#GeriMedJC: December 19, 2014

The two articles critically appraised during  #GeriMedJC on Dec 19 were:

Smith T, Pelpola K, Ball M, Ong A, Myint PK. Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age Ageing. 2014 Jul;43(4):464-71. 

Frankenthal D1, Lerman Y, Kalendaryev E, Lerman Y. Intervention with the screening tool of older persons potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatr Soc. 2014 Sep;62(9):1658-65. 

What a great discussion! Thanks especially to international expert involvement from @DrPhilipBraude who has a special interest in perioperative geriatrics. We also welcomed the McMaster University Division of Geriatric Medicine (Hamilton, Ontario, Canada) crew to the live telemedicine version of the journal club.

This is what Symplur analytics had to say about the December tweet chat:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

Thanks again to all those who participated in the Tweet chat:

The next #GeriMedJC will be on January 30, 2015 08:00 EST / 13:00 GMT.  See you then!

Our live journal club is also growing!

We are growing!  Just look at this list of sites participating via telemedicine!

The University of Toronto Division of Geriatric Medicine organizes a monthly Geriatric Medicine Journal Club where residents and faculty have the opportunity to critically appraise recent geriatric medicine literature. Two Geriatric Medicine residents review and present a critical appraisal of an original research article. There is one long presentation of 45 minutes and one short presentation of 15 minutes. The meetings take place on the fourth Friday of each month from 08:00 to 09:00. The Journal Club is broadcast by video-conference via the Ontario Telemedicine Network (OTN) to satellite sites around the province of Ontario.  

1. Sunnybrook Health Sciences Centre (Toronto)
2. Grand River Hospital (Kitchener-Waterloo)
3. Mount Sinai Hospital (Toronto)
4. St. Mary's General Hospital (Kitchener-Waterloo)
5. Orillia Soldiers' Memorial Hospital (Orillia)
6. St. Joseph's Health Centre (Toronto)
7. North York General Hospital (Toronto)
8. St. Joseph's Healthcare (Hamilton) 
9. Juravinski Hospital (Hamilton)
10. Hamilton Health Sciences Corporation - General Hospital Site (Hamilton)
11. St. Michael's Hospital (Toronto)
12. Baycrest Centre for Geriatric Care (Toronto)
13. Lakeridge Health (Oshawa)
14. St. Peter's Hospital (Hamilton)
15. Trillium Health Centre (Mississauga)

We hope the #GeriMedJC hashtag on Twitter will complement the live journal club discussion but also engage participation internationally for a much more enriched analysis of the literature.

Short article chosen for December 2014 #GeriMedJC

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, the last 15 minutes of the hour is devoted to the presentation and discussion of the article.

When to start and when to stop.  Potentially inappropriate prescriptions (PIPs) occur when the risks associated with prescribing a medication outweigh the potential benefits of that medication. Does this use of validated criteria for PIP, such as the Screening Tool of Older Person's potentially inappropriate Prescriptions and Screening Tool to Alert doctors to Right Treatment (STOPP/START) in chronic geriatric facilities result in clinically meaningful outcomes?

Frankenthal D1, Lerman Y, Kalendaryev E, Lerman Y. Intervention with the screening tool of older persons potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatr Soc. 2014 Sep;62(9):1658-65. 

The article can be found here: and the abstract is posted below.

Engage in the discussion on Twitter on December 19, 2014 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

OBJECTIVES: To assess the effect of a Screening Tool of Older Persons potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) medication intervention on clinical and economic outcomes.

DESIGN: Parallel-group randomized trial.

SETTING: Chronic care geriatric facility.

PARTICIPANTS: Residents aged 65 and older prescribed with at least one medication (N = 359) were randomized to receive usual pharmaceutical care or undergo medication intervention.

INTERVENTION: Screening medications with STOPP/START criteria followed up with recommendations to the chief physician.

MEASUREMENTS: The outcome measures assessed at the initiation of the intervention and 1 year later were number of hospitalizations and falls, Functional Independence Measure (FIM), quality of life (measured using the Medical Outcomes Study 12-item Short-Form Health Survey), and costs of medications.

RESULTS: The average number of drugs prescribed was significantly lower in the intervention than in the control group after 1 year (P < .001). The average drug costs in the intervention group decreased by 103 shekels (US$29) per participant per month (P < .001). The average number of falls in the intervention group dropped significantly (P = .006). Rates of hospitalization, FIM scores, and quality of life measurements were similar for both groups.

CONCLUSION: Implementation of STOPP/START criteria reduced the number of medications, falls, and costs in a geriatric facility. Their incorporation in those and similar settings is recommended.

Long article chosen for the December 2014 #GeriMedJC.

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, the first 45 minutes of the hour is devoted to the presentation and discussion of the article.

Hip fracture is an important cause of mortality in the elderly. When cumulative mortality at on year among hip fracture patients is about 25-35%, should we be identifying and quantifying the impact of pre-operatively risk factors? This systematic review and meta-analysis attempts to achieve this.

Smith T, Pelpola K, Ball M, Ong A, Myint PK. Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age Ageing. 2014 Jul;43(4):464-71. 

The full text of the article can be found here and the abstract is posted below.

Engage in the discussion on Twitter on December 19, 2014 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

OBJECTIVE:
hip fracture is a common and serious condition associated with high mortality. This study aimed to identify pre-operative characteristics which are associated with an increased risk of mortality after hip fracture surgery.

DESIGN:
systematic search of published and unpublished literature databases, including EMBASE, MEDLINE, AMED, CINAHL, PubMed and the Cochrane Library, was undertaken to identify all clinical studies on pre-operative predictors of mortality after surgery in hip fracture with at least 3-month follow-up. Data pertaining to the study objectives was extracted by two reviewers independently. Where study homogeneity was evidence, a meta-analysis of pooled relative risk and 95% confidence intervals was performed for mortality against pre-admission characteristics.

RESULTS:
fifty-three studies including 544,733 participants were included. Thirteen characteristics were identified as possible pre-operative indicators for mortality. Following meta-analysis, the four key characteristics associated with the risk of mortality up to 12 months were abnormal ECG (RR: 2.00; 95% CI: 1.45, 2.76), cognitive impairment (RR: 1.91; 95% CI: 1.35, 2.70), age >85 years (RR: 0.42; 95% CI: 0.20, 0.90) and pre-fracture mobility (RR: 0.13; 95% CI: 0.05, 0.34). Other statistically significant pre-fracture predictors of increased mortality were male gender, being resident in a care institution, intra-capsular fracture type, high ASA grade and high Charlson comorbidity score on admission.

CONCLUSIONS:
this review has identified the characteristics of patients with a high risk of mortality after a hip fracture surgery beyond the peri-operative period who may benefit from comprehensive assessment and appropriate management.

Where are the viewers of this blog coming from?

#GeriMedJC: November 28, 2014

The two articles critically appraised during  #GeriMedJC on November 28 were:

Marcantonio ER, Ngo LH, O'Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study. Ann Intern Med. 2014 Oct 21;161(8):554-61.

Ensrud KE, Taylor BC, Peters KW, Gourlay ML, Donaldson MG, Leslie WD, Blackwell TL, Fink HA, Orwoll ES, Schousboe J. Osteoporotic Fractures in Men Study Group. Implications of expanding indications for drug treatment to prevent fracture in older men in United States: cross sectional and longitudinal analysis of prospective cohort study. BMJ. 2014 Jul 3;349:g4120. 

What a great discussion!  Thanks especially to the international expert involvement from @A_MacLullich for the delirium discussion and to local expert involvement from @AngelaMCheung for the osteoporosis discussion.

There were more impressions and participants compared to the last #GeriMedJC! Let's keep this growing! This is what Symplur analytics had to say about the November tweet chat:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

Thanks to all those who participated in the Tweet chat:

Short article chosen for the November 2014 #GeriMedJC.

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 15 minutes is devoted to the presentation and discussion of the article.

Diagnostic criteria for osteoporosis in men based on bone mineral density remains controversial. Ensrud et al. explore how the different approaches to diagnosis alter the proportion of older men identified as candidates for treatment.

Ensrud KE, Taylor BC, Peters KW, Gourlay ML, Donaldson MG, Leslie WD, Blackwell TL, Fink HA, Orwoll ES, Schousboe J. Osteoporotic Fractures in Men Study Group. Implications of expanding indications for drug treatment to prevent fracture in older men in United States: cross sectional and longitudinal analysis of prospective cohort study. BMJ. 2014 Jul 3;349:g4120. 

The full text of the article can be found here and the abstract is posted below.

Engage in the discussion on Twitter on November 28, 2014 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC. 

OBJECTIVES: To quantify incremental effects of applying different criteria to identify men who are candidates for drug treatment to prevent fracture and to examine the extent to which fracture probabilities vary across distinct categories of men defined by these criteria.

DESIGN: Cross sectional and longitudinal analysis of a prospective cohort study.

SETTING: Multicenter Osteoporotic Fractures in Men (MrOS) study in the United States.

PARTICIPANTS: 5880 untreated community dwelling men aged 65 years or over classified into four distinct groups: osteoporosis by World Health Organization criteria alone; osteoporosis by National Osteoporosis Foundation (NOF) but not WHO criteria; no osteoporosis but at high fracture risk (at or above NOF derived FRAX intervention thresholds recommended for US); and no osteoporosis and at low fracture risk (below NOF derived FRAX intervention thresholds recommended for US).

MAIN OUTCOME MEASURES: Proportion of men identified for drug treatment; predicted 10 year probabilities of hip and major osteoporotic fracture calculated using FRAX algorithm with femoral neck bone mineral density; observed 10 year probabilities for confirmed incident hip and major osteoporotic (hip, clinical vertebral, wrist, or humerus) fracture events calculated using cumulative incidence estimation, accounting for competing risk of mortality.

RESULTS: 130 (2.2%) men were identified as having osteoporosis by using the WHO definition, and an additional 422 were identified by applying the NOF definition (total osteoporosis prevalence 9.4%). Application of NOF derived FRAX intervention thresholds led to 936 (15.9%) additional men without osteoporosis being identified as at high fracture risk, raising the total prevalence of men potentially eligible for drug treatment to 25.3%. Observed 10 year hip fracture probabilities were 20.6% for men with osteoporosis by WHO criteria alone, 6.8% for men with osteoporosis by NOF (but not WHO) criteria, 6.4% for men without osteoporosis but classified as at high fracture risk, and 1.5% for men without osteoporosis and classified as at low fracture risk. A similar pattern was noted in observed fracture probabilities for major osteoporotic fracture. Among men with osteoporosis by WHO criteria, observed fracture probabilities were greater than FRAX predicted probabilities (20.6% v 9.5% for hip fracture and 30.0% v 17.4% for major osteoporotic fracture).

CONCLUSIONS AND RELEVANCE: Choice of definition of osteoporosis and use of NOF derived FRAX intervention thresholds have major effects on the proportion of older men identified as warranting drug treatment to prevent fracture. Among men identified with osteoporosis by WHO criteria, who comprised 2% of the study population, actual observed fracture probabilities during 10 years of follow-up were highest and exceeded FRAX predicted fracture probabilities. On the basis of findings from randomized trials in women, these men are most likely to benefit from treatment. Expanding indications for treatment beyond this small group has uncertain value owing to lower observed fracture probabilities and uncertain benefits of treatment among men not selected on the basis of WHO criteria.

The long article for the November #GeriMedJC goes 3D!

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 45 minutes is devoted to the presentation and discussion of the article.

While the Confusion Assessment Method (CAM) may be the best-performing bedside delirium assessment tool, it can be challenging to operationalize. Did you know that to perform the CAM correctly, the interviewer must undergo extensive training?  Also the operationalization requires performing a structured mental status assessment first!  In this article to be discussed, the 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM) claims brevity, but not at the expense of validity or reliability. Will this tool change the way you recognize delirium?

Marcantonio ER, Ngo LH, O'Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study. Ann Intern Med. 2014 Oct 21;161(8):554-61. 

The article can be found here: and the abstract is posted below.

Engage in the discussion on Twitter on November 28, 2014 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

BACKGROUND: Delirium is common, leads to other adverse outcomes, and is costly. However, it often remains unrecognized in most clinical settings. The Confusion Assessment Method (CAM) is the most widely used diagnostic algorithm, and operationalizing its features would be a substantial advance for clinical care.

OBJECTIVE: To derive the 3D-CAM, a new 3-minute diagnostic assessment for CAM-defined delirium, and validate it against a clinical reference standard.

DESIGN: Derivation and validation study.

SETTING: 4 general medicine units in an academic medical center.

PARTICIPANTS: 201 inpatients aged 75 years or older.

MEASUREMENTS: 20 items that best operationalized the 4 CAM diagnostic features were identified to create the 3D-CAM. For prospective validation, 3D-CAM assessments were administered by trained research assistants. Clinicians independently did an extensive assessment, including patient and family interviews and medical record reviews. These data were considered by an expert panel to determine the presence or absence of delirium and dementia (reference standard). The 3D-CAM delirium diagnosis was compared with the reference standard in all patients and subgroups with and without dementia.

RESULTS: The 201 participants in the prospective validation study had a mean age of 84 years, and 28% had dementia. The expert panel identified 21% with delirium, 88% of whom had hypoactive or normal psychomotor features. Median administration time for the 3D-CAM was 3 minutes (interquartile range, 2 to 5 minutes), sensitivity was 95% (95% CI, 84% to 99%), and specificity was 94% (CI, 90% to 97%). The 3D-CAM did well in patients with dementia (sensitivity, 96% [CI, 82% to 100%]; specificity, 86% [CI, 67% to 96%]) and without dementia (sensitivity, 93% [CI, 66% to 100%]; specificity, 96% [CI, 91% to 99%]).

LIMITATION: Limited to single-center, cross-sectional, and medical patients only.

CONCLUSION: The 3D-CAM operationalizes the CAM algorithm using a 3-minute structured assessment with high sensitivity and specificity relative to a reference standard and could be an important tool for improving recognition of delirium.

@GeriMedJC keeps growing! Thanks for following!

The moderator account for #GeriMedJC, @GeriMedJC now has 164 followers.  Here's a look at the growth since inception three months ago:

#GeriMedJC: October 31, 2014

The two articles critically appraised during  #GeriMedJC on October 31 were:

Long article (45 minutes is dedicated to discussion in the live version of the journal club):
de Jonghe A, van Munster BC, Goslings JC, Kloen P, van Rees C, Wolvius R, van Velde R, Levi M, de Haan RJ, de Rooij SE; Amsterdam Delirium Study Group. Effect of melatonin on incidence of delirium among patients with hip fracture: a multicentre, double-blind randomized controlled trial. CMAJ. 2014 Oct 7;186(14):E547-56.

Short article (15 minutes is dedicated to discussion in the live version of the journal club):
Kim L. Bennell et al. Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis. A Randomized Clinical Trial JAMA. 2014;311(19):1987-1997.

There were more than double the impressions and participants compared to the last #GeriMedJC! This is what Symplur analytics had to say about the October tweet chat:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

And special thanks to all those who participated in the Tweet chat:

For all those still lurking, you'll have your chance to engage on November 28, 2014 08:00 EST at the next #GeriMedJC. Follow @GeriMedJC on Twitter for the announcement on the articles for the next #GeriMedJC!

Short article chosen for the October 2014 #GeriMedJC.

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 15 minutes is devoted to the presentation and discussion of the article.

There is limited evidence supporting use of physical therapy for hip osteoarthritis.  Will this article lay the uncertainty to rest?

Kim L. Bennell et al. Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis. A Randomized Clinical Trial JAMA. 2014;311(19):1987-1997.

The full text of the article can be found here and the abstract is posted below.

Engage in the discussion October 31, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC. 

IMPORTANCE:
There is limited evidence supporting use of physical therapy for hip osteoarthritis.

OBJECTIVE:
To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS:
Randomized, placebo-controlled, participant- and assessor-blinded trial involving 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up (May 2010-February 2013) INTERVENTIONS: Participants attended 10 treatment sessions over 12 weeks. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly.

MAIN OUTCOMES AND MEASURES:
Primary outcomes were average pain (0 mm, no pain; 100 mm, worst pain possible) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 no difficulty to 68 extreme difficulty) at week 13. Secondary outcomes were these measures at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36.

RESULTS:
Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (SD) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6); for the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, -3.9 to 17.7). The function scores were not significantly different between groups. The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units, whereas the baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, -3.8 to 6.5) at week 13. There were no between-group differences in secondary outcomes (except greater week-13 improvement in the balance step test in the active group). Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects and 7 of 49 (14%) in the sham group reported 9 mild adverse events (P = .003).

CONCLUSIONS AND RELEVANCE:
Among adults with painful hip osteoarthritis, physical therapy did not result in greater improvement in pain or function compared with sham treatment, raising questions about its value for these patients.

Long article chosen for the October 2014 #GeriMedJC.

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 45 minutes is devoted to the presentation and discussion of the article.

de Jonghe A, van Munster BC, Goslings JC, Kloen P, van Rees C, Wolvius R, van Velde R, Levi M, de Haan RJ, de Rooij SE; Amsterdam Delirium Study Group. Effect of melatonin on incidence of delirium among patients with hip fracture: a multicentre, double-blind randomized controlled trial. CMAJ. 2014 Oct 7;186(14):E547-56.

Melatonin previously showed promise in a Canadian randomized trial for delirium prevention among medical patients (Int J Geriatr Psychiatry. 2011 Jul;26(7):687-94) and similarly, a melatonin agonist showed promise in another delirium prevention trial (JAMA Psychiatry. 2014 Apr;71(4):397-403). The new study chosen for the long article was a study conducted by the Amsterdam Delirium Study Group. This will surely be of interest to geriatricians, orthopedic surgeons, and generalists alike!

The article can be found here: and the abstract is posted below.

Engage in the discussion October 31, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC.

BACKGROUND:
Disturbance of the sleep-wake cycle is a characteristic of delirium. In addition, changes in melatonin rhythm influence the circadian rhythm and are associated with delirium. We compared the effect of melatonin and placebo on the incidence and duration of delirium.

METHODS:
We performed this multicentre, double-blind, randomized controlled trial between November 2008 and May 2012 in 1 academic and 2 nonacademic hospitals. Patients aged 65 years or older who were scheduled for acute hip surgery were eligible for inclusion. Patients received melatonin 3 mg or placebo in the evening for 5 consecutive days, starting within 24 hours after admission. The primary outcome was incidence of delirium within 8 days of admission. We also monitored the duration of delirium.

RESULTS:
A total of 452 patients were randomly assigned to the 2 study groups. We subsequently excluded 74 patients for whom the primary end point could not be measured or who had delirium before the second day of the study. After these postrandomization exclusions, data for 378 patients were included in the main analysis. The overall mean age was 84 years, 238 (63.0%) of the patients lived at home before admission, and 210 (55.6%) had cognitive impairment. We observed no effect of melatonin on the incidence of delirium: 55/186 (29.6%) in the melatonin group v. 49/192 (25.5%) in the placebo group; difference 4.1 (95% confidence interval -0.05 to 13.1) percentage points. There were no between-group differences in mortality or in cognitive or functional outcomes at 3-month follow-up.

INTERPRETATION:
In this older population with hip fracture, treatment with melatonin did not reduce the incidence of delirium.

@GeriMedJC keeps growing! Thanks for following!

The moderator account for #GeriMedJC, @GeriMedJC now has 131 followers.  Here's a look at the growth since inception two months ago:

And the representation continues to be global:

And here is the impression @GeriMedJC is making:

Thanks for following and contributing to #GeriMedJC!  

Like #GeriMedJC? Want to follow other Twitter journal clubs?

A quick search in Symplur for other Twitter medical journal clubs reveal the following hashtags:

International Urology Journal Club - #urojc
Respirology and Sleep Journal Club - #rsjc
Nephrology Journal Club - #nephjc
General Surgery Journal Club - #ISGJC

#GeriMedJC featured in this month's MediNews

MediNews, the newsletter of the Department of Medicine at the University of Toronto, featured #GeriMedJC in this month's issue here.  Inspired by our Respirology colleagues (check out #rsjc), we hope that other subspecialty divisions will follow suit.

@GeriMedJC has an international following

As of this week, the Twitter moderator account for #GeriMedJC, @GeriMedJC, has 116 followers.  Here's a look at the geographical distribution:

This is nice to see especially since the live version of the journal club is based in Toronto, Canada.

#GeriMedJC: September 19, 2014

The two articles critically appraised during today's #GeriMedJC were:

Long article (45 minutes is dedicated to discussion in the live version of the journal club):
Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Other Adverse Outcomes in Older Adults.  Ann Intern Med. 2014;161:242-248.

Short article (15 minutes is dedicated to discussion in the live version of the journal club):
The efficacy and tolerability of the b3-adrenoceptor agonist Mirabegron for the treatment of symptoms of overactive bladder in older patients. Age and Ageing 2014;43:666–675.

More than double the impressions and more than double the tweets compared to the first #GeriMedJC! This is what Symplur analytics had to say about today's tweet chat:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

And special thanks to all those who participated in the Tweet chat:

For all those still lurking, you'll have your chance to engage on October 31, 2014 at the next #GeriMedJC. Follow @GeriMedJC on Twitter for the announcement on the articles for the next #GeriMedJC!

Short article chosen for the September 2014 #GeriMedJC.

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 15 minutes is devoted to the presentation and discussion of the article.

The efficacy and tolerability of the b3-adrenoceptor agonist Mirabegron for the treatment of symptoms of overactive bladder in older patients. Age and Ageing 2014;43:666–675.

Overactive bladder symptoms are common in the elderly and adversely affect quality of life. The side effect profile of existing pharmacotherapy limits use. This study of a newer medication may be of interest. Note that #GeriMedJC has no financial conflicts of interest and articles are chosen for critical appraisal based on interest and potential impact.

The full text of the article can be found here and the abstract is posted below.

Engage in the discussion September 19, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC. 

BACKGROUND: Mirabegron is a β3-adrenoceptor agonist developed for the treatment of symptoms of overactive bladder (OAB). As the prevalence of OAB increases with age, a prospective subanalysis of individual and pooled efficacy and tolerability data from three 12-week, randomised, Phase III trials, and of tolerability data from a 1-year safety trial were conducted in order to evaluate the efficacy and tolerability of mirabegron in subgroups of patients aged ≥65 and ≥75 years.

METHODS: Primary efficacy outcomes were change from baseline to final visit in the mean number of incontinence episodes/24 h and the mean number of micturitions/24 h. Tolerability was assessed by the incidence of treatment-emergent adverse events (TEAEs).

RESULTS: Over 12 weeks mirabegron 25 mg and 50 mg once-daily reduced the mean numbers of incontinence episodes and micturitions/24 h from baseline to final visit in patients aged ≥65 and ≥75 years. Mirabegron was well tolerated: in both age groups, hypertension and urinary tract infection were among the most common TEAEs over 12 weeks and 1 year. The incidence of dry mouth, a typical anticholinergic TEAE, was up to sixfold higher among the older patients randomised to tolterodine than any dose of mirabegron.

CONCLUSIONS: These analyses have demonstrated the efficacy of mirabegron over 12 weeks and the tolerability of mirabegron over 12 weeks and 1 year in OAB patients aged ≥65 and ≥75 years, supporting mirabegron as a therapeutic option in older patients with OAB.

Long article chosen for the September 2014 #GeriMedJC.

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club held at the University of Toronto, 45 minutes is devoted to the presentation and discussion of the article.

Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Other Adverse Outcomes in Older Adults.  Ann Intern Med. 2014;161:242-248. 

The long article chosen is an Ontario based study conducted at the Institute for Clinical Evaluative Sciences (ICES). It is sure to be of interest!  Atypical antipsychotics are getting a lot of bad press and here is just some fuel to the fire. Perhaps the participants from the Nephrology Journal Club (#NephJC) would be interested in this critical appraisal of this article too.

The article can be found here: and the abstract is posted below.

Engage in the discussion September 19, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC. 

BACKGROUND: Several adverse outcomes attributed to atypical antipsychotic drugs, specifically quetiapine, risperidone, and olanzapine, are known to cause acute kidney injury (AKI). Such outcomes include hypotension, acute urinary retention, and the neuroleptic malignant syndrome or rhabdomyolysis.

OBJECTIVE: To investigate the risk for AKI and other adverse outcomes associated with use of atypical antipsychotic drugs versus nonuse.

DESIGN: Population-based cohort study.

SETTING: Ontario, Canada, from 2003 to 2012.

PATIENTS: Adults aged 65 years or older who received a new outpatient prescription for an oral atypical antipsychotic drug (n = 97 777) matched 1:1 with those who did not receive such a prescription.

MEASUREMENTS: The primary outcome was hospitalization with AKI (assessed by using a hospital diagnosis code and, in a subpopulation, serum creatinine levels) within 90 days of prescription for atypical antipsychotic drugs.

RESULTS: Atypical antipsychotic drug use versus nonuse was associated with a higher risk for hospitalization with AKI (relative risk [RR], 1.73 [95% CI, 1.55 to 1.92]). This association was consistent when AKI was assessed in a subpopulation for which information on serum creatinine levels was available (5.46% vs. 3.34%; RR, 1.70 [CI, 1.22 to 2.38]; absolute risk increase, 2.12% [CI, 0.80% to 3.43%]). Drug use was also associated with hypotension (RR, 1.91 [CI, 1.60 to 2.28]), acute urinary retention (RR, 1.98 [CI, 1.63 to 2.40]), and all-cause mortality (RR, 2.39 [CI, 2.28 to 2.50]).

LIMITATION: Only older adults were included in the study.

CONCLUSION: Atypical antipsychotic drug use is associated with an increased risk for AKI and other adverse outcomes that may explain the observed association with AKI. The findings support current safety concerns about the use of these drugs in older adults.

Thanks for the support! @GeriMedJC at over 100 followers!

Just over a month since inception, the moderator account for the Geriatric Medicine Journal Club, @GeriMedJC, has just over 100 followers on Twitter.

Discussions are only as rich as the engagement, so spread the word!

The next #GeriMedJC will be on September 19, 2014 at 08:00 EDT / noon GMT. Articles TBA.

Date and time for next Geriatric Medicine Journal Club tweet chat (#GeriMedJC)

September 19, 2014 at 08:00 EDT / 12:00 noon GMT.

Articles to be announced.

Follow us on Twitter @GeriMedJC!  Remember to use the hashtag #GeriMedJC.

@GeriMedJC still growing!

The moderator account for the Geriatric Medicine Journal Club (#GeriMedJC) is up to 90 followers after launching a month ago.

There's a nice international representation! The top ten countries in the audience for the Geriatric Medicine Journal Club blog are as follows:

According to Tweetreach, this week's #GeriMedJC activity made 15,643 impressions.

First #GeriMedJC

Two articles were discussed for the first #GeriMedJC:

Long article (45 minutes is dedicated to discussion in the live version of the journal club):
The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014 Apr 15;160(8):526-33.

Short article (15 minutes is dedicated to discussion in the live version of the journal club):
Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg. 2014;149(7):633-640.

This is what Symplur analytics had to say about the discussion:

Missed the discussion?  You can get the transcript of the #GeriMedJC tweet chat here.

Follow @GeriMedJC on Twitter for the announcement on the next #GeriMedJC!

@GeriMedJC is gaining followers all over the world!

This has been an exciting week for #GeriMedJC. The moderator account,@GeriMedJC, now has 78 followers including physicians, other allied health care workers, and organizations from all over the world. This should make for a very lively discussion for the first tweet chat Geriatric Medicine Journal Club on August 29, 2014 at 08:00 EDT / noon GMT.

According to Tweetreach, a number of impressions have also been made:

This blog is also getting a few views from around the world, including Zambia.  Welcome!  Hearing what geriatric medicine is like internationally would be of great interest!

Don't forget to read the two articles in advance of the first #GeriMedJC tweet chat on August 29, 2014 at 08:00 EDT / noon GMT:

Long article (45 minutes is dedicated to discussion in the live version of the journal club):
The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014 Apr 15;160(8):526-33. 
Access the article here.

Short article (15 minutes is dedicated to discussion in the live version of the journal club):
Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg. 2014;149(7):633-640. 
Access the article here. 

Any easy way to stream the tweet chat for the first #GeriMedJC

Gearing up for the first Geriatric Medicine Journal Club tweet chat, #GeriMedJC, and need any easy way to follow and engage in the conversation?

Try TChat.io and log in using your Twitter account. 

Enter the hashtag #GeriMedJC a few minutes before the chat. This program filters out all other tweets so you can focus on discussing this one topic.

Every tweet anyone publishes with the hashtag #GeriMedJC, will show-up in the stream. Any tweet you type in the box will have #GeriMedJC added to the back of it, so other people using this (or similar programs) will be able to see your tweet even though they may not follow you.

Make sure you read the two chosen articles ahead of time:

Long article (45 minutes is dedicated to discussion in the live version of the journal club):
The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014 Apr 15;160(8):526-33. 
Access the article here.

Short article (15 minutes is dedicated to discussion in the live version of the journal club):
Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg. 2014;149(7):633-640. 
Access the article here. 

Long article chosen for the first #GeriMedJC.

What does a long article mean?  In the live version of the Geriatric Medicine Journal Club, 45 minutes is devoted to the presentation and discussion of the article.  Do you use the Confusion Assessment Method (CAM) to help detect delirium?  How about the CAM-S for measuring severity? The chosen long article will be of great interest:

The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014 Apr 15;160(8):526-33. 

The article can be found on Annals of Internal Medicine here and abstract is posted below. Engage in the discussion August 29, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC.  We would especially love to hear the perspective from the across the pond where the the 4AT is being promoted through organizations such as the Scottish Delirium Association.


BACKGROUND: Quantifying the severity of delirium is essential to advancing clinical care by improved understanding of delirium effect, prognosis, pathophysiology, and response to treatment.

OBJECTIVE: To develop and validate a new delirium severity measure (CAM-S) based on the Confusion Assessment Method.

DESIGN: Validation analysis in 2 independent cohorts.

SETTING: Three academic medical centers.

PATIENTS: The first cohort included 300 patients aged 70 years or older scheduled for major surgery. The second included 919 medical patients aged 70 years or older.

MEASUREMENTS: A 4-item short form and a 10-item long form were developed. Association of the maximum CAM-S score during hospitalization with hospital and posthospital outcomes related to delirium was evaluated.

RESULTS: Representative results included adjusted mean length of stay, which increased across levels of short-form severity from 6.5 days (95% CI, 6.2 to 6.9 days) to 12.7 days (CI, 11.2 to 14.3 days) (P for trend &lt; 0.001) and across levels of long-form severity from 5.6 days (CI, 5.1 to 6.1 days) to 11.9 days (CI, 10.8 to 12.9 days) (P for trend &lt; 0.001). Representative results for the composite outcome of adjusted relative risk of death or nursing home residence at 90 days increased progressively across levels of short-form severity from 1.0 (referent) to 2.5 (CI, 1.9 to 3.3) (P for trend &lt; 0.001) and across levels of long-form severity from 1.0 (referent) to 2.5 (CI, 1.6 to 3.7) (P for trend &lt; 0.001).

LIMITATION: Data on clinical outcomes were measured in an older data set limited to patients aged 70 years or older.

CONCLUSION: The CAM-S provides a new delirium severity measure with strong psychometric properties and strong associations with important clinical outcomes.

Short article chosen for the first #GeriMedJC.

What does a short article mean?  In the live version of the Geriatric Medicine Journal Club, 15 minutes is devoted to the presentation and discussion of the article.  Frailty is very hot these days and the surgeons are onto the concept. The chosen short article is timely:

Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg. 2014;149(7):633-640. 

The article can be found on JAMA Surgery here and abstract is posted below.  Join the discussion August 29, 2014 at 08:00 EDT / noon GMT and don't forget to use the hashtag #GeriMedJC.

Importance  The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly.

Objective  To design a predictive model for adverse outcomes in older surgical patients.

Design, Setting, and Participants  From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery.

Main Outcomes and Measures  The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility.

Results  Twenty-five patients (9.1%) died during the follow-up period (median [interquartile range], 13.3 [11.5-16.1] months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model’s cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median [interquartile range], 9 [5-15] vs 6 [3-9] days; P < .001).

Conclusions and Relevance  The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.

The second week for #GeriMedJC on Twitter.

This is what Symplur analytics had to say about the hashtag's second week.

It's not surprising that activity is a bit quiet as the hashtag is a timed, monthly tweet chat.  We anticipate that when the journal club is happening (first one slated for August 29, 2014 at 8:00 EDT / noon GMT), that'll be when the bulk of Twitter activity will take place.

In the meantime, there has been some exciting stuff happening from the new followers front for the moderator's account, @GeriMedJC.  There are have been several new followers including representation from other Canadian provinces (@JennyBasran) as well as medical schools across the pond (@MMGgeris).

Twitter also has its own analytic metrics!

Just turned on the analytics option for the @GeriMedJC account.  Unfortunately, data prior to turning this feature on is not available.  This may be useful going forward to track impressions (times a user is served a tweet in timeline or search results) and engagements (total number of times a user interacts with a tweet).  This is what Twitter analytics had to say about the @GeriMedJC followers in terms of location, gender and who the followers follow:

Symplur analytics for #GeriMedJC

Have you taken a look at Symplur's Healthcare Hashtag Project? The goal of the Healthcare Hashtag Project is to make the use of Twitter more accessible for providers and the healthcare community as a whole. It is a tool for finding conversations of interest and importance.  It also provides great analytics such as top influencers, tweet activity and Twitter transcripts.

Check out the scope of #GeriMedJC's first week on Twitter!

Who is looking at this blog?

This blog is just a way of chronicling the development of #GeriMedJC.  While the main project is on Twitter, the microbloging application, this "macro"blog is also getting some views around the world:

TweetReach: How far has #GeriMedJC gone in its first week?

TweetReach is an interesting Twitter analytics tool.  We have 57 followers so far.  Here is what TweetReach had to say about #GeriMedJC's first week:

A tweet chat (#GeriMedJC) sounds great, but what happens at the real journal club?

The University of Toronto Division of Geriatric Medicine organizes a monthly Geriatric Medicine Journal Club where residents and faculty have the opportunity to critically appraise recent geriatric medicine literature. Two Geriatric Medicine residents review and present a critical appraisal of an original research article. There is one long presentation of 45 minutes and one short presentation of 15 minutes. The meetings take place on the fourth Friday of each month from 08:00 to 09:00. The Journal Club is broadcast by video-conference via the Ontario Telemedicine Network (OTN) to satellite sites around the province of Ontario including:

Baycrest Hospital (Toronto)
Mount Sinai Hospital (Toronto)
North York General Hospital (Toronto)
Orillia Soldier’s Memorial Hospital (Orillia)
St. Joseph’s Health Centre (Toronto)
St. Mary’s General Hospital (Kitchener-Waterloo)
Grandriver Hospital (Kitchener-Waterloo)
Sunnybrook Health Sciences Centre (Toronto)
St. Michael's Hospital (Toronto)
Trillium Hospital (Mississauga)

It is the hope that the #GeriMedJC hashtag will complement the live journal club discussion but also allow for participation internationally for a much more enriched analysis of the literature.

Why even have a tweet chat (#GeriMedJC) to complement a live journal club?

The urology community has really been the leader in using Twitter as a medium for academic discussion of recent medical literature. The hashtag #urojc is an asynchronous 48-h monthly journal club focusing on recent articles. Traditionally, journal clubs have been confined to physical space and time. Wouldn't it be great to have discussions engaging an international representation?  Here is an interesting study of the successes of #urojc including growth and sustainability.

International Urology Journal Club via Twitter: 12-month experience. Eur Urol. 2014 Jul;66(1):112-7.
The article can be accessed here.

Let's make this happen for #GeriMedJC!

We may have one article chosen for our first #GeriMedJC Geriatric Medicine Journal Club! The final decision will be confirmed.

The following recent article was proposed for review.  What do you think about this choice?

Vitamin D and the risk of dementia and Alzheimer disease

Neurology. Published online before print August 6, 2014.

Thomas J. Littlejohns, MSc, William E. Henley, PhD, Iain A. Lang, PhD, Cedric Annweiler, MD, PhD, Olivier Beauchet, MD, PhD, Paulo H.M. Chaves, MD, PhD, Linda Fried, MD, MPH, Bryan R. Kestenbaum, MD, MS, Lewis H. Kuller, MD, DrPH, Kenneth M. Langa, MD, PhD, Oscar L. Lopez, MD, Katarina Kos, MD, PhD, Maya Soni, PhD* and David J. Llewellyn, PhD*

Objective: To determine whether low vitamin D concentrations are associated with an increased risk of incident all-cause dementia and Alzheimer disease.

Methods: One thousand six hundred fifty-eight elderly ambulatory adults free from dementia, cardiovascular disease, and stroke who participated in the US population–based Cardiovascular Health Study between 1992–1993 and 1999 were included. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were determined by liquid chromatography-tandem mass spectrometry from blood samples collected in 1992–1993. Incident all-cause dementia and Alzheimer disease status were assessed during follow-up using National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association criteria.

Results: During a mean follow-up of 5.6 years, 171 participants developed all-cause dementia, including 102 cases of Alzheimer disease. Using Cox proportional hazards models, the multivariate adjusted hazard ratios (95% confidence interval [CI]) for incident all-cause dementia in participants who were severely 25(OH)D deficient (<25 nmol/L) and deficient (≥25 to <50 nmol/L) were 2.25 (95% CI: 1.23–4.13) and 1.53 (95% CI: 1.06–2.21) compared to participants with sufficient concentrations (≥50 nmol/L). The multivariate adjusted hazard ratios for incident Alzheimer disease in participants who were severely 25(OH)D deficient and deficient compared to participants with sufficient concentrations were 2.22 (95% CI: 1.02–4.83) and 1.69 (95% CI: 1.06–2.69). In multivariate adjusted penalized smoothing spline plots, the risk of all-cause dementia and Alzheimer disease markedly increased below a threshold of 50 nmol/L.

Conclusion: Our results confirm that vitamin D deficiency is associated with a substantially increased risk of all-cause dementia and Alzheimer disease. This adds to the ongoing debate about the role of vitamin D in nonskeletal conditions.

The article can be accessed here.

#GeriMedJC

@symplur has a few categories in which a hashtag can be registered.  The site seems perpetually bugged with failed attempts to register new hashtags under the "tweet chat" category, and thus the hashtag for this journal club, #GeriMedJC, was submitted today to @symplur as a "regular" category hashtag.  No error message popped up --- hooray!  We should find out in a few days if the registration was successful and can start commenting on users, metrics and other fun stats.

A Twitter-based Geriatric Medicine Journal Club (#GeriMedJC) ? Sounds like a great idea ... except I don't use Twitter!

The Twitter version of the Geriatric Medicine Journal Club facilitates continuing medical education (CME) and promotes international  discussion of recent literature in Geriatric Medicine. #GeriMedJC will occur monthly concurrent with the live journal club that takes place at the Division of Geriatric Medicine at the University of Toronto.  To follow the discussion please use #GeriMedJC and include this in all your tweets.

Don't yet have a Twitter account?  Follow these steps:

1. Sign up for Twitter at twitter.com using your name and email address.

2. After you have created a Twitter account you will be asked to follow a few people. Add @GeriMedJC. This account is where the date, time and articles for the the next Geriatric Medicine Journal Club will be announced.

3. To follow or participate with any tweets for the journal club tweet chat, use #GeriMedJC. For any tweets you write, add #GeriMedJC in the tweet (this serves as a "keyword" and enables anyone interested to follow the discussion without necessarily following all the participants directly).

A few other useful links include:

Basics of twitter: http://www.momthisishowtwitterworks.com/
Twitter guide to lingo: http://mashable.com/2013/07/19/twitter-lingo-guide/

CPSO and CMA guidelines on the appropriate use of social media

Date and time for first Geriatric Medicine Journal Club tweet chat (#GeriMedJC)

August 29, 2014 at 08:00 EDT / 12:00 noon GMT.

Articles to be announced.

Maintenance of Certification credits

Eventually, we will register the tweet chat #GeriMedJC to be eligible for the Royal College of Physicians and Surgeons Section 1 (self-accredited) Maintenance of Certification credits. Tweeting would be required to obtain the credits.

Geriatric Medicine Journal Club (#GeriMedJC)

It has been a long time coming, but to follow in the footsteps of the International Urology Journal Club (#urojc) and the Respirology and Sleep Journal Club (#rsjc), a Geriatric Medicine Journal Club has been born on Twitter! @GeriMedJC was created today and monthly journal club tweet chats will use the hashtag #GeriMedJC.

Now if only @symplur would fix the bug that is currently not allowing the registration of new health care hashtags, metrics and influencers for #GeriMedJC will be available.

This will be a monthly journal club based on the University of Toronto Division of Geriatric Medicine journal club which is held at one of the various academic health sciences centres in Toronto.  Each month two recent papers will be selected for discussion.  The chosen articles will be announced on Twitter in advance.  Dates and times will be announced monthly.  The goal of the tweet chat (#GeriMedJC) will be to complement the discussion at the journal club but to also allow a broader international audience to chime in!

Follow us on Twitter @GeriMedJC !