confidence interval 0.04 to 0.96) for subsequent heart failure hospitalization (p = 0.044). In conclusion, patients with less-than-moderate residual MR despite a MMG of ≥5 had a 79% reduction in hazard for subsequent heart failure hospitalization compared with patients with moderate residual MR.