Publications by authors named "Michael S Wolf"

288 Publications

Ascorbate deficiency confers resistance to hippocampal neurodegeneration after asphyxial cardiac arrest in juvenile rats.

Pediatr Res 2021 Apr 12. Epub 2021 Apr 12.

Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: Asphyxial cardiac arrest (CA) is a significant cause of death and disability in children. Using juvenile Osteogenic disorder Shionogi (ODS) rats that, like humans, do not synthesize ascorbate, we tested the effect of ascorbate deficiency on functional and histological outcome after CA.

Methods: Postnatal day 16-18 milk-fed ODS and wild-type Wistar rats underwent 9-min asphyxial CA (n = 8/group) or sham surgery (n = 4/group). ODS mothers received ascorbate in drinking water to prevent scurvy. Levels of ascorbate and glutathione (GSH) were measured in plasma and hippocampus at baseline and after CA. Neurologic deficit score (NDS) was measured at 3, 24, and 48 h and hippocampal neuronal counts, neurodegeneration, and microglial activation were assessed at day 7.

Results: ODS rats showed depletion of plasma and hippocampal ascorbate, attenuated hippocampal neurodegeneration and microglial activation, and increased CA1 hippocampal neuron survival vs. Wistar rats while NDS were similar. Hippocampal GSH levels were higher in ODS vs. Wistar rats at baseline and 10 min, whereas hypoxia-inducible factor-1α levels were higher in Wistar vs. ODS rats at 24 , after CA.

Conclusion: Ascorbate-deficient juvenile ODS rats appear resistant to neurodegeneration produced by asphyxia CA, possibly related to upregulation of the endogenous antioxidant GSH in brain.

Impact: Like humans and unlike other rodents, osteogenic disorder Shionogi (ODS) rats do not synthesize ascorbate, and thus may serve as a useful model for studying the role of ascorbate in human disease. Conflicting evidence exists regarding ascorbate's protective versus detrimental effects in animal models and clinical studies. Ascorbate-deficient ODS rats are resistant to neurodegeneration after experimental cardiac arrest.
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http://dx.doi.org/10.1038/s41390-021-01515-5DOI Listing
April 2021

Perceptions of Signs of Addiction Among Opioid Naive Patients Prescribed Opioids in the Emergency Department.

J Addict Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Emergency Medicine, Northwestern University, Chicago, IL (PTS, PML, HSK, DMM); Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL (KAC, LAO, LMC, MSW); Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (DMC).

Objectives: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction.

Methods: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes.

Results: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use.

Conclusions: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.
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http://dx.doi.org/10.1097/ADM.0000000000000806DOI Listing
February 2021

Change in Health Literacy over a Decade in a Prospective Cohort of Community-Dwelling Older Adults.

J Gen Intern Med 2021 Apr 9;36(4):916-922. Epub 2021 Feb 9.

Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.

Background: Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health.

Objectives: We sought to examine health literacy over time among older adults using three widely used measures.

Design: A prospective cohort study.

Participants: Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL.

Measures: Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points.

Results: In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity.

Conclusion: We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.
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http://dx.doi.org/10.1007/s11606-020-06423-8DOI Listing
April 2021

Comorbidities and depressive symptoms among older adults with asthma.

J Asthma 2021 Feb 20:1-7. Epub 2021 Feb 20.

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective: Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma.

Methods: Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors.

Results: Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms ( (8, 330) = 7.7,  < 0.0001, = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses.

Conclusions: In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.
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http://dx.doi.org/10.1080/02770903.2021.1887890DOI Listing
February 2021

Transplant regimen adherence for kidney recipients by engaging information technologies (TAKE IT): Rationale and methods for a randomized controlled trial of a strategy to promote medication adherence among transplant recipients.

Contemp Clin Trials 2021 Jan 27;103:106294. Epub 2021 Jan 27.

Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America.

Background: Several studies report a high prevalence of non-adherence to prescribed immunosuppressive (IS) medications among kidney transplant recipients (KTRs), yet few interventions have been effective for helping patients sustain appropriate post-transplant adherence. We describe a multifaceted, evidence-based, medication adherence monitoring strategy ('TAKE IT') that leverages available transplant center resources to identify potential medication non-adherence and other concerns earlier to prevent complications that could result from inadequate IS adherence.

Methods: The TAKE IT strategy includes: 1) medication adherence mobile application; 2) routine, online patient self-reported adherence assessments; 3) care alert notifications via the electronic health record (EHR) directed to transplant coordinators; 4) quarterly adherence reports to monitor IS values and summarize adherence trends; 5) deployment of adherence support tools tailored to specific adherence concerns. To test the TAKE IT intervention, we will conduct a two-arm, patient-randomized controlled trial at two large, diverse transplant centers (Northwestern University, Mayo Clinic, AZ) with planned recruitment of 450 KTRs (n = 225 per site) within 2 years of transplantation and 2 years of follow-up. Study assessments will take place at baseline, 6 weeks, 6, 12, 18 and 24 months. The primary effectiveness outcome is medication adherence via pill count, secondary outcomes include self-reported adherence and clinical outcomes. Process outcomes and cost-effectiveness will also be examined.

Conclusion: The TAKE IT trial presents an innovative approach to monitoring and optimizing medication adherence among a population taking complex medication regimens. This trial seeks to evaluate the effectiveness and feasibility of this strategy compared to usual care.
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http://dx.doi.org/10.1016/j.cct.2021.106294DOI Listing
January 2021

Health Literacy, Processing Capacity, Illness Knowledge, and Actionable Memory for Medication Taking in Type 2 Diabetes: Cross-Sectional Analysis.

J Gen Intern Med 2021 Jan 28. Epub 2021 Jan 28.

University of Illinois at Urbana-Champaign, Champaign, IL, USA.

Background: Patient knowledge about the purpose of medications is crucial to ensure safe and correct use, so it is an important index of adherence in patients with chronic illness.

Objective: We examined how health literacy and its components (processing capacity and knowledge about illness) influence memory for medication purposes.

Design: We conducted a cross-sectional study to examine memory for medication purposes in relation to health literacy, processing capacity, and illness knowledge among patients with diabetes in outpatient clinics.

Participants: Six hundred seventy-four adults who were diagnosed with type II diabetes mellitus, age 40 years or older, taking 5 or more current medications, native speakers of English, and with glycosylated hemoglobin (HbA1c) of 6.0 or more, were recruited to the study.

Main Measures: We included measures of processing capacity, illness knowledge, health literacy, and actionable memory for medication taking (memory for medication purpose).

Key Results: Results suggested an association between health literacy and both processing capacity and health knowledge, with some evidence that knowledge can compensate for limited processing capacity in order to maintain health literacy. Furthermore, health literacy was associated with memory for medication purposes, with processing capacity and health knowledge partly mediating this association. This pattern of results supports the process-knowledge model of health literacy.

Conclusions: Our findings establish the role of health literacy in medication taking, in relation to broader cognitive abilities and knowledge. Implications for improving the learning of medication purpose among diverse older adults with chronic illness are discussed.

Trial Registration: NIH trial registry number: NCT01296633.
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http://dx.doi.org/10.1007/s11606-020-06472-zDOI Listing
January 2021

The Effects of a Multicomponent Colorectal Cancer Screening Intervention on Knowledge, Recommendation, and Screening among Underserved Populations.

J Health Care Poor Underserved 2020 ;31(4):1612-1633

This trial tested a multicomponent intervention to increase colorectal cancer (CRC) screening among underserved patients. Participants were randomized to: (1) physician + patient intervention, (2) physician-only intervention, or (3) usual care (UC). Study outcomes included patient knowledge, physician recommendation of CRC screening, and screening completion via colonoscopy or stool tests. Among 538 participants, those exposed to the physician + patient intervention had significantly increased knowledge over patients in physician-only (p=.0008) or UC arms (p=.0003). However, there were no statistically significant differences in completion of CRC screening, with 10%, 20%, and 16% of UC, physician-only, and physician + patient participants screened, respectively. In UC, all completed screenings were colonoscopy, whereas in the physician-only and physician + patient arms, 39% and 46% of completed tests were via stool test, respectively. The multicomponent intervention did not increase overall CRC screening, yet results underscore the need to provide patients options for completing CRC screening.
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http://dx.doi.org/10.1353/hpu.2020.0122DOI Listing
January 2020

Health literacy and disparities in COVID-19-related knowledge, attitudes, beliefs and behaviours in Australia.

Public Health Res Pract 2020 Dec 9;30(4). Epub 2020 Dec 9.

Center for Applied Health Research on Aging, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, US.

Objectives: To explore the variation in understanding of, attitudes towards, and uptake of, health advice on coronavirus disease 2019 (COVID-19) during the 2020 pandemic stage 3 restrictions ('lockdown') by health literacy in the Australian population.

Study Design: National cross-sectional community survey.

Setting: Australian general public.

Participants: Adults aged over 18 years (N = 4362).

Main Outcome Measures: Knowledge, attitudes and behaviours related to COVID-19; health literacy and sociodemographic factors.

Results: People with inadequate health literacy had poorer understanding of COVID-19 symptoms (49% vs 68%; p < 0.001), were less able to identify behaviours to prevent infection (59%% vs 72% p < 0.001), and experienced more difficulty finding information and understanding government messaging about COVID-19 than people with adequate health literacy. People with inadequate health literacy were less likely to rate social distancing as important (6.1 vs 6.5; p < 0.001) and reported more difficulty with remembering and accessing medicines since lockdown (3.6 vs 2.7; p < 0.001). People with lower health literacy were also more likely to endorse misinformed beliefs about COVID-19 and vaccinations (in general) than those with adequate health literacy. The same pattern of results was observed among people who primarily speak a language other than English at home.

Conclusion: Our findings show that there are important disparities in COVID-19-related knowledge, attitudes and behaviours according to people's health literacy and language. These have the potential to undermine efforts to reduce viral transmission and may lead to social inequalities in health outcomes in Australia. People with the greatest burden of chronic disease are most disadvantaged, and are also most likely to experience severe disease and die from COVID-19. Addressing the health literacy, language and cultural needs of the community in public health messaging about COVID-19 must now be a priority in Australia.
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http://dx.doi.org/10.17061/phrp30342012DOI Listing
December 2020

eHealth literacy and web-based patient portal usage among kidney and liver transplant recipients.

Clin Transplant 2021 Feb 16;35(2):e14184. Epub 2020 Dec 16.

Division of Transplantation, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA.

Patient portals promote self-management, but require skills with electronic health information which can be measured by a patient's eHealth literacy. We aimed to describe eHealth literacy among a population of kidney transplant (KT) and liver transplant (LT) recipients and to investigate the relationship between eHealth literacy and Web-based patient portal utilization. We conducted phone surveys (August 2016-March 2017) among 178 KT and 110 LT recipients at two large transplant centers, including the eHealth Literacy Scale (eHEALS) and items assessing routine portal usage. Portal users were defined as routine if usage was every day, weekly, or monthly. The mean eHEALS score was 30.9 (SD: 5.4), and 45.4% routinely used the patient portal more than a few times per month. Routine users had higher eHealth literacy than non-routine users and non-users (31.97 vs. 29.97 vs. 28.20, p < .001). Routine users had higher eHealth literacy scores compared with non-users after adjusting for transplant organ type, age, educational level, employment status, mobile Internet access, and transplant center (OR: 1.10, 95% CI: 1.03-1.17). KT and LT recipients who routinely use patient portals have high eHealth literacy compared with other diseased populations, which should be leveraged by encouraging routine usage to improve post-transplant health and medication adherence.
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http://dx.doi.org/10.1111/ctr.14184DOI Listing
February 2021

Screen-Based Physical Activity Tools: Are the Current Recommendations Causing More Harm Than Good?

J Am Geriatr Soc 2021 Feb 8;69(2):322-324. Epub 2020 Dec 8.

Department of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

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http://dx.doi.org/10.1111/jgs.16972DOI Listing
February 2021

Broadband multi-magnon relaxometry using a quantum spin sensor for high frequency ferromagnetic dynamics sensing.

Nat Commun 2020 Oct 16;11(1):5229. Epub 2020 Oct 16.

Department of Physics, The Ohio State University, Columbus, OH, 43210, USA.

Development of sensitive local probes of magnon dynamics is essential to further understand the physical processes that govern magnon generation, propagation, scattering, and relaxation. Quantum spin sensors like the NV center in diamond have long spin lifetimes and their relaxation can be used to sense magnetic field noise at gigahertz frequencies. Thus far, NV sensing of ferromagnetic dynamics has been constrained to the case where the NV spin is resonant with a magnon mode in the sample meaning that the NV frequency provides an upper bound to detection. In this work we demonstrate ensemble NV detection of spinwaves generated via a nonlinear instability process where spinwaves of nonzero wavevector are parametrically driven by a high amplitude microwave field. NV relaxation caused by these driven spinwaves can be divided into two regimes; one- and multi-magnon NV relaxometry. In the one-magnon NV relaxometry regime the driven spinwave frequency is below the NV frequencies. The driven spinwave undergoes four-magnon scattering resulting in an increase in the population of magnons which are frequency matched to the NVs. The dipole magnetic fields of the NV-resonant magnons couple to and relax nearby NV spins. The amplitude of the NV relaxation increases with the wavevector of the driven spinwave mode which we are able to vary up to 3 × 10 m, well into the part of the spinwave spectrum dominated by the exchange interaction. Increasing the strength of the applied magnetic field brings all spinwave modes to higher frequencies than the NV frequencies. We find that the NVs are relaxed by the driven spinwave instability despite the absence of any individual NV-resonant magnons, suggesting that multiple magnons participate in creating magnetic field noise below the ferromagnetic gap frequency which causes NV spin relaxation.
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http://dx.doi.org/10.1038/s41467-020-19121-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568545PMC
October 2020

Identifying Behavioral Phenotypes in Chronic Illness: Self-Management of COPD and Comorbid Hypertension.

Patient Educ Couns 2021 Mar 29;104(3):627-633. Epub 2020 Aug 29.

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States. Electronic address:

Objectives: To identify and characterize the constellation, or clusters, of self-management behaviors in patients with chronic obstructive pulmonary disease (COPD) and comorbid hypertension.

Methods: Cluster analysis (n = 204) was performed with standardized scores for medication adherence to COPD and hypertension medications, inhaler technique, and diet as well as self-reported information on physical activity, appointment keeping, smoking status, and yearly influenza vaccination for a total of eight variables. Classification and regression tree analysis (CART) was performed to further characterize the resulting clusters.

Results: Patients were divided into three clusters based on eight self-management behaviors, which included 95 patients in cluster 1, 42 in cluster 2, and 67 in cluster 3. All behaviors except for inhaler technique differed significantly among the three clusters (P's<0.005). CART indicated physical activity was the first differentiating variable.

Conclusions: Patients with COPD and hypertensioncan be separated into those with adequate and inadequate adherence. The group with inadequate adherence can further be divided into those with poor adherence to medical behaviors compared to those with poor adherence to lifestyle behaviors.

Practice Implications: Once validated in other populations, the identification of patient clusters using patient self-management behaviors could be used to inform interventions for patients with multimorbidity.
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http://dx.doi.org/10.1016/j.pec.2020.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914263PMC
March 2021

Changes in COVID-19 Knowledge, Beliefs, Behaviors, and Preparedness Among High-Risk Adults from the Onset to the Acceleration Phase of the US Outbreak.

J Gen Intern Med 2020 11 1;35(11):3285-3292. Epub 2020 Sep 1.

Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine at Northwestern University, , 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.

Background: The US outbreak of coronavirus disease 2019 (COVID-19) accelerated rapidly over a short time to become a public health crisis.

Objective: To assess how high-risk adults' COVID-19 knowledge, beliefs, behaviors, and sense of preparedness changed from the onset of the US outbreak (March 13-20, 2020) to the acceleration phase (March 27-April 7, 2020).

Design: Longitudinal, two-wave telephone survey.

Participants: 588 predominately older adults with ≥ 1 chronic condition recruited from 4 active, federally funded studies in Chicago.

Main Measures: Self-reported knowledge of COVID-19 symptoms and prevention, related beliefs, behaviors, and sense of preparedness.

Key Results: From the onset to the acceleration phase, participants increasingly perceived COVID-19 to be a serious public health threat, reported more changes to their daily routine and plans, and reported greater preparedness. The proportion of respondents who believed they were "not at all likely" to get the virus decreased slightly (24.9 to 22.4%; p = 0.04), but there was no significant change in the proportion of those who were unable to accurately identify ways to prevent infection (29.2 to 25.7%; p 0.14). In multivariable analyses, black adults and those with lower health literacy were more likely to report less perceived susceptibility to COVID-19 (black adults: relative risk (RR) 1.62, 95% confidence interval (CI) 1.07-2.44, p = 0.02; marginal health literacy: RR 1.96, 95% CI 1.26-3.07, p < 0.01). Individuals with low health literacy remained more likely to feel unprepared for the outbreak (RR 1.80, 95% CI 1.11-2.92, p = 0.02) and to express confidence in the federal government response (RR 2.11, 95% CI 1.49-3.00, p < 0.001) CONCLUSIONS: Adults at higher risk for COVID-19 continue to lack critical knowledge about prevention. While participants reported greater changes to daily routines and plans, disparities continued to exist in perceived susceptibility to COVID-19 and in preparedness. Public health messaging to date may not be effectively reaching vulnerable communities.
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http://dx.doi.org/10.1007/s11606-020-05980-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462357PMC
November 2020

Evaluation of a Discussion Guide to Promote Patient Understanding of Menopause and Informed Treatment Decision-Making.

J Womens Health (Larchmt) 2021 Mar 27;30(3):445-451. Epub 2020 Aug 27.

Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Patient-provider communication surrounding menopause symptoms and treatment is often limited. We developed and evaluated a health literacy-appropriate discussion guide to support patient education. A cross-sectional randomized study was conducted among 100 English-speaking women, aged 45-60 years, in Chicago, IL, and Durham, NC. Participants were randomly assigned to review either the discussion guide or a standard education material ( = 50 per arm) and to complete an open book knowledge questionnaire; they then rated the appearance and quality of both materials. Bivariate analyses examined knowledge and satisfaction by study arm and across sociodemographic characteristics. Multivariable models tested the effectiveness of the discussion guide to improve knowledge compared with the standard material. Women receiving the discussion guide demonstrated significantly higher knowledge scores compared with those who reviewed the standard material (mean [] = 20.0, standard deviation [SD] = 2.7, vs.  = 18.1, SD = 2.6;  < 0.001); 82.0% of those exposed to the discussion guide correctly answered ≥85% of knowledge items compared with only 48.0% of those reviewing the standard material ( < 0.001). In multivariable analyses, participants receiving the discussion guide displayed significantly greater knowledge in comparison with those receiving the standard material regardless of whether knowledge was examined as a score ( = 1.9, 95% confidence interval [CI]: 0.9-2.9,  < 0.001) or 85% threshold (odds ratio: 5.7, 95% CI: 2.0-16.2,  < 0.001). More than two-thirds of women (68%) preferred the discussion guide; it was rated highly in terms of appearance and content. The discussion guide improved understanding of menopause symptoms and treatment options in comparison with a current standard and was well received by a diverse audience.
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http://dx.doi.org/10.1089/jwh.2020.8436DOI Listing
March 2021

Patient characteristics associated with improvements in asthma control and reduction in emergency department visits for older adults with asthma.

J Asthma 2020 Aug 19:1-8. Epub 2020 Aug 19.

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective: To identify patient characteristics associated with improvements in asthma control among older adults with asthma.

Methods: Secondary analysis of data from a randomized controlled trial of an asthma self-management support intervention for adults ages 60 and older with moderate-severe persistent asthma ( = 391). We tested the association of baseline patient characteristics with reduced emergency department (ED) visits and improvement in asthma control equal to or exceeding the minimal clinically important difference (MCID) in asthma control test (ACT) scores (3.0) 12 months.

Results: At baseline, the mean age was 68 years, 15.0% were male, 30.3% were black, and 56.5% were Hispanic. Patients with a history of ED visits in the 12 months preceding study enrollment were significantly more likely to experience an ED visit during the study period (adjusted odds ratio [AOR] 6.92, 95% confidence interval [CI] 2.18-21.9,  < .0001). Similarly, those with poorer asthma control (baseline ACT scores <13) had greater odds of achieving improved asthma control (AOR 13.7, 95% CI 5.32-35.1,  < .0001). No other variables had statistically significant associations with the outcomes.

Conclusions: Low scores on the asthma control test and prior ED visits for asthma are strong correlates of later clinically meaningful changes in asthma control among older adults. Health systems preparing for population management of patients with asthma ought to consider incorporating serial collection of data on the ACT into the monitoring and management of older asthmatics, a high-risk patient population.
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http://dx.doi.org/10.1080/02770903.2020.1805753DOI Listing
August 2020

Knowledge and Behaviors of Adults with Underlying Health Conditions During the Onset of the COVID-19 U.S. Outbreak: The Chicago COVID-19 Comorbidities Survey.

J Community Health 2020 12;45(6):1149-1157

Division of General Internal Medicine and Geriatrics, Center for Applied Health Research On Aging (CAHRA), Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, 10th Floor, Chicago, IL, 60611, USA.

Accurate understanding of COVID-19 safety recommendations early in the outbreak was complicated by inconsistencies in public health and media messages. We sought to characterize high-risk adults' knowledge of COVID-19 symptoms, prevention strategies, and prevention behaviors. We used data from the Chicago COVID-19 Comorbidities (C3) survey collected between March 13 thru March 20, 2020. A total of 673 predominately older adults with ≥ 1 chronic condition completed the telephone interview. Knowledge was assessed by asking participants to name three symptoms of COVID-19 and three actions to prevent infection. Participants were then asked if and how they had changed plans due to coronavirus. Most participants could identify three symptoms (71.0%) and three preventive actions (69.2%). Commonly reported symptoms included: fever (78.5%), cough (70.6%), and shortness of breath (45.2%); preventive actions included: washing hands (86.5%) and social distancing (86.2%). More than a third of participants reported social distancing themselves (38.3%), and 28.8% reported obtaining prescription medication to prepare for the outbreak. In multivariable analyses, no participant characteristics were associated with COVID-19 knowledge. Women were more likely than men, and Black adults were less likely than White adults to report practicing social distancing. Individuals with low health literacy were less likely to report obtaining medication supplies. In conclusion, though most higher-risk individuals were aware of social distancing as a prevention strategy early in the outbreak, less than half reported enacting it, and racial disparities were apparent. Consistent messaging and the provision of tangible resources may improve future adherence to safety recommendations.
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http://dx.doi.org/10.1007/s10900-020-00906-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418091PMC
December 2020

Health Literacy and Its Impact on Health and Healthcare Outcomes.

Stud Health Technol Inform 2020 Jun;269:3-21

Feinberg School of Medicine, Northwestern University, U.S.A.

This chapter summarizes research that investigated relationships between health literacy (using currently accepted measures) and specific classifications of health outcomes, including healthcare utilization. To better understand the causal pathway which limited health literacy affects poorer health outcomes, the literature is presented from proximal (health knowledge) to distal (mortality) outcomes. Overall, the most consistent evidence was observed at the most proximal and distal outcomes, but less consistent evidence with intermediary outcomes, particularly self-management behaviors and clinical health outcomes. The chapter concludes with a discussion of the findings and larger implications for the causal mechanisms which health literacy impacts health outcomes.
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http://dx.doi.org/10.3233/SHTI200019DOI Listing
June 2020

Low Health Literacy Is Associated With Frailty and Reduced Likelihood of Liver Transplant Listing: A Prospective Cohort Study.

Liver Transpl 2020 11 7;26(11):1409-1421. Epub 2020 Oct 7.

Division of Gastroenterology and Hepatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.

The effect of low health literacy (HL) on outcomes in end-stage liver disease (ESLD) is largely unknown. The association of low HL on clinical outcomes was investigated in a prospective cohort of outpatients with ESLD undergoing liver transplantation (LT) evaluation. From 2014 to 2017, 276 patients underwent LT evaluation with assessments of liver disease severity, medical and psychosocial comorbidities, physical frailty, and malnutrition. Literacy was measured with the Newest Vital Sign, a brief validated assessment. Multivariate models assessed relationships between HL and clinical outcomes adjusting for clinical and psychosocial variables. The median Model for End-Stage Liver Disease-sodium score of the study sample was 15 (interquartile range, 11-19), 71 (25.7%) of candidates were frail, 117 (42.4%) had malnutrition, 151 (54.7%) had hepatic encephalopathy, 104 (37.7%) had low HL, and 85 (39.2%) had marginal or poor social support. Adjusting for education level, socioeconomic factors, and severity of illness, low HL was independently associated with physical frailty (adjusted odds ratio [aOR], 3.59; 95% confidence interval [CI], 1.50-8.59; P = 0.004) and not being wait-listed (aOR 1.96; 95% CI, 1.03-3.75; P = 0.04). Strong social support attenuated the relationship between low HL and not being wait-listed (aOR, 1.58; 95% CI, 0.74-3.36; P = 0.24). Low HL is common and a largely unrecognized risk factor for poor health outcomes among patients with ESLD. Patient-oriented infrastructure and support are needed at the health system level to ensure all patients can successfully navigate the complex process of LT evaluation and wait-listing.
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http://dx.doi.org/10.1002/lt.25830DOI Listing
November 2020

Assessment of Dynamic Intracranial Compliance in Children with Severe Traumatic Brain Injury: Proof-of-Concept.

Neurocrit Care 2021 02;34(1):209-217

Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background And Aims: Intracranial compliance refers to the relationship between a change in intracranial volume and the resultant change in intracranial pressure (ICP). Measurement of compliance is useful in managing cardiovascular and respiratory failure; however, there are no contemporary means to assess intracranial compliance. Knowledge of intracranial compliance could complement ICP and cerebral perfusion pressure (CPP) monitoring in patients with severe traumatic brain injury (TBI) and may enable a proactive approach to ICP management. In this proof-of-concept study, we aimed to capitalize on the physiologic principles of intracranial compliance and vascular reactivity to CO, and standard-of-care neurocritical care monitoring, to develop a method to assess dynamic intracranial compliance.

Methods: Continuous ICP and end-tidal CO (ETCO) data from children with severe TBI were collected after obtaining informed consent in this Institutional Review Board-approved study. An intracranial pressure-PCO Compliance Index (PCI) was derived by calculating the moment-to-moment correlation between change in ICP and change in ETCO. As such, "good" compliance may be reflected by a lack of correlation between time-synched changes in ICP in response to changes in ETCO, and "poor" compliance may be reflected by a positive correlation between changes in ICP in response to changes in ETCO.

Results: A total of 978 h of ICP and ETCO data were collected and analyzed from eight patients with severe TBI. Demographic and clinical characteristics included patient age 7.1 ± 5.8 years (mean ± SD); 6/8 male; initial Glasgow Coma Scale score 3 [3-7] (median [IQR]); 6/8 had decompressive surgery; 7.1 ± 1.4 ICP monitor days; ICU length of stay (LOS) 16.1 ± 6.8 days; hospital LOS 25.9 ± 8.4 days; and survival 100%. The mean PCI for all patients throughout the monitoring period was 0.18 ± 0.04, where mean ICP was 13.7 ± 2.1 mmHg. In this cohort, PCI was observed to be consistently above 0.18 by 12 h after monitor placement. Percent time spent with PCI thresholds > 0.1, 0.2, and 0.3 were 62% [24], 38% [14], and 23% [15], respectively. The percentage of time spent with an ICP threshold > 20 mmHg was 5.1% [14.6].

Conclusions: Indirect assessment of dynamic intracranial compliance in TBI patients using standard-of-care monitoring appears feasible and suggests a prolonged period of derangement out to 5 days post-injury. Further study is ongoing to determine if the PCI-a new physiologic index, complements utility of ICP and/or CPP in guiding management of patients with severe TBI.
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http://dx.doi.org/10.1007/s12028-020-01004-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299131PMC
February 2021

Awareness, Attitudes, and Actions Related to COVID-19 Among Adults With Chronic Conditions at the Onset of the U.S. Outbreak: A Cross-sectional Survey.

Ann Intern Med 2020 07 9;173(2):100-109. Epub 2020 Apr 9.

Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (M.S.W., L.O., R.M.O., L.C., J.Y.B., G.W., S.B., M.E., P.Z., A.R., M.A., S.C.B.).

Background: The evolving outbreak of coronavirus disease 2019 (COVID-19) is requiring social distancing and other measures to protect public health. However, messaging has been inconsistent and unclear.

Objective: To determine COVID-19 awareness, knowledge, attitudes, and related behaviors among U.S. adults who are more vulnerable to complications of infection because of age and comorbid conditions.

Design: Cross-sectional survey linked to 3 active clinical trials and 1 cohort study.

Setting: 5 academic internal medicine practices and 2 federally qualified health centers.

Patients: 630 adults aged 23 to 88 years living with 1 or more chronic conditions.

Measurements: Self-reported knowledge, attitudes, and behaviors related to COVID-19.

Results: A fourth (24.6%) of participants were "very worried" about getting the coronavirus. Nearly a third could not correctly identify symptoms (28.3%) or ways to prevent infection (30.2%). One in 4 adults (24.6%) believed that they were "not at all likely" to get the virus, and 21.9% reported that COVID-19 had little or no effect on their daily routine. One in 10 respondents was very confident that the federal government could prevent a nationwide outbreak. In multivariable analyses, participants who were black, were living below the poverty level, and had low health literacy were more likely to be less worried about COVID-19, to not believe that they would become infected, and to feel less prepared for an outbreak. Those with low health literacy had greater confidence in the federal government response.

Limitation: Cross-sectional study of adults with underlying health conditions in 1 city during the initial week of the COVID-19 U.S. outbreak.

Conclusion: Many adults with comorbid conditions lacked critical knowledge about COVID-19 and, despite concern, were not changing routines or plans. Noted disparities suggest that greater public health efforts may be needed to mobilize the most vulnerable communities.

Primary Funding Source: National Institutes of Health.
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http://dx.doi.org/10.7326/M20-1239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151355PMC
July 2020

Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using?

Pain Med 2021 Feb;22(2):292-302

Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA.

Objectives: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain.

Design: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge.

Setting: Urban academic emergency department (>88,000 annual visits).

Subjects: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary.

Methods: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis.

Results: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills.

Conclusions: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.
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http://dx.doi.org/10.1093/pm/pnaa048DOI Listing
February 2021

Cognitive impairment no dementia and associations with health literacy, self-management skills, and functional health status.

Patient Educ Couns 2020 09 12;103(9):1805-1811. Epub 2020 Mar 12.

Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, USA. Electronic address:

Objectives: To determine the prevalence of cognitive impairment no dementia (CIND) among a diverse, community-based population, and establish associations between CIND and health literacy, chronic disease self-management and functional health status.

Methods: 863 primary care adults without dementia aged 55-74. Adjusted logistic and linear regressions were used to assess associations between CIND (None, Mild, Moderate/Severe) and outcomes.

Results: 36 % participants exhibited CIND. It was strongly associated with limited health literacy (Newest Vital Signs: Mild [OR 3.25; 95 % CI 1.93, 5.49], Moderate/Severe [OR 6.45; 95 % CI 3.16, 13.2]; Test of Functional Health Literacy in Adults: Mild [OR 3.46; 95 % CI 2.08, 5.75], Moderate/Severe [OR 8.82; 95 % CI 4.87, 16.0]; all p's < 0.001) and poor chronic disease self-management (Mild [B = -11.2; 95 % CI -13.5, -8.90], Moderate/Severe CI [B = -21.0; 95 % CI -23.6, -18.4]; both p's < 0.001). Associations between CIND and functional health status were non-significant.

Conclusions: CIND was prevalent in this cohort, and strongly associated with requisite skills for managing everyday health needs.

Practice Implications: Attention to subtle declines in chronic disease self-care may assist with CIND identification and care management within this population. When CIND is observed, clinicians should also expect and address difficulties with self-management.
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http://dx.doi.org/10.1016/j.pec.2020.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864102PMC
September 2020

Barriers and solutions to implementing a pragmatic diabetes education trial in rural primary care clinics.

Contemp Clin Trials Commun 2020 Jun 3;18:100550. Epub 2020 Mar 3.

Northwestern University, Department of Preventive Medicine, 680 N. Lake Shore Drive, Chicago, IL, 60611, USA.

Introduction: The purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics.

Methods: The two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention.

Results: Barriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches.

Conclusions: Successful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.
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http://dx.doi.org/10.1016/j.conctc.2020.100550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068634PMC
June 2020

Associations Between Health Literacy and Medication Self-Management Among Community Health Center Patients with Uncontrolled Hypertension.

Patient Prefer Adherence 2020 15;14:87-95. Epub 2020 Jan 15.

Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Purpose: Examine associations between health literacy and several medication self-management constructs among a population of adults with uncontrolled hypertension.

Patients And Methods: Cross-sectional study of health center patients from the Chicago area with uncontrolled hypertension enrolled between April 2012 and February 2015. Medication self-management constructs-applied to hypertension medications, chronic condition medications and all medications-included: 1) medication reconciliation, 2) knowledge of drug indications, 3) understanding instructions and dosing, and 4) self-reported adherence over 4 days (no missed doses). We determined associations between health literacy and self-management outcomes using multivariable generalized linear regression.

Results: There were 1460 patients who completed screening interviews; 62.9% enrolled and had complete baseline data collected, and were included in the analysis. Of 919 participants, 47.4% had likely limited (low), 33.2% possibly limited, and 19.4% likely adequate health literacy. Compared to participants with likely adequate health literacy, participants with low health literacy were less likely to have chronic medications reconciled (18.0% versus 29.6%, p=0.007), know indications for chronic medications (64.1% versus 83.1%, p<0.001), and demonstrate understanding of instructions and dosing (68.1% versus 82.9%, p=0.001). Self-reported adherence to hypertension medications was higher among the low health literacy group (65.6% versus 56.0%, p=0.010). In multivariable models, health literacy was strongly associated with knowledge of drug indications, and understanding of instructions and dosing.

Conclusion: Low health literacy was associated with worse medication self-management in several domains. However, non-adherence was greatest in the most health literate in unadjusted analysis. Among a population of patients with uncontrolled hypertension, the drivers of poor control may vary by health literacy.
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http://dx.doi.org/10.2147/PPA.S226619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970267PMC
January 2020

Effects of Estimated Community-Level Health Literacy on Treatment Initiation and Preventive Care Among Older Adults with Newly Diagnosed Diabetes.

Patient Prefer Adherence 2020 7;14:1-11. Epub 2020 Jan 7.

College of Pharmacy, The University of Michigan, Ann Arbor, MI, USA.

Purpose: Individual measures of health literacy are not feasible for administration on a large scale, yet estimates of community-level health literacy in the US recently became available. We sought to investigate whether community-level health literacy estimates are associated with the initiation of oral antihyperglycemic agents (OHA) and the use of standard preventive care services among older adults with newly diagnosed diabetes.

Patients And Methods: We conducted a retrospective cohort study of 169,758 patients, ≥65 years old with hypertension and newly diagnosed type 2 diabetes using 2007-2011 data from the Center for Medicare and Medicaid Services Chronic Conditions Warehouse. We examined the relationship between community-level health literacy estimates and initiation of OHA, receipt of flu shots, eye exams, Hemoglobin A1c tests, and lipid tests within 12 months post diabetes diagnosis.

Results: Patients living in communities with above basic health literacy (vs. basic/below basic) were 15% more likely to initiate OHA (Hazard Ratio=1.15; 95% CI 1.12 to 1.18). After classifying the health literacy distribution as quintiles, the analysis revealed a dose-response relationship with OHA initiation that plateaued at the third and fourth quintiles and declined at the fifth quintile. Individuals residing in communities with higher health literacy were more likely to participate in preventive care services (relative risk ranged from 1.09 for lipid test [95% CI 1.07-1.11] to 1.43 for flu shot [95% CI 1.41-1.46]).

Conclusion: Community-level health literacy estimates were associated with the initiation of OHA and uptake of standard preventive care services in older adults. Community-level health literacy may help to inform targeted diabetes education and support efforts.
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http://dx.doi.org/10.2147/PPA.S211784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954850PMC
January 2020

Prevalence of Universal Medication Schedule prescribing and links to adherence.

Am J Health Syst Pharm 2020 Jan;77(3):196-205

Division of General Internal Medicine, Emory School of Medicine, Atlanta, GA.

Purpose: A Universal Medication Schedule (UMS) that uses explicit language to describe when to take medicine has been proposed as a patient-centered prescribing and dispensing standard. Despite widespread support, evidence of its actual use and efficacy is limited. We investigated the prevalence of UMS instructions and whether their use was associated with higher rates of medication adherence.

Methods: National pharmacy records were analyzed for a cohort of type 2 diabetic adults ≥18 years old (N = 676,739) new to ≥1 oral diabetes medications between January and June 2014. Prescription instructions (N = 796,909) dispensed with medications were classified as UMS or non-UMS. Instructions coded as UMS were further categorized as either providing precise UMS language (tier 1: "take 1 pill at morning, noon, evening, or bedtime") or offering some explicit guidance (tier 2: "take 1 tablet by mouth before breakfast"; tier 3: "take 1 tablet twice daily with a meal"). Adherence over 12 months was measured by proportion of days covered.

Results: One-third of instructions (32.4%, n = 258,508) were classified as UMS (tier 1: 12.6%, n = 100,589; tier 2: 6.0%, n = 47,914; tier 3: 13.8%, n = 110,005). In multivariable analyses, UMS instructions (all tiers) exhibited better adherence compared to non-UMS instructions (relative risk [RR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = 0.01). Patients older than 65 years who were less educated and taking medication more than once daily received greater benefit from tier 1 UMS instructions (RR, 1.14; 95% CI, 1.07-1.21; P < 0.001).

Conclusion: While infrequently used, the UMS could help older, less-educated patients adhere to more complex regimens with minimal investment.
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http://dx.doi.org/10.1093/ajhp/zxz305DOI Listing
January 2020

Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease.

COPD 2020 02 17;17(1):74-80. Epub 2020 Jan 17.

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated ( = 0.33,  < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, =.49). Findings were similar for COPD patients:  = 0.26,  = 0.003; kappa 0.19,  = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.
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http://dx.doi.org/10.1080/15412555.2020.1712688DOI Listing
February 2020

Successful Use of Cidofovir in an Immunocompetent Child With Severe Adenoviral Sepsis.

Pediatrics 2020 01 11;145(1). Epub 2019 Dec 11.

Departments of Critical Care Medicine and

Adenovirus infection is common in childhood and is generally associated with self-limited disease. Cidofovir, a viral DNA polymerase inhibitor, is used to treat adenovirus infection in select populations but is not often recommended for immunocompetent patients because of limited antiviral activity and nephrotoxicity. Here, we report a case of fulminant adenovirus infection associated with lymphopenia and multiple organ failure requiring extracorporeal membrane oxygenation support in a previously healthy child. After 1 week of supportive therapy, the patient had persistent organ failure and continued to have adenoviremia of >560 000 copies per mL. Weekly doses of cidofovir with concurrent probenecid for renal protection was initiated. Adenovirus blood load declined after the first cidofovir dose, becoming undetectable after 3 doses. The patient was successfully decannulated from extracorporeal membrane oxygenation, extubated, and eventually discharged at his functional baseline without need for ongoing respiratory support. Lymphopenia improved after viremia resolved, and a subsequent immunologic workup revealed no evidence of primary immunodeficiency. The viral isolate was genotyped as adenovirus type 7. This case reveals the successful use of cidofovir for management of severe adenovirus infection in a previously healthy child. To date, there are no universally accepted recommendations for the use of cidofovir in this population. Further study is warranted to determine the potential role of cidofovir in treating severe adenovirus infections in immunocompetent children.
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http://dx.doi.org/10.1542/peds.2019-1632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939840PMC
January 2020

Development of the influence, motivation, and patient activation in diabetes (IMPACT-D™) measure.

Diabetes Res Clin Pract 2020 Jan 2;159:107965. Epub 2019 Dec 2.

Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.

Aims: We sought to create a new research and clinical instrument -the Influence and Motivation for Patient ACTivation in Diabetes care (IMPACT-D™) - to measure the degree to which patients with type 2 diabetes (T2DM) value health and believe they can influence it.

Methods: Candidate items were generated via a literature review, expert opinion, and qualitative interviews and focus groups with T2DM patients in Chicago, IL and Chapel Hill, NC. Psychometric testing guided by item response theory was conducted among an online panel of 500 English-speaking adults with T2DM. Differential item functioning analyses evaluated item performance across key participant characteristics. To determine construct validity, IMPACT-D™ scores were compared to other general measures of personality and patient activation. A second study among 300 patients recruited from two internal medicine clinics further assessed associations between the IMPACT-D™ and health outcomes. Cognitive interviews confirmed patient understanding of IMPACT-D™ items and instructions.

Results: Exploratory factor analyses revealed a single-factor solution that included 6 items. The IMPACT-D™ demonstrated adequate reliability (α = 0.72) and moderate construct validity with patient activation (r = 0.51, p < 0.001) and personality-conscientiousness subscales (r = 0.29, p < 0.001). Higher scores on the IMPACT-D™ were associated with better physical health (r = 0.17, p = 0.003) and lower severity of depressive (r = -0.35, p < 0.001) and anxiety (r = -0.28, p < 0.001) symptoms. There were no significant differences by blood pressure (r = -0.0021, p = 0.9) or haemoglobin A1c (r = -0.069p = 0.2).

Conclusions: The IMPACT-D holds potential for use in both clinical care and research applications. Future studies should evaluate how to best operationalize its use for both settings.
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http://dx.doi.org/10.1016/j.diabres.2019.107965DOI Listing
January 2020

Longitudinal Investigation of Older Adults' Ability to Self-Manage Complex Drug Regimens.

J Am Geriatr Soc 2020 03 25;68(3):569-575. Epub 2019 Nov 25.

Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Objectives: We sought to investigate older patients' ability to correctly and efficiently dose multidrug regimens over nearly a decade and to explore factors predicting declines in medication self-management.

Design: Longitudinal cohort study funded by the National Institute on Aging.

Setting: One academic internal medicine clinic and six community health centers.

Participants: Beginning in 2008, 900 English-speaking adults, aged 55 to 74 years, were enrolled in the study, completing a baseline (T1) assessment. To date, 303 participants have completed the same assessment 9 years postbaseline (T4).

Measurements: At T1, subjects were given a standardized, seven-drug regimen and asked to demonstrate how they would take medicine over 24 hours. The number of dosing errors made and times per day that a participant would take medicine were recorded. Health literacy was measured via the Newest Vital Sign, and cognitive decline was measured by the Mini-Mental State Examination.

Results: Participants on average made 2.9 dosing errors (SD = 2.5 dosing errors; range = 0-21 dosing errors) of 21 potential errors at T1 and 5.0 errors (SD = 2.1 errors; range = 1-18 errors; P < .001) at T4. In a multivariate model, limited literacy (β = .69; 95% confidence interval [CI] = .18-1.20; P = .01), meaningful cognitive decline (β = 1.72; 95% CI = .70-2.74; P = .01), number of chronic conditions (β = .21; 95% CI = .07-.34; P = .01), and number of baseline dosing errors (β = -.76; 95% CI = -.85 to -.67; P < .001) were significant, independent predictors of changes in dosing errors. Most patients overcomplicated their daily medication schedule; no sociodemographic characteristics were predictive of poor regimen organization in multivariate models. In a multivariate model, there were no significant predictors of changes in regimen consolidation over time, except regimen consolidation at T1.

Conclusions: Older patients frequently overcomplicated drug regimens and increasingly made more dosing errors over 9 years of follow-up. Patients with limited literacy, cognitive decline, and multimorbidity were at greatest risk for errors. J Am Geriatr Soc 68:569-575, 2020.
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http://dx.doi.org/10.1111/jgs.16255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056504PMC
March 2020