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.
Friday, 21 November 2014
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!
Monday, 27 October 2014
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.
There is limited evidence supporting use of physical therapy for hip osteoarthritis. Will this article lay the uncertainty to rest?
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.
Sunday, 26 October 2014
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.
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.
Sunday, 5 October 2014
@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 the representation continues to be global:
And here is the impression @GeriMedJC is making:
Thanks for following and contributing to #GeriMedJC!
Friday, 3 October 2014
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
International Urology Journal Club - #urojc
Respirology and Sleep Journal Club - #rsjc
Nephrology Journal Club - #nephjc
General Surgery Journal Club - #ISGJC
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