Comparative Analysis of Frailty Scores for Predicting Adverse Outcomes in Hip Fracture Patients: Insights from the United States National Inpatient Sample.

The aim of the current investigation was to compare the ability of several frailty scores to predict adverse outcomes in hip fracture patients. All adult patients (18 years or older) who suffered a hip fracture due to a fall and underwent surgical fixation were extracted from the 2019 National Inpatient Sample (NIS) Database. A combination of logistic regression and bootstrapping was used to compare the predictive ability of the Orthopedic Frailty Score (OFS), the Nottingham Hip Fracture Score (NHFS), the 11-factor modified Frailty Index (11-mFI) and 5-factor (5-mFI) modified Frailty Index, as well as the Johns Hopkins Frailty Indicator. A total of 227,850 patients were extracted from the NIS. In the prediction of in-hospital mortality and failure-to-rescue (FTR), the OFS surpassed all other frailty measures, approaching an acceptable predictive ability for mortality [AUC (95% CI): 0.69 (0.67-0.72)] and achieving an acceptable predictive ability for FTR [AUC (95% CI): 0.70 (0.67-0.72)]. The NHFS demonstrated the highest predictive ability for predicting any complication [AUC (95% CI): 0.62 (0.62-0.63)]. The 11-mFI exhibited the highest predictive ability for cardiovascular complications [AUC (95% CI): 0.66 (0.64-0.67)] and the NHFS achieved the highest predictive ability for delirium [AUC (95% CI): 0.69 (0.68-0.70)]. No score succeeded in effectively predicting venous thromboembolism or infections. In summary, the investigated frailty scores were most effective in predicting in-hospital mortality and failure-to-rescue; however, they struggled to predict complications.

The Giants of Rheumatology at Johns Hopkins: Lawrence E Shulman, MD, PhD and Mary Betty Stevens, MD.

Drs Lawrence E. Shulman and Mary Betty Stevens were the giants of rheumatology at Johns Hopkins during the latter half of the twentieth century. Together, they made immense contributions to our knowledge of systemic lupus erythematosus as well as other systemic autoimmune rheumatic diseases, provided excellent clinical care to thousands of patients with rheumatoid arthritis, systemic lupus erythematosus, and other systemic autoimmune rheumatic diseases, and trained almost 100 postdoctoral fellows, many of whom went on to highly successful careers in academic medicine, including the Directors of Divisions of Rheumatology and the Chairs of Departments of Medicine.

Usefulness of Force-Controlled Pelvic Stress Radiograph in the Evaluation and Treatment of Fragility Fractures of the Pelvis in Geriatric Patients: A Pilot Study.

This study aimed to investigate the usefulness of force-controlled pelvic stress radiographs in the evaluation and treatment of fragility fractures of the pelvis (FFP) using a functional treatment strategy. We conducted a retrospective study of 55 geriatric patients with FFP who underwent pelvic stress radiographs on admission. The differences in the sacral width, pelvic ring width, and medial femoral head width between the radiographs with and without the Sam Sling II M size were defined as Δ sacral width, Δ pelvic ring width, and Δ medial femoral head width, respectively. We used Pearson's correlation test to assess the relationship between the degree of radiographic instability and the Johns Hopkins highest level of mobility scale (JH-HLM) at 10-days postadmission. Conventional receiver-operating-characteristic curve analysis was used to identify cases requiring surgery using the best cutoff value for radiographic instability. The JH-HLM was significantly correlated with Δ sacral width (r=-0.401, p=0.017), but not with Δ pelvic ring width (r=-0.298, p=0.080) nor with Δ medial femoral head width (r= -0.261, p=0.128). The best cutoff value of Δ sacral width in identifying surgical cases was 10.7 mm (sensitivity 75.0%, specificity 98.0%). Force-controlled pelvic stress radiographs could be helpful in assessing the need for surgery on admission.

The Prognostic Value of Johns Hopkins Hospital Nutrition Support Score in Older Patients Undergoing Cardiovascular Surgery.

OBJECTIVES: Clarify the prognostic value of the Johns Hopkins Hospital Nutrition Support (JHHNS) score on clinical outcomes in older patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). DESIGN: A retrospective observational study. SETTING: A teaching and university hospital and tertiary referral center. PARTICIPANTS: The authors analyzed 328 older patients aged ≥65 who underwent cardiovascular surgery with CPB in 2020. INTERVENTIONS: Malnutrition risk was identified by the JHHNS score calculated based on specific preoperative and intraoperative objective parameters. Patients were divided into low- and high-JHHNS groups. Early morbidity, including pneumonia, bacteremia, wound infection, cerebrovascular accident, gastrointestinal bleeding, acute kidney injury, delirium, requirement for extracorporeal membrane oxygenation, and readmission to the intensive care unit (ICU), were the primary outcome; whereas in-hospital mortality, length of ICU and hospital stay, duration of mechanical ventilation and short-term mortality were secondary outcomes. The independent risk factors for postoperative complications were analyzed by logistic regression analyses. MEASUREMENTS AND MAIN RESULTS: The JHHNS score identified 21.0% of patients at risk for malnutrition. Patients in the high-JHHNS group had prolonged median length hospital stay (21 v 24 days, p = 0.002) and mechanical ventilation (13.0 v 16.0 hours, p = 0.038), and more patients in this subgroup stayed longer than 3 days in ICU (30.1% v 43.5%, p = 0.036). Besides, they experienced more postoperative complications (11.2% v 39.1%, p < 0.001). Furthermore, multivariate logistic regression analysis demonstrated that the JHHNS score independently predicted the risk of postoperative complications. No significant intergroup difference was observed for the short-term mortality. CONCLUSIONS: The JHHNS score was an independent predictor for postoperative complications but did not significantly affect short-term mortality in older patients undergoing cardiovascular surgery with CPB.

Atypical Category of the Johns Hopkins Template Has Higher Risk of Malignancy than the Paris System but the Paris System Is More Applicable for Suspicious Category.

INTRODUCTION: The aim of this study was to compare performance of individual categories between the Johns Hopkins template and the Paris system for reporting urinary cytology. METHODS: Medical records of patients with bladder biopsy and relevant cytology slides were obtained from archived material. Slides were reclassified according to Johns Hopkins template and the Paris system. Results were compared to histological diagnoses. RESULTS: BD SurePath preparations from 205 cases with biopsy follow-up (118 benign, 5 dysplasia, 23 low, and 59 malignant urothelial carcinoma [UC]) were reviewed. There were 2 inadequate specimens in each system. According to the Johns Hopkins template, there were 96 (46.8%) no urothelial atypia or malignancy, 37 (18%) atypical urothelial cells of uncertain significance (AUC-US), 21 (10.2%) atypical urothelial cells, cannot exclude high-grade urothelial carcinoma (HGUC), 38 (18.5%) HGUC, and 11 (5.4%) low-grade urothelial carcinoma (LGUC). The Paris system categorized 111 (54.1%) negative for high-grade urothelial carcinoma, 29 (14.1%) atypical urothelial cells (AUCs), 25 (12.2%) suspicious for HGUC (SHGUC), 36 (17.6%) HGUC, and 2 (1%) LGUC. The Johns Hopkins template had a sensitivity of 95.6%, specificity of 73.6%, positive predictive value of 61.5%, negative predictive value of 96.3, with an overall diagnostic accuracy of 79.8%. The Paris System had a sensitivity of 93.6%, specificity of 77.9%, positive predictive value of 65.6%, negative predictive value of 96.5, with an overall diagnostic accuracy of 82.8%. The risk of malignancy (ROM) for atypical category (AUC-US/AUC) in the Johns Hopkins template was 43.2%, while it has been 24.1% for the Paris System. The ROM for suspicious category was 47.6% and 68.0%, respectively. There were statistically significant differences between negative and atypical, suspicious, and HGUC categories in each system (p < 0.0001). CONCLUSIONS: Discrete negative or benign urine cytology had the same sensitivity and specificity between two systems. Although atypical category was associated with a higher ROM with the Hopkins template, the ROM for the suspicious category yielded better result with the Paris system.

Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study.

PURPOSE: Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of administrative database frailty instruments for patients undergoing TAVI. This study aimed to examine the performance of administrative database frailty instruments in predicting clinical outcomes and costs in patients who underwent TAVI. METHODS: We conducted a historical cohort study of 3,848 patients aged 66 yr or older who underwent a TAVI procedure in Ontario, Canada from 1 April 2012 to 31 March 2018. We used the Johns Hopkins Adjusted Clinical Group (ACG) frailty indicator and the Hospital Frailty Risk Score (HFRS) to assign frailty status. Outcomes of interest were in-hospital mortality, one-year mortality, rehospitalization, and healthcare costs. We compared the performance of the two frailty instruments with that of a reference model that adjusted baseline covariates and procedural characteristics. Accuracy measures included c-statistics, Akaike information criterion (AIC), Bayesian information criterion (BIC), integrated discrimination improvement (IDI), net reclassification index (NRI), bias, and accuracy of cost estimates. RESULTS: A total of 863 patients (22.4%) were identified as frail using the Johns Hopkins ACG frailty indicator and 865 (22.5%) were identified as frail using the HFRS. Although agreement between the frailty instruments was fair (Kappa statistic = 0.322), each instrument classified different subgroups as frail. Both the Johns Hopkins ACG frailty indicator (rate ratio [RR], 1.13; 95% confidence interval [CI], 1.06 to 1.20) and the HFRS (RR, 1.14; 95% CI, 1.07 to 1.21) were significantly associated with increased one-year costs. Compared with the reference model, both the Johns Hopkins ACG frailty indicator and HFRS significantly improved NRI for one-year mortality (Johns Hopkins ACG frailty indicator: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) and rehospitalization (Johns Hopkins ACG frailty indicator: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001). These improvements in NRI largely resulted from classification improvement among those who did not experience the event. With one-year mortality, there was a significant improvement in IDI (IDI, 0.003; P < 0.001) with the Johns Hopkins ACG frailty indicator. This improvement in performance resulted from an increase in the mean probability of the event among those with the event. CONCLUSION: Preoperative frailty assessment may add some predictive value for TAVI outcomes. Use of administrative database frailty instruments may provide small but significant improvements in case-mix adjustment when profiling hospitals for certain outcomes.

RéSUMé: OBJECTIF: L'utilisation d'indicateur de fragilité pourrait améliorer l'évaluation pronostique des patients bénéficiant d'un remplacement valvulaire aortique par voie percutanée (procédure TAVI). Peu d'études ont évalué et comparé la performance des instruments d'évaluation de la fragilité développés à partir de données administratives chez les patients bénéficiant d'un TAVI. Nous avions pour objectif d'examiner la performance des instruments d'évaluation de la fragilité développés à partir de données administratives dans la prédiction des issues cliniques et des coûts chez les patients ayant bénéficié d'un TAVI. MéTHODE: Nous avons réalisé une étude de cohorte historique auprès de 3848 patients âgés de 66 ans ou plus qui ont bénéficié d'une procédure TAVI en Ontario, Canada, du 1er avril 2012 au 31 mars 2018. Nous avons utilisé l'indicateur de fragilité ACG (Adjusted Clinical Group) de Johns Hopkins et le score de risque de fragilité à l'hôpital (HFRS) pour définir la fragilité. Les critères d'évaluation étaient la mortalité hospitalière, la mortalité à un an, la réhospitalisation et les coûts des soins de santé. Nous avons comparé la performance des deux instruments d'évaluation de la fragilité à celle d'un modèle de référence qui ajustait les covariables de base et les caractéristiques procédurales. Les mesures d'exactitude comprenaient l'analyse statistique c, le critère d'information d'Akaike (AIC), le critère d'information bayésien (BIC), l'amélioration de la discrimination intégrée (IDI), l'indice NRI (net reclassification index), le biais et l'exactitude des estimations de coûts. RéSULTATS: Au total, 863 patients (22,4 %) ont été identifiés comme fragiles à l'aide de l'indicateur de fragilité ACG de Johns Hopkins, et 865 (22,5 %) ont été identifiés comme fragiles à l'aide du HFRS. Bien que l'agrément entre les instruments d'évaluation de la fragilité ait été acceptable (statistique de Kappa = 0,322), chaque instrument a classé des sous-groupes différents comme étant fragiles. L'indicateur de fragilité ACG de Johns Hopkins (rapport de taux [RR], 1,13; intervalle de confiance à 95 % [IC], 1,06 à 1,20) et le HFRS (RR, 1,14; IC 95 %, 1,07 à 1,21) étaient associés de façon significative à une augmentation des coûts sur un an. Par rapport au modèle de référence, l'indicateur de fragilité ACG de Johns Hopkins améliorent de façon significative le NRI pour la mortalité (l'indicateur de fragilité ACG de Johns Hopkins: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) et la réhospitalisation (l'indicateur de fragilité ACG: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001) à un an. Ces améliorations du NRI résultent en grande partie de l'amélioration de la classification chez ceux qui n'ont pas bénéficié d'un TAVI. En ce qui a trait à la mortalité à un an, il y a eu une amélioration significative de l'IDI (IDI, 0,003; P < 0,001) avec l'indicateur de fragilité ACG de Johns Hopkins. Cette amélioration de la performance résultait d'une augmentation de la probabilité moyenne de TAVI chez les personnes ayant vécu l'événement. CONCLUSION: L'évaluation préopératoire de la fragilité peut ajouter une certaine valeur prédictive aux issues cliniques suivant une procédure de TAVI. L'utilisation d'instruments d'évaluation de la fragilité développés à partir de données administratives peut apporter des améliorations mineures mais significatives pour l'ajustement de risque lors de l'évaluation des hôpitaux en fonction de certaines issues cliniques.

The impact of partner autonomy constraints on women's health-seeking across the maternal and newborn continuum of care.

Background: Gendered health inequities impede women's reproductive autonomy over the life course. Pregnancy is a critical time point for assessing inequities and partners are integral actors in the achievement or impediment of women's and children's health during this time. Methods: Among a nationally representative cohort of Ethiopian women 5-9 weeks postpartum with data collected from October 2019-September 2020, this study aimed to 1) understand the prevalence and interplay of partner-related autonomy constraints (intimate partner violence (IPV), reproductive coercion (RC), lack of encouragement from seeking antenatal care (ANC), and lack of encouragement from seeking postnatal care (PNC), and 2) examine the impact of autonomy constraints on the maternal and newborn health (MNH) continuum of care. Findings: Sixty percent of women experienced a partner-related autonomy constraint prior to or during pregnancy. Approximately 20% of women were not encouraged to seek antenatal care and postpartum care, respectively, whereas fewer women experienced IPV during pregnancy (12.3%) and RC (11.0%). Less than one in five women completed the MNH continuum of care. Lack of encouragement of ANC and PNC were associated with decreased care-seeking at every point across the MNH continuum of care. Lack of encouragement of ANC (aOR = 0.45; p = 0.05) and of PNC (aOR = 0.16; p < 0.001) were associated with reductions in completing the continuum. Interpretation: Partner engagement, interventions, and messaging are critical to enhance MNH care-seeking behaviors. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [INV 009466]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

Comparing three wearable accelerometers to measure early activity after cardiac surgery.

Objective: Wearable activity monitors can provide detailed data on activity after cardiac surgery and discriminate a patient's risk for hospital-based outcomes. However, comparative data for different monitoring approaches, as well as predictive ability over clinical characteristics, are lacking. In addition, data on specific thresholds of activity are needed. The objective of this study was to compare 3 wearable activity monitors and 1 observational mobility scale in discriminating risk for 3 hospital-based outcomes, and to establish clinically relevant step thresholds. Methods: Cardiac surgery patients were enrolled between June 2016 and August 2017 in a cohort study. Postoperative activity was measured by 3 accelerometry monitors (StepWatch Ambulation Monitor, Fitbit Charge HR, and ActiGraph GT9X) and 1 nurse-based observation scale. Monitors represent a spectrum of characteristics, including wear location (ankle/wrist), output (activity counts/steps), consumer accessibility, and cost. Primary outcomes were duration of hospitalization >7 days, discharge to a nonhome location, and 30-day readmission. Results: Data were available from 193 patients (median age 67 years [interquartile range, 58-72]). All postoperative day 2 activity metrics (ie, from StepWatch, Fitbit, ActiGraph, and the observation scale) were independently associated with prolonged hospitalization and discharge to a nonhome location. Only steps as measured by StepWatch was independently associated with 30-day readmission. Overall, StepWatch provided the greatest discrimination (C-statistics 0.71-0.76 for all outcomes). Step thresholds between 250 and 500 steps/day identified between 74% and 96% of patients with any primary outcome. Conclusions: Data from wearable accelerometers provide additive value in early postoperative risk-stratification for hospital-based outcomes. These results both support and provide guidance for activity-monitoring programs after cardiac surgery.

Assessment of the predictive ability of the Johns Hopkins Fall Risk Assessment Tool (Chinese Version) in inpatient settings.

AIMS: This study was to assess the predictive ability of the Johns Hopkins Fall Risk Assessment Tool (Chinese Version) in inpatient settings. DESIGN: A case-control study. METHODS: This study was conducted in a tertiary hospital based on 2019 data. With a case-control design in a 1:2 ratio, the predictive ability of the Johns Hopkins Fall Risk Assessment Tool (Chinese Version) was determined by ROC curve. The best cut point was identified based on sensitivity, specificity, positive predict value and negative predict value. Conditional logistical regression analysis was conducted to test the predictive ability of each indicator. RESULTS: The study included 309 patients, with 103 in the case group and 206 in the control groups. Generally, the predictive ability was acceptable with the area under ROC curve value at 0.73 (95% CI: 0.67-0.79). Positive predict value and negative predict value performed best at the cut point of 13. Sensitivity at cut point 6 was much higher than that at cut point 13, though specificity was lower. Except for age, all indicators in the Johns Hopkins Fall Risk Assessment Tool (Chinese Version) demonstrated significant predictive ability as to occurrence of fall. CONCLUSION: The Johns Hopkins Fall Risk Assessment Tool (Chinese Version) is a reliable assessment instrument in the inpatient settings. IMPACT: This is the first study that evaluated the predictive ability of the Johns Hopkins Fall Risk Assessment Tool (Chinese version) in the inpatient settings, and proved that the instrument is reliable for assessing inpatient fall risks. Further studies could be carried out to assess the predict ability of Johns Hopkins Fall Risk Assessment Tool (Chinese version) among specific populations.

Relationship between antibiotic exposure and subsequent mental health disorders in a primary care health system.

OBJECTIVE: To evaluate the relationship between antibiotic exposure and subsequent psychiatric disorders in a Pediatric primary care setting. STUDY DESIGN: We conducted a retrospective cohort study using electronic clinical record data for patients ages 8-20 years seen in the outpatient setting of a large urban primary health care practice from 1/1/13 to 12/1/2018. We employed adjusted Cox regression analyses to study the relationship between prescriptions for anti-infective agents and subsequent diagnosis of anxiety or depression. RESULTS: Prescription of anti-infective medication was associated with a hazard rate ratio (HRR) of 1.21 (95%-CI â€‹= â€‹1.00-1.45). A first prescription for a broad-spectrum antibiotic (compared to those with no prescription, narrow-spectrum prescription, or topical prescription) was associated with an HRR of 1.27 (95%-CI â€‹= â€‹1.04-1.54). The number of anti-infectives prescribed over the course of the study period was associated with an HRR of 1.05 (95%-CI â€‹= â€‹1.00-1.10). There was no significant relationship between prescription of topical or narrow-spectrum antibiotics, antifungal, or antiviral medication and subsequent diagnosis of anxiety or depression. Stratified analysis revealed that the association between anti-infective prescription and anxiety and depression was driven by males, among whom prescription of any antibiotic was associated with an HRR of 1.45 (95%-CI â€‹= â€‹1.05-1.99). CONCLUSIONS: Infections treated with broad-spectrum antibiotics were associated with increased risks of anxiety and/or depression, especially in males. Exploration of the relationship between antibiotic exposure and subsequent mental health disorders is warranted along with continued vigilance in antibiotic prescribing practices in children.

Highlight of potential impact of new viral genotypes of SARS-CoV-2 on vaccines and anti-viral therapeutics.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causal agent of the coronavirus disease (COVID-19) pandemic, has infected millions of people globally. Genetic variation and selective pressures lead to the accumulation of single nucleotide polymorphism (SNP) within the viral genome that may affect virulence, transmission rate, viral recognition and the efficacy of prophylactic and interventional measures. To address these concerns at the genomic level, we assessed the phylogeny and SNPs of the SARS-CoV-2 mutant population collected to date in Iran in relation to globally reported variants. Phylogenetic analysis of mutant strains revealed the occurrence of the variants known as B.1.1.7 (Alpha), B.1.525 (Eta), and B.1.617 (Delta) that appear to have delineated independently in Iran. SNP analysis of the Iranian sequences revealed that the mutations were predominantly positioned within the S protein-coding region, with most SNPs localizing to the S1 subunit. Seventeen S1-localizing SNPs occurred in the RNA binding domain that interacts with ACE2 of the host cell. Importantly, many of these SNPs are predicted to influence the binding of antibodies and anti-viral therapeutics, indicating that the adaptive host response appears to be imposing a selective pressure that is driving the evolution of the virus in this closed population through enhancing virulence. The SNPs detected within these mutant cohorts are addressed with respect to current prophylactic measures and therapeutic interventions.

Online patient portal-based management of medication renewal and refill pickup in ambulatory care settings: A retrospective utilization study at tertiary care hospital in Saudi Arabia.

BACKGROUND: The prescription pickup and renewal process in ambulatory care settings requires numerous steps, such as making an appointment with a physician to renew prescriptions and direct pharmacy visits to pick up medications. This process can be difficult or cumbersome for some patients; however, digital health-associated patient portals can reduce the burden on both patients and healthcare professionals. METHODS: A retrospective study was conducted in an ambulatory care setting of Johns Hopkins Aramco Healthcare. We analyzed the utilization pattern of MyChart for medication renewal and refill pickup services for ambulatory care patients of all specialties from October 1, 2018, to September 30, 2020. The data were extracted electronically from the Epic-Hyperspace EHR system, and the effects of factors such as year of access and COVID-19 on MyChart utilization were analyzed. RESULTS: A total of 125,538 patients were registered using MyChart. In the first and second year of this study, MyChart was utilized by 44,063 (8.7%) and 59,622 (13.6%) patients, respectively, for medication pickup. Additionally, in these two years, 92,997 (21.6%) and 156,020 (38.9%) medication refills were requested through MyChart (with no direct pharmacy visit) and collected from different pickup locations, respectively. In two years, there were 363,159 medications sent to physicians for renewal through Epic-MyChart, of which 347,244 (95.6%) were approved and 15,915 (4.4%) were denied. A significant increasing (p less than 0.05) trend in utilization, medication requests, and renewal requests using the MyChart were observed over a period of 24 months and during quarantine due to COVID-19. Although there was a decrease in physicians denying renewal request, these were not significantly affected by time or COVID-19. CONCLUSION: The high and consistent utilization of the patient portal MyChart indicates its broad acceptance, significantly minimizing the barriers to medication pickup and renewal processes in ambulatory care settings. The year of access and COVID-19 were significantly associated with an increasing trend in MyChart utilization. With increased utilization and higher acceptability, the internet-based patient portal MyChart continues to hold great potential for providing quality healthcare services by increasing access and making patients decision-makers in their healthcare.

Clinical frailty is a risk factor of adverse outcomes in patients with esophageal cancer undergoing esophagectomy: analysis of 2011-2017 US hospitals.

Frailty is an aggregate of medical and geriatric conditions that affect elderly and vulnerable patients; as frailty is known to affect postoperative outcomes, we evaluate the effects of frailty in patients undergoing esophageal resection surgery for esophageal cancer. 2011-2017 National Inpatient Sample was used to isolate younger (18 to <65) and older (65 or greater) patients undergoing esophagectomy for esophageal cancer, substratified using frailty (defined by Johns-Hopkins ACG frailty indicator) into frail patients and non-frail controls; the controls were 1:1 matched with frail patients using propensity score. Endpoints included mortality, length of stay (LOS), costs, discharge disposition, and postsurgical complications. Following the match, there were 363 and equal number controls in younger cohort; 383 and equal number controls in older cohort. For younger cohort, frail patients had higher mortality (odds ratio [OR] 3.14 95% confidence interval [CI] 1.39-7.09), LOS (20.5 vs. 13.6 days), costs ($320,074 vs. $190,235) and were likely to be discharged to skilled nursing facilities; however, there was no difference in postsurgical complications. In multivariate, frail patients had higher mortality (aOR 3.00 95%CI 1.29-6.99). In older cohort, frail patients had higher mortality (OR 1.96 95%CI 1.07-3.60), LOS (19.9 vs. 14.3 days), costs ($301,335 vs. $206,648) and were more likely to be discharged to short-term hospitals or skilled nursing facilities; the frail patients were more likely to suffer postsurgical respiratory failure (OR 2.03 95%CI 1.31-3.15). In multivariate, frail patients had higher mortality (aOR 1.93 95%CI 1.04-3.58). Clinical frailty adversely affects both younger and older patients undergoing esophagectomy for esophageal cancer.

The effect of frailty on post-operative outcomes and health care expenditures in patients treated with partial nephrectomy.

OBJECTIVE: To examine the effect of frailty on short-term post-operative outcomes and total hospital charges (THCs) in patients with non-metastatic renal cell carcinoma, treated with partial nephrectomy (PN). METHODS: Within the National Inpatient Sample (NIS) database we identified 25,545 patients treated with PN from 2000 to 2015. We used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining indicator and we examined the rates of frailty over time, as well as its effect on overall complications, major complications, blood transfusions, non-home-based discharge, length of stay (LOS) and THCs. Time trends and multivariable logistic, Poisson and linear regression models were applied. RESULTS: Overall, 3574 (14.0%) patients were frail, 2677 (10.5%) were older than 75 years and 2888 (11.3%) had Charlson comorbidity index (CCI) ≥ 2. However, the vast majority of frail patients were neither elderly nor comorbid (83%). Rates of frail patients treated with PN increased over time, from 8.3 in 2000 to 18.1% in 2015 (all p < 0.001). Frail patients showed higher rates of overall complications (43.5 vs. 30.3%), major complications (16.6 vs. 9.8%), blood transfusions (11.6 vs 8.3%) and non-home-based discharge (9.9 vs. 5.4%). longer LOS [4 (IQR: 3-6) vs. 4 (IQR: 2-5) days] and higher THCs ($43,906 vs. $38,447 - all p < 0.001). Moreover, frailty status independently predicted overall complications (OR: 1.73), major complications (OR: 1.63), longer LOS (RR: 1.07) and higher THCs (RR: +$7506). Finally, a dose-response on the risk of suboptimal surgical outcomes was shown in patients with multiple risk factors. CONCLUSIONS: One out of seven patients is frail at time of surgery and this rate is on the rise. Moreover, frailty is associated with adverse outcomes after PN. In consequence, preoperative assessment of frailty status should be implemented, to identify patients who may benefit from pre- or postoperative measures aimed at improving surgical outcomes in this patient population.

The clinical impact of frailty on the postoperative outcomes of patients undergoing gastrectomy for gastric cancer: a propensity-score matched database study.

BACKGROUND: Frailty aggregates a composite of geriatric and elderly features that is classified into a singular syndrome; literature thus far has proven its influence over postoperative outcomes. In this study, we evaluate the effects of frailty following gastrectomy for gastric cancer. METHODS: 2011-2017 National Inpatient Sample was used to isolate patients with gastric cancer undergoing gastrectomy; from this, the Johns Hopkins ACG frailty criteria were applied to segregate frailty-present and absent populations. The case-controls were matched using propensity-score matching and compared to various endpoints. RESULTS: Post match, there were 1171 with and without frailty who were undergoing gastrectomy for gastric cancer. Those with frailty had higher mortality (6.83 vs 3.50% p < 0.001, OR 2.02 95% CI 1.37-2.97), length of stay (16.7 vs 12.0d; p < 0.001), and costs ($191,418 vs $131,367; p < 0.001); frail patients also had higher rates of complications including wound complications (3.42 vs 0.94% p < 0.001, OR 3.73 95% CI 1.90-7.31), infection (5.98 vs 3.67% p = 0.012, OR 1.67 95% CI 1.13-2.46), and respiratory failure (6.32 vs 3.84% p = 0.0084, OR 1.69 95% CI 1.15-2.47). In multivariate, those with frailty had higher mortality (p < 0.001, aOR 2.04 95% CI 1.38-3.01), length of stay (p < 0.001, aOR 1.40 95% CI 1.37-1.43), and costs (p < 0.001, aOR 1.46 95% CI 1.46-1.46). CONCLUSION: This study finding demonstrates the presence of frailty is an independent risk factor of adverse outcomes following gastrectomy; as such, it is important that these high-risk patients are stratified preoperatively and provided risk-averting procedures to alleviate their frailty-defining features.

Validity of the Morse Fall Scale and the Johns Hopkins Fall Risk Assessment Tool for fall risk assessment in an acute care setting.

AIMS AND OBJECTIVES: To evaluate the measured fall risk score that more accurately reflects the changeable conditions in acute care settings, and to efficiently evaluate the association between falls and fall risk score. BACKGROUND: The Morse Fall Scale (MFS) is a well-known easy-to-use tool, while the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) consists of items with high specificity. Evaluating suitable fall-risk assessment tools to measure these changeable conditions may contribute to preventing falls in acute care settings. DESIGN: Retrospective case-control study using the STROBE checklist. METHODS: In an acute care setting (708-bedded university hospital with a regional emergency medical centre), the non-fall group was adjusted to fall group using propensity score matching. According to the fall rate of 3-5%, non-fall groups for each tool were selected (1386 and 1947) from the before adjusted data, and the fall groups included 42 and 59. The applied covariates were individual characteristics that ordinarily changed such as age, gender, diagnostic department and hospitalisation period. The adjusted data were analysed using generalised estimating equations and mixed effect model. RESULTS: After adjustment, the fall group measured using the JHFRAT had a significantly higher difference between the initial and re-measured total score than the non-fall group. The JHFRAT, especially with the re-measured score, had a higher AUC value for predicting falls than the MFS. MFS's sensitivity was 85.7%, and specificity was 58.8% at 50 points; for JHFRAT, these were 67.8% and 80.2% at 14 points, respectively. These cut-off points were used to evaluate validity during tool development and are commonly used as reference scores. CONCLUSIONS: JHFRAT more accurately reflects acute changeable conditions related to fall risk measurements after admission. RELEVANCE TO CLINICAL PRACTICE: JHFRAT may be useful for effective fall prevention activities in acute care settings.

Implementation of pharmacist-led tele medication management clinic in ambulatory care settings: A patient-centered care model in COVID-19 Era.

Over the past 20 years, owing to rapid advances in technological innovation, namely in telecommunication and telemedicine, healthcare institutions have integrated clinical practices with cutting-edge telecommunication technology to enhance access to patient care, improve continuity of clinical care, and ensure patient safety. Johns Hopkins Aramco Healthcare (JHAH) is a gold-certified tertiary care institution, and it is an excellent center for patient-centered care. In response to the Coronavirus 2019 (COVID-19) pandemic, it has adopted various telecommunication technologies to provide patient-care services. This article describes the integration of telecommunication technology, such as telephone and video consultation, with a pharmacist-led medication management clinic (MMC) to provide person-centered patient care services at JHAH. The JHAH pharmacy services were found to be essential in establishing face-to-face outcome-oriented pharmacist-led medication management services for patients requiring chronic ambulatory care. The established tele-MMC services enhanced patient engagement and treatment compliance, and the integration process and its challenges were assessed. Especially during this COVID-19 pandemic, the pharmacist-led tele-MMC services were beneficial to chronic disease patients and ensured the continuity of care, maintenance of up-to-date lab tests, management of polypharmacy, minimization of the use of unwanted medications and medication synchronization. Further, the pharmacist-led tele-MMC services provided comprehensive patient counseling, which included the use of visual aids. This new integrated model provides an example for other healthcare organizations to adopt and implement the program in ambulatory care settings, to better ensure the continuity of quality healthcare, especially for elderly patients and those with chronic diseases.

Victor McKusick and his short course.

The Short Course in Human and Mammalian Genetics and Genomics (aka the "Short Course" or the "Bar Harbor course") is one of Victor McKusick's landmark contributions to medical genetics. Conceived in 1959 as a way to increase the contribution of genetic advances to medicine, it has directly affected more than 7000 students and 600 participating faculty from around the world. Now, more than 10 years after his death, it continues to be a vibrant disseminator of genetics, and genomics knowledge for medicine, a catalytic agent for ongoing research and a source of collegiality in our field. What an extraordinary gift!