Saturday 29 November 2014
#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:
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.
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:
Saturday 22 November 2014
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.
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.
Friday 21 November 2014
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.
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.
Saturday 8 November 2014
@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:
Thursday 6 November 2014
#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!
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!
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