Saturday 30 May 2015

May 2015 #GeriMedJC

The two articles critically appraised and discussed during the May 2015 #GeriMedJC were:

Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med. 2015 Jan;22(1):1-21. 

Black DS, O'Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015 Apr 1;175(4):494-501.

It was great having our emergency medicine colleagues (such as @geri_em, @GeriatricEDNews) contribute to the long article discussion. It seems like there's lots of opportunity for research in the area of risk stratification in elderly emergency department patients.  Thanks for making this the largest #GeriMedJC to date:
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:


You may also view articles discussed at prior #GeriMedJC tweetchats at PubMed Commons. (linkWe'll be taking a break from #GeriMedJC in June and will return in July. Stay tuned for the date and articles!  Tweet you then!

Thursday 21 May 2015

#GeriMedJC welcomes #PsychJC for short article tweet chat on May 29

What does the 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. The short article for the May 29 #GeriMedJC discussion is:
Who doesn't want more sleep?  Older adults are no exemption.  We will be reviewing this study which examines the efficacy of a mind-body medicine intervention, called mindfulness meditation, to promote sleep quality in older adults with moderate sleep disturbances.


Given the nature of the topic, we would like to extend a formal invitation to #PsychJC to weigh in on the discussion!  This article can be found here.  The abstract can be found below.

Black DS, O'Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015 Apr 1;175(4):494-501.

IMPORTANCE: Sleep disturbances are most prevalent among older adults and often go untreated. Treatment options for sleep disturbances remain limited, and there is a need for community-accessible programs that can improve sleep.

OBJECTIVE: To determine the efficacy of a mind-body medicine intervention, called mindfulness meditation, to promote sleep quality in older adults with moderate sleep disturbances.

DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial with 2 parallel groups conducted from January 1 to December 31, 2012, at a medical research center among an older adult sample (mean [SD] age, 66.3 [7.4] years) with moderate sleep disturbances (Pittsburgh Sleep Quality Index [PSQI] >5).

INTERVENTIONS: A standardized mindful awareness practices (MAPs) intervention (n = 24) or a sleep hygiene education (SHE) intervention (n = 25) was randomized to participants, who received a 6-week intervention (2 hours per week) with assigned homework.

MAIN OUTCOMES AND MEASURES: The study was powered to detect between-group differences in moderate sleep disturbance measured via the PSQI at postintervention. Secondary outcomes pertained to sleep-related daytime impairment and included validated measures of insomnia symptoms, depression, anxiety, stress, and fatigue, as well as inflammatory signaling via nuclear factor (NF)-κB.

RESULTS: Using an intent-to-treat analysis, participants in the MAPs group showed significant improvement relative to those in the SHE group on the PSQI. With the MAPs intervention, the mean (SD) PSQIs were 10.2 (1.7) at baseline and 7.4 (1.9) at postintervention. With the SHE intervention, the mean (SD) PSQIs were 10.2 (1.8) at baseline and 9.1 (2.0) at postintervention. The between-group mean difference was 1.8 (95% CI, 0.6-2.9), with an effect size of 0.89. The MAPs group showed significant improvement relative to the SHE group on secondary health outcomes of insomnia symptoms, depression symptoms, fatigue interference, and fatigue severity (P < .05 for all). Between-group differences were not observed for anxiety, stress, or NF-κB, although NF-κB concentrations significantly declined over time in both groups (P < .05).

CONCLUSIONS AND RELEVANCE: The use of a community-accessible MAPs intervention resulted in improvements in sleep quality at immediate postintervention, which was superior to a highly structured SHE intervention. Formalized mindfulness-based interventions have clinical importance by possibly serving to remediate sleep problems among older adults in the short term, and this effect appears to carry over into reducing sleep-related daytime impairment that has implications for quality of life.

Did you know that the live version of #GeriMedJC runs for an hour and is broadcast to nine different hospitals in four different cities via the Ontario Telemedicine Network?  Can't join us live? No worries!  Engage in the discussion on Twitter on May 29, 2015 at 08:00 EDT / 12:00 GMT and don't forget to use the hashtag #GeriMedJC.

#GeriMedJC welcomes #ALiEMJC for long article tweet chat on May 29

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. The long article for the May 29 #GeriMedJC discussion is:



Providing high-quality emergency care for older adults is challenging because older patients tend to have more co-morbidities, higher rates of serious illnesses, and frequent communication barriers.  Use of screening instruments may allow identification of geriatric patients who are at increased risk for readmission or other adverse outcomes; the results of the screening could potentially be then used to guide targeted interventions.

Given the nature of the topic, we would like to extend a formal invitation to Academic Life in Emergency Medicine (ALiEM) Journal Club (#ALiEMJC) to weigh in on the discussion!
  
This article is open access and can be found here.  The abstract can be found below.

Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med. 2015 Jan;22(1):1-21. 

OBJECTIVES:
A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death.

METHODS:
A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome.

RESULTS:
A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%.

CONCLUSIONS:
Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.

Did you know that the live version of #GeriMedJC runs for an hour and is broadcast to nine different hospitals in four different cities via the Ontario Telemedicine Network?  
  • Toronto: Mount Sinai Hospital, Sunnybrook Hospital, St. Michael’s Hospital, Baycrest Hospital, North York General Hospital, St. Joseph’s Hospital
  • Mississauga: Trillium Hospital
  • Kitchener-Waterloo: Grand River Hospital
  • Orillia: Soldier's Memorial Hospital

Can't join us live? No worries!  Engage in the discussion on Twitter on May 29, 2015 at 08:00 EDT / 12:00 GMT and don't forget to use the hashtag #GeriMedJC.


Thank you to our over 400 @GeriMedJC followers!

Here's a shout out to the 400 @GeriMedJC followers!  Thanks for making the #GeriMedJC an international discussion!