PubMed Commons: The club of Journal Clubs!

#GeriMedJC has its PubMed Commons account up and running. 

PubMed Commons Journal Clubs is a new initiative to capture discussions of scientific publications and connect them to citations in PubMed. This initiative is currently open to journal clubs holding regular discussions for research, graduate and postgraduate education, or continuing professional education. 

Check it out here.

"Fallen" in love with #GeriMedJC? February 2015 article chosen.

A recent Cochrane review examined the effectiveness of various interventions to prevent falls among older people living in the community.  Home-safety assessment and modification interventions were effective at reducing the rate and risk of falls. This month, we discuss a cluster-randomised controlled trial from New Zealand, in which they assessed the benefits of a basic set of home-safety modifications.

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

Engage in the discussion on Twitter on February 27, 2015 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

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: St. Mary’s General Hospital
• Oshawa: Lakeridge Health

Keall MD, Pierse N, Howden-Chapman P, Cunningham C, Cunningham M, Guria J, Baker MG. Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: a cluster-randomised controlled trial. The Lancet, Volume 385, Issue 9964, 17–23 January 2015, Pages 231-238

BACKGROUND:
Despite the considerable injury burden attributable to falls at home among the general population, few effective safety interventions have been identified. We tested the safety benefits of home modifications, including handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, edging for outside steps, and slip-resistant surfacing for outside areas such as decks and porches.

METHODS:
We did a single-blind, cluster-randomised controlled trial of households from the Taranaki region of New Zealand. To be eligible, participants had to live in an owner-occupied dwelling constructed before 1980 and at least one member of every household had to be in receipt of state benefits or subsidies. We randomly assigned households by electronic coin toss to either immediate home modifications (treatment group) or a 3-year wait before modifications (control group). Household members in the treatment group could not be masked to their assigned status because modifications were made to their homes. The primary outcome was the rate of falls at home per person per year that needed medical treatment, which we derived from administrative data for insurance claims. Coders who were unaware of the random allocation analysed text descriptions of injuries and coded injuries as all falls and injuries most likely to be affected by the home modifications tested. To account for clustering at the household level, we analysed all injuries from falls at home per person-year with a negative binomial generalised linear model with generalised estimating equations. Analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000779279.

FINDINGS:
Of 842 households recruited, 436 (n=950 individual occupants) were randomly assigned to the treatment group and 406 (n=898 occupants) were allocated to the control group. After a median observation period of 1148 days (IQR 1085-1263), the crude rate of fall injuries per person per year was 0·061 in the treatment group and 0·072 in the control group (relative rate 0·86, 95% CI 0·66-1·12). The crude rate of injuries specific to the intervention per person per year was 0·018 in the treatment group and 0·028 in the control group (0·66, 0·43-1·00). A 26% reduction in the rate of injuries caused by falls at home per year exposed to the intervention was estimated in people allocated to the treatment group compared with those assigned to the control group, after adjustment for age, previous falls, sex, and ethnic origin (relative rate 0·74, 95% CI 0·58-0·94). Injuries specific to the home-modification intervention were cut by 39% per year exposed (0·61, 0·41-0·91).

INTERPRETATION:
Our findings suggest that low-cost home modifications and repairs can be a means to reduce injury in the general population. Further research is needed to identify the effectiveness of particular modifications from the package tested.

#GeriMedJC: January 30, 2015

The two articles critically appraised during  #GeriMedJC on January 30th were:

Bauer DC, Schwartz A, Palermo L, Cauley J, Hochberg M, Santora A, Cummings SR, Black DM. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: the FLEX study. JAMA Intern Med. 2014 Jul;174(7):1126-34. 

Kiosses DN, Ravdin LD, Gross JJ, Raue P, Kotbi N, Alexopoulos GS. Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial. JAMA Psychiatry. 2015 Jan 1;72(1):22-30. 

Thanks especially to the #PsychJC participants who chimed in on the discussion! 

This is what Symplur analytics had to say about the January 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 February 27, 2015 08:00 EST / 13:00 GMT.  See you then!

Long article for January 2015 #GeriMedJC chosen.

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.

Because the balance between potential benefits and risks of bisphosphonates becomes less clear after extended use, some authorities recommend interrupting bisphosphonate therapy after about 5 years. However, the best way to follow patients who discontinue these drugs is unknown. Do age, BMD results or markers of bone turnover help in this difficult clinical decision?

Bauer DC, Schwartz A, Palermo L, Cauley J, Hochberg M, Santora A, Cummings SR, Black DM. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: the FLEX study. JAMA Intern Med. 2014 Jul;174(7):1126-34. 

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

Engage in the discussion on Twitter on January 30, 2015 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

IMPORTANCE:
Discontinuation of bisphosphonate therapy after 3 to 5 years is increasingly considered, but methods to monitor fracture risk after discontinuation have not been established.

OBJECTIVE:
To test methods of predicting fracture risk among women who have discontinued alendronate therapy after 4 to 5 years.

DESIGN, SETTING, AND PARTICIPANTS:
The prospective Fracture Intervention Trial Long-term Extension (FLEX) study randomized postmenopausal women aged 61 to 86 years previously treated with 4 to 5 years of alendronate therapy to 5 more years of alendronate or placebo from 1998 through 2003; the present analysis includes only the placebo group. Hip and spine dual-energy x-ray absorptiometry (DXA) were measured when placebo was begun (FLEX baseline) and after 1 to 3 years of follow-up. Two biochemical markers of bone turnover, urinary type 1 collagen cross-linked N-telopeptide (NTX) and serum bone-specific alkaline phosphatase (BAP), were measured at FLEX baseline and after 1 and 3 years.

MAIN OUTCOMES AND MEASURES:
Symptomatic spine and nonspine fractures occurring after the follow-up measurement of DXA or bone turnover.

RESULTS:
During 5 years of placebo, 94 of 437 women (22%) experienced 1 or more symptomatic fractures; 82 had fractures after 1 year. One-year changes in hip DXA, NTX, and BAP were not related to subsequent fracture risk, but older age and lower hip DXA at time of discontinuation were significantly related to increased fracture risk (lowest tertile of baseline femoral neck DXA vs other 2 tertiles relative hazard ratio, 2.17 [95% CI, 1.38-3.41]; total hip DXA relative hazard ratio, 1.87 [95% CI, 1.20-2.92]).

CONCLUSIONS AND RELEVANCE:
Among postmenopausal women who discontinue alendronate therapy after 4 to 5 years, age and hip BMD at discontinuation predict clinical fractures during the subsequent 5 years. Follow-up measurements of DXA 1 year after discontinuation and of BAP or NTX 1 to 2 years after discontinuation are not associated with fracture risk and cannot be recommended.

#GeriMedJC invites #PsychJC to join in the January 2015 short article discussion.

For this month’s short article, #GeriMedJC would like to extend a warm invitation to the fans of #PsychJC, a Twitter-based psychiatry journal club.  This article is sure to be of interest to both groups.

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.

Antidepressants have limited efficacy in older adults with major depression, cognitive impairment and disability. Can problem adaptation therapy (PATH), which uses strategies consistent with the process model of emotion regulation when delivered in the home setting work?  Join the discussion when we focus on this randomized trial:

Kiosses DN, Ravdin LD, Gross JJ, Raue P, Kotbi N, Alexopoulos GS. Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial. JAMA Psychiatry. 2015 Jan 1;72(1):22-30. 

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

Engage in the discussion on Twitter on January 30, 2015 at 08:00 EST / 13:00 GMT and don't forget to use the hashtag #GeriMedJC.

OBJECTIVE:
To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability.

DESIGN, SETTING, AND PARTICIPANTS:
A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ≥65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate).

INTERVENTIONS:
Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy.

MAIN OUTCOMES AND MEASURES:
Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment.

RESULTS:
Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F1,179 = 8.03; P = .005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F1,169 = 14.86; P = .001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; χ2 = 5.74; P = .02; number needed to treat = 4.11) (secondary outcome).

CONCLUSIONS AND RELEVANCE:
Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options.

We're invited by @psychiatryjc!

In the spirit of collaboration, which is really at the heart of Twitter-based journal clubs, @psychiatryjc has invited @GeriMedJC to join in the next #PsychJC discussion. Thanks for the invitation! 

Tune into Twitter and use the hashtag, #PsychJC, on January 22, 2015 for a discussion on an interesting Canadian-based RCT led by Montreal-based geriatrician Dr. Cara Tannenbaum, on reducing benzodiazepine use in the elderly.  

Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.
JAMA Intern Med. 2014 Jun;174(6):890-8.

The University of Toronto Geriatric Medicine Journal Club discussed this study at the live version of the journal club in July 2014, a month before #GeriMedJC was launched but this will surely be a lively Twitter discussion, so don't miss out!

The article can be accessed by clicking here.  You will also want to check out the intervention which is a sedative-hypnotic deprescribing brochure here.

Help us improve #GeriMedJC

#GeriMedJC is an evolving process.

The learning objective for #GeriMedJC is to critically appraise influential articles relevant to the practice of geriatric medicine in an interactive, Twitter-based format.

Please help us improve by completing an evaluation form, as set out by the Royal College of Physicians and Surgeons of Canada (RCPSC).  Comment on the degree to which the learning objectives were met, whether you perceived any bias and whether adequate time for interactive learning was provided. Click here for the form (will open new window).