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Examine feasibility and construct validity of Pictorial fit frail scale (PFFS) for the first time in older surgical patients.The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics.Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and FRAIL scale were obtained. To assess the validity of the PFFS in this population, the Spearman's rank correlations (rspearman) between PFFStrans and VES-13, FI-CGA, FRAIL were calculated.All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFStrans was 0.27 (IQR 0.12-0.34), PFFS was 11 (IQR 5-14) and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFStrans and FI-CGA (rspearman = 0.81, p0.001) and a moderate correlation between PFFStrans and VES-13 and FRAIL score (rspearman 0.68 and 0.64 respectively, p0.001).PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.

To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups:70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.

Important trade-offs of risks versus benefits of surgery need to be discussed with older adults, in particular nonagenarians who are candidates for surgery. Data that examine specific outcomes of surgical interventions in this age group are sparse. We aimed to evaluate the clinical presentation and postoperative outcomes of nonagenarians undergoing surgery.A retrospective cohort study of consecutive patients 90 years of age and older who underwent surgery between 2014 and 2018 in general surgical ward of a large-volume academic center. Subgroups were designed according to type of surgery (elective versus emergency surgery) and diagnosis (oncology versus non-oncology). Preoperative assessments included Malnutrition Universal Screening Tool, Norton Scale, Morse Scale, Katz, and Lawton-Brody indices.A total of 198 nonagenarians underwent surgery, of which 38% were elective and 62% were emergency surgery. Median follow-up was 26 months. More patients in the elective group compared with the emergency group had oncology diagnoses (42.1% and 14.7%, respectively, P.001), resided preoperatively at home (93.4% and 77.9%, respectively, P = .003), and were functionally independent (71.1% and 41.8%, respectively, P = .0005). Postoperative 30-day mortality frequency was 6.6% in the elective group and 39.3% in the emergency group (P.001). Two-year survival frequency of non-oncology group was 72.7% in elective surgeries and 40.6% in emergency surgeries (P.001). Two-year survival frequency of oncology group was 37% in elective surgeries and 27.8% in emergency surgeries (P = .12).Elective surgery in adults aged 90 and above can be safely performed with acceptable 2-year outcomes. Emergency surgery for oncology diagnoses carries dismal outcomes, so palliative approaches should be considered.

BACKGROUND: Patterns of overall and disease-free survival after esophagectomy for esophageal cancer in older adults have not been carefully studied. METHODS: Retrospective analysis of all patients with esophageal cancer undergoing esophagectomy from 2005 to 2020 at our institution was performed. Differences in outcomes were stratified by age groups, < 75 and ≥ 75 years old, and two time periods, 2005–2012 and 2013–2020. RESULTS: A total of 1135 patients were included: 979 (86.3%) patients were < 75 (86.3%), and 156 (13.7%) were ≥ 75 years old. Younger patients had fewer comorbidities, better nutritional status, and were more likely to receive neoadjuvant and adjuvant therapy (all p < 0.05). However, tumor stage and operative approach were similar, except for increased performance of the McKeown technique in younger patients (p = 0.02). Perioperatively, younger patients experienced fewer overall and grade II complications (both p < 0.05). They had better overall survival (log-rank p-value < 0.001) and median survival, 62.2 vs. 21.5 months (p < 0.05). When stratified by pathologic stage, survival was similar for yp0 and pathologic stage II disease (both log-rank p-value > 0.05). Multivariable Cox models showed older age (≥ 75 years old) had increased hazard for reduced overall survival (HR 2.04 95% CI 1.5–2.8; p < 0.001) but not disease-free survival (HR 1.1 95% CI 0.78–1.6; p = 0.54). Over time, baseline characteristics remained largely similar, while stage became more advanced with a rise in neoadjuvant use and increased performance of minimally invasive esophagectomy (all p < 0.05). While overall complication rates improved (p < 0.05), overall and recurrence-free survival did not. Overall survival was better in younger patients during both time periods (both log-rank p < 0.05). CONCLUSIONS: Despite similar disease-free survival rates, long-term survival was decreased in older adults as compared to younger patients. This may be related to unmeasured factors including frailty, long-term complications after surgery, and competing causes of death. However, our results suggest that survival is similar in those with complete pathologic responses.

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 FI-CGA 0.4. A qualitative analysis of geriatric interventions was performed.Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States.Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p 0.05).Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Background/Aims: The novel coronavirus SARS-CoV-2 has caused a pandemic threatening millions of people worldwide. This study aimed to describe clinical characteristics, outcomes, and risk factors of SARS-CoV-2-positive, asymptomatic, frail older adults. Methods: A retrospective cohort study was conducted in 6 designated COVID-19 units, in skilled nursing homes. Subjects were severely frail older adults, positive for SARS-CoV-2, and asymptomatic at the time of their admission in these units. Residents’ characteristics and symptoms were obtained via electronic medical records. The primary outcome was a composite of death or hospitalization by day 40. We looked at time to the primary outcome and used Cox regression for a multivariate analysis. Results: During March–November 2020, 849 residents met inclusion criteria. Median age was 84 years. Most were completely dependent for basic activities of daily living and showed cognitive impairment. Six hundred forty-one (75.5%) residents were discharged after considered cured from COVID-19, 125 (14.7%) were hospitalized, and 82 (9.7%) died in the facilities. In survival analysis, 35% reached the primary outcome of death or hospitalization by day 40. Age (hazard ratio [HR] 1.23; 95% confidence interval [CI] 1.1–1.4), male gender (HR 1.41; 95% CI: 1.1–1.88), and COPD (HR 1.8; 95% CI: 1.23–2.67) were significant risk factors. Conclusions: In this large cohort, we report care and prognosis of asymptomatic older adults with major functional or cognitive impairments during the COVID-19 pandemic. Most presymptomatic patients do not develop severe infection, and age stays a predominant risk factor, even in the frailest older adults.

Objective To assess the feasibility of administering the MoCA 5-minute test/Telephone (T-MoCA), an abbreviated version of the Montreal Cognitive Assessment to older adults perioperatively Design A feasibility study including patients aged ≥ 70 years scheduled for surgery from December 2020 to March 2021 Setting Preoperative virtual clinic Patients Patients ≥70 years undergoing major elective surgery Intervention A study investigator called eligible patients prior to surgery, obtained consent, and completed the preoperative cognitive assessment. Follow-up assessment was completed 1-month postoperatively, and participating clinicians were surveyed at the completion of the study. Measurements An attention test, T-MoCA, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and Generalized Anxiety Disorder 2-item (GAD-2) Main results Overall, 37/40 (92.5%) patients completed the pre- and post-operative assessments. The cohort was 50% female, white (97.5%), with a median age of 76 years (interquartile range (IQR) 73-79), and education level was higher than high school in 82.5% of patients. Preoperatively, the median number of medications was 8 (IQR 7-11), 27/40 (67.5%) had medications with anticholinergic effects, and 6/40 (15%) had benzodiazepines. Median completion time of the phone assessment was 10 min (IQR 8.25-12) and 4 min (IQR 3-5) for the T-MoCA with a median T-MoCA score of 13 (IQR 12-14). Most patients (37/40) completed the post-operative assessment, and 6/37 (16.2%) reported they had experienced a change in memory or attention post-operatively. Clinician’s survey reported ease and feasibility in performing T-MoCA as a preoperative cognitive evaluation. Conclusion Preoperative cognitive assessment of older adults using T-MoCA over the phone is easy to perform by clinicians and had a high completion rate by patients. This test is feasible for virtual assessments. Further research is needed to better define validity and correlation with postoperative outcomes.

Population divergence and gene flow are key processes in evolution and ecology. Model-based analysis of genome-wide datasets allows discrimination between alternative scenarios for these processes even in non-model taxa. We used two complementary approaches (one based on the blockwise site frequency spectrum (bSFS), the second on the Pairwise Sequentially Markovian Coalescent (PSMC)) to infer the divergence history of a fig wasp,Pleistodontes nigriventris. Pleistodontes nigriventrisand its fig tree mutualistFicus watkinsianaare restricted to rain forest patches along the eastern coast of Australia, and are separated into northern and southern populations by two dry forest corridors (the Burdekin and St. Lawrence Gaps). We generated whole genome sequence data for two haploid males per population and used the bSFS approach to infer the timing of divergence between northern and southern populations ofP. nigriventris,and to discriminate between alternative isolation with migration (IM) and instantaneous admixture (ADM) models of post divergence gene flow.Pleistodontes nigriventrishas low genetic diversity (π = 0.0008), to our knowledge one of the lowest estimates reported for a sexually reproducing arthropod. We find strongest support for an ADM model in which the two populations divergedca. 196kya in the late Pleistocene, with almost 25% of northern lineages introduced from the south during an admixture eventca.57kya. This divergence history is highly concordant with individual population demographies inferred from each pair of haploid males using PSMC. Our analysis illustrates the inferences possible with genome-level data for small population samples of tiny, non-model organisms and adds to a growing body of knowledge on the population structure of Australian rain forest taxa.

Advanced understanding of the molecular pathways of oncologic diseases has shifted therapeutic treatment development to focus on mechanism of actions targeting specific genomic alterations. These precision medicines are indicated for patient subsets defined by these specific mutations as determined by diagnostic devices approved by the Food and Drug Administration (FDA). The Intended Use section within the companion diagnostic (CDx) labeling has historically specified the therapeutic products for which they have been clinically validated. In April 2020, the FDA reiterated their position that therapeutic class labeling may be used, if appropriate, instead of named products. Labels for FDA approved in vitro CDxs were reviewed to evaluate the implementation of therapeutic class labeling. A total of 47 devices have been approved as of 2 January 2022, of which 3 labels were found to contain therapeutic class labeling: two devices targeting EGFR mutations for the treatment of non-small cell lung cancer (NSCLC), and one targeting BRAF V600E and BRAF/MEK inhibitor combinations for melanoma. Two devices received therapeutic class labeling upon initial approval, while the third implemented the language though a label revision. A total of 25 different indications were identified across the 47 CDx devices, of which 9 (34.6%) were associated with more than 1 CDx device. Implementation of therapeutic class labeling has been slow following the release of the FDA’s April 2020 guidance; however, the potential to incorporate such language into existing and newly approved CDx labels exists. Precedence and manufacturer experience are expected to drive an increase in therapeutic class labeling.

Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date.Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress.Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.

Poor food environments and disproportionate food insecurity among African Americans (AAs) represent determinants of chronic disease disparities by race/ethnicity. We used PhotoVoice to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension. Findings illuminated structural racism and classism as root causes of “food desert” conditions. Respondents provided critical analysis of existing food access barriers, including problematic policies, and offered asset-based solutions. Using an exhibition of participants’ photographs to set the tone of the discussion, we will convene a stakeholder meeting including study participants, community advisory board members, local and state government agencies, civic organizations, community farmers, agricultural organizations, non-profit food providers, churches, local restauranteurs, convenience store owners, insurance payers, and transportation providers. Discussion will center on three areas of action informed by findings: systems level issues; individual activation, agency, and advocacy; and community-based solutions. Meeting proceedings will be disseminated through academic and lay publications.

Introduction: The COVID-19 pandemic has impacted millions of lives globally. To learn more about this disease and find potential diagnostic, therapeutic, and preventative products, the healthcare community has initiated a staggering number of clinical trials. Methods: ClinicalTrials.gov was reviewed to determine if trial sponsor type had a relationship to time to COVID-19 response, which was defined as the date from disease discovery in Wuhan, China to ClinicalTrials.gov study “First Posted” date. Results: A total of 673 United States (US) sponsored, interventional study listings were retrieved, of which 293 (43.5%) were Industry-sponsored, 349 (51.9%) were Academic sponsored, and 31 (4.6%) were Other sponsor types. Of the Academic studies, 181 (51.9%) were Clinical and Translational Science Award (CTSA) hubs. The average response time for all sponsor types was 189 days, with Academic sponsors having the shortest average response time of 172.6 days (P < 0.001). CTSA hubs had a significantly (P < 0.001) shorter average response time (168.1 days) compared to all other sponsor types (197.4 days). However, while shorter in duration by 9.4 days, response time was not significantly different from non-CTSA sponsors (177.5 days; P = 0.238). Additionally, ANOVA indicated significant relationships (P < 0.001) between funding type, study phase, number of sites, and enrollment size on response time. Conclusions: Studies posted with the shortest response time were Academic-sponsored trials and included smaller sized investigations of repurposed approved or investigational drugs for the treatment of COVID-19 symptoms. A small second wave of study postings occurred approximately 4 months later, and included small, unique therapies targeting prevention or treatment of COVID-19.

Hip fractures (HF) are common among the elderly. The prevalence increases with age and occurs more frequently among females. Up to 30% mortality rates have been observed during the first year following HF, with or without surgery. Additional implications may include functional and cognitive decline and significant morbidity. Many factors are associated with morbidity and mortality after HF repair surgery, including anemia. Anemia is present in approximately 50% of these patients upon admission to the hospital and its incidence increases further following surgery. The mean reduction in the hemoglobin level after surgery is estimated at 0.7-2.5 g/dL. There are several causes of anemia, some are patient dependent and some are related to the type of fracture and surgery. Anemia has a significant effect on the elderly patient in general, and on the patient's condition post-HF in particular. Anemia on admission is associated with short and long-term mortality, in addition to the length of stay, amount of blood transfusions, repeated hospitalizations, post-operative complications, poor functioning and a reduced quality of life. The most common treatment for anemic patients before and after HF repair surgery is the administration of blood transfusions. It has been common practice to administer blood transfusions when hemoglobin reaches a level of 8g/dL, however the effectiveness of this approach in older patients is not conclusive. Regarding other modalities, i.e., iron, erythropoietin and tranexamic acid, there are currently no clear guidelines in the literature and their effectiveness has not been fully established. Further research is needed to address these issues.

In recent years, there has been a significant increase in the number of adult patients with malignant diseases. These patients are a major therapeutic challenge due to a high incidence of comorbidities, lower functional status and often a diagnosis of the disease at a relatively advanced stage. The preferred approach to the treatment of cancer is a multidisciplinary approach. In the last decade, we have witnessed the integration of geriatricians as part of the multidisciplinary team in order to better assess patients' ability to withstand oncological or surgical treatment and, if necessary, to prepare them better for these treatments. In this article we review the use of various geriatric tools, such as generalized geriatric assessment, fragility and sarcopenia, and their effect on the decision-making process of the treating physicians and on the outcomes of the various treatments, including the outcomes of the operations. We show that comprehensive geriatric assessment is the basis for the evaluation of the adult oncology patients, and proper preparation for treatment in order to improve the outcomes of the treatment and reduce its complications. The rapid growth rate of the elderly population in Israel, together with the continuous development of oncology and cancer treatments, indicate the need to allocate resources and efforts to treat this unique population. We recommend an integration of geriatricians in the multidisciplinary team that treats this population.

The COVID-19 pandemic poses a barrier to equal and evidence-based management of cancer in older adults. The International Society of Geriatric Oncology (SIOG) formed a panel of experts to develop consensus recommendations on the implications of the pandemic on several aspects of cancer care in this age group including geriatric assessment (GA), surgery, radiotherapy, systemic treatment, palliative care and research. Age and cancer diagnosis are significant predictors of adverse outcomes of the COVID-19 infection. In this setting, GA is particularly valuable to drive decision-making. GA may aid estimating physiologic reserve and adaptive capability, assessing risk-benefits of either providing or temporarily withholding treatments, and determining patient preferences to help inform treatment decisions. In a resource-constrained setting, geriatric screening tools may be administered remotely to identify patients requiring comprehensive GA. Tele-health is also crucial to ensure adequate continuity of care and minimize the risk of infection exposure. In general, therapeutic decisions should favor the most effective and least invasive approach with the lowest risk of adverse outcomes. In selected cases, this might require deferring or omitting surgery, radiotherapy or systemic treatments especially where benefits are marginal and alternative safe therapeutic options are available. Ongoing research is necessary to expand knowledge of the management of cancer in older adults. However, the pandemic presents a significant barrier and efforts should be made to ensure equitable access to clinical trials and prospective data collection to elucidate the outcomes of COVID-19 in this population. ispartof: JOURNAL OF GERIATRIC ONCOLOGY vol:11 issue:8 pages:1190-1198 ispartof: location:Netherlands status: published

OBJECTIVES/GOALS: Review all approved companion diagnostics (CDxs) labeling for therapeutic class language. Examine the regulatory pathways of CDx products whose labels contain therapeutic class labeling. Develop recommendations for pharmaceutical industry professionals on best practices in the co-development of CDxs and oncology therapeutic products. METHODS/STUDY POPULATION: Literature discussing companion diagnostics was reviewed from EBSCOhost, PubMed, and OVID. The Intended Use language within CDx labels on the Food and Drug Administrations “List of Cleared or Approved Companion Diagnostic Devices (In Vitro and Imaging Tools)” website were reviewed on November 1, 2021 for therapeutics class language. For CDx products with therapeutic class label language, the regulatory history was evaluated to determine the development approach taken to achieve the language. RESULTS/ANTICIPATED RESULTS: A total of 45 CDxs were identified, of which only 2 contained therapeutic class labeling, both of which were devices for the identification of epidermal growth factor receptor (EGFR) mutations for the treatment of non-small cell lung cancer (NSCLC). Three additional EGFR CDxs were approved; however, they did not contain therapeutic class labeling. The first CDx was the Cobas EGFR Mutation Test V2, which received therapeutic group label language as an update on October 27, 2020; however, prior to the therapeutic class labeling, three oncology products were named in the Intended Use: Tarceva (erlotinib), Tagrisso (osimertinib), and Iressa (gefitinib). The second CDx to incorporate therapeutic class labeling was the ONCO/Reveal Diagnostic Lung and Colon Cancer Assay upon initial approval on July 30, 2021. DISCUSSION/SIGNIFICANCE: EGFR CDxs are the first to shift towards therapeutic class labeling. Indication, molecular alterations, and mechanism of action of the approved therapeutic class products, number of products approved, as well as CDx analytical and clinical validation influence class label relevance. Discussions with the FDA are encouraged early in development.

There is a paucity of data on apixaban levels among octogenarians with non-valvular atrial fibrillation (NVAF). We aimed to compare apixaban levels between octogenarians (with and without dose reduction) and younger patients, to assess the frequency of high and above-range drug levels. A cross-sectional, prospective study of 80 patients treated with apixaban for NVAF was conducted. Apixaban levels were compared among octogenarians treated with 5 mg twice daily (bid), octogenarians with appropriately reduced dose (2.5 mg bid), octogenarians with inappropriately reduced dose and younger patients (age

Photographs taken by Gertrude Bell during her 1909 and 1911 archaeological trips to Mesopotamia provide not only a valuable record of sites, monuments, and landscapes that have suffered near or complete destruction over the past one hundred years, they also provide insight into the mindset, aims, and agendas Bell held when she produced these images. Her photographs taken at two sites in particular, Assur and Ukhaidir, highlight some of her attitudes and motivations at the time. On the one hand, in the case of Assur, the photos reflect her admiration for her European archaeological colleagues' skill at excavation and concede their claim to the ancient city's glorious past. On the other hand, the photographs highlight her efforts to showcase her own archaeological knowledge. Many also reflect a sympathetic stance towards the people of modern Mesopotamia, acknowledging their vital presence and often regarding them as the inheritors of the country's rich ancient legacy.

Objectives Influenza is associated with significant morbidity and mortality, especially in older and immunocompromised patients. Few data are available on the clinical benefit of high dose trivalent influenza vaccine (TIV). We aimed to assess the clinical efficacy and safety of high dose TIV. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), evaluating high dose versus standard dose TIV for prevention of seasonal influenza in adult population. Primary outcome was laboratory-confirmed influenza. Subgroups analyses included older adults and immunocompromised patients. Results We included 16 trials, 47,857 patients; 10 included older adults and three immunocompromised patients. Laboratory confirmed influenza was significantly reduced with high dose TIV (relative risk 0.76, 95% confidence interval 0.64 to 0.9). This outcome stemmed mainly from one trial in older adults. Specifically, A(H3N2) laboratory confirmed influenza, but not A(H1N1) or B lineages, was reduced. No difference in mortality or hospitalizations was demonstrated. Immunological response was significantly higher with high dose vaccine. Serious adverse events were significantly less common in the high dose group. Conclusions High dose TIV lowers the rates of laboratory confirmed influenza, mainly A (H3N2), in older adults vs. standard dose. Further studies should address immunocompromised patients and report clinical outcomes.

Objective: Older patients with cancer value functional outcomes as much as survival, but surgical studies lack functional recovery (FR) data. The value of a standardized frailty assessment has been confirmed, yet it's infrequently utilized due to time restrictions into everyday practice. The multicenter GOSAFE study was designed to (1) evaluate the trajectory of patients' quality of life (QoL) after cancer surgery (2) assess baseline frailty indicators in unselected patients (3) clarify the most relevant tools in predicting FR and clinical outcomes. This is a report of the study design and baseline patient evaluations. Materials & Methods: GOSAFE prospectively collected a baseline multidimensional evaluation before major elective surgery in patients (≥70 years) from 26 international units. Short−/mid−/long-term surgical outcomes were recorded with QoL and FR data. Results: 1003 patients were enrolled in a 26-month span. Complete baseline data were available for 977(97.4%). Median age was 78 years (range 70–94); 52.8% males. 968(99%) lived at home, 51.6% without caregiver. 54.4% had ≥ 3 medications, 5.9% none. Patients were dependent (ADL < 5) in 7.9% of the cases. Frailty was either detected by G8 ≤ 14(68.4%), fTRST ≥ 2(37.4%), TUG > 20 s (5.2%) or ASAIII-IV (48.8%). Major comorbidities (CACI > 6) were detected in 36%; 20.9% of patients had cognitive impairment according to Mini-Cog. Conclusion: The GOSAFE showed that frailty is frequent in older patients undergoing cancer surgery. QoL and FR, for the first time, are going to be primary outcomes of a real-life observational study. The crucial role of frailty assessment is going to be addressed in the ability to predict postoperative outcomes and to correlate with QoL and FR.

ObjectiveData describing outcomes after implantable cardioverter-defibrillator (ICD) unit generator replacement in patients with heart failure (HF) with primary prevention devices are limited.MethodData on patients with HF who underwent primary prevention ICD/cardiac resynchronisation therapy-defibrillator (CRT-D) implantation from 2007 until mid-2015 who subsequently received unit generator replacement were analysed. Outcomes assessed were mortality, appropriate ICD therapy and shock, and procedural complications.Results61 of 385 patients with HF with primary prevention ICD/CRT-D undergoing unit generator replacement were identified. Follow-up period was 1.8±1.5 years after replacement. 43 (70.5%) patients had not received prior appropriate ICD therapy prior to unit replacement. The cumulative risks of appropriate ICD therapy at 1, 3 and 5 years after unit replacement in those without prior ICD therapy were 0%, 6.2% and 50% compared with 6.2%, 59.8% and 86.6%, respectively (p=0.005) in those with prior ICD therapies. No predictive factors associated with appropriate ICD therapy after replacement could be identified. 41 (32.8%) patients no longer met guideline indications at the time of unit replacement but risks of subsequent appropriate ICD interventions were not different compared with those who continued to meet primary prevention ICD indications.The 5-year mortality risk after unit replacement was 18.4% and there were high procedural complication rates (9.8%).ConclusionNo predictive marker successfully stratified patients no longer needing ICD support prospectively. Finding such a marker is important in decision-making about device replacement particularly given the concerns about the complication rates. These factors should be considered at the time of ICD unit replacement.

Anemia has been reported to be associated with diabetes, but the association between new-onset diabetes after transplantation (NODAT) and anemia has not been reported.Patients who underwent kidney transplantation and did not have diabetes prior to transplantation were included in this study. Hemoglobin levels and the prevalence of anemia (hemoglobin12 g/dL in females and13 g/dL in males) were evaluated at three time points (prior to transplantation, 6 months following transplantation or 1 month before the development of NODAT, 2 years following transplantation, or following the development of NODAT) and were compared between those who developed NODAT and those who did not. Variables associated with the development of anemia were compared between the two groups.A total of 266 kidney transplant recipients were included, of which 71 (27%) developed NODAT during the time of the follow-up. Hemoglobin and hematocrit levels and the prevalence of anemia were similar in those with and without NODAT at all three time points evaluated. Ferritin levels, prior to transplantation and mean corpuscular volume (MCV) posttransplantation post-NODAT development, were slightly but significantly lower in those with NODAT, although both were within the normal range.Pretransplantation ferritin levels and posttransplantation post-NODAT development MCV are inversely associated with the development of NODAT in kidney transplants.

Background Implantable cardioverter‐defibrillator (ICD) therapy is indicated for selected heart failure patients for the primary prevention of sudden cardiac death. Little is known about the outcomes in patients selected for primary prevention device therapy in the northern region of New Zealand. Method Heart failure patients with systolic dysfunction who underwent primary prevention ICD/cardiac resynchronization therapy‐defibrillator (CRT‐D) implantation between January 1, 2007, and June 1, 2015, were included. Complications, mortality, and hospitalization events were reviewed. Results Three hundred and eighty‐five primary prevention devices were implanted (269 ICD, 116 CRT‐D). Mean age at implant was 59.1 ± 11.4 years. Mean duration of follow‐up was 3.64 ± 2.17 years. The commonest cause of death was heart failure (41.8%). Only 2 patients died from sudden arrhythmic death. The 5‐year heart failure mortality rate was 6%, whereas the 5‐year sudden arrhythmic death rate was 0.3%. Heart failure hospitalizations were commoner in those who received ICD than CRT‐D (67.7% vs 25.8%, P < .001). Maori patients have low implant rates (14%) with relatively high rates of admissions with heart failure and ventricular arrhythmia admissions, Conclusions Even in appropriately selected heart failure patients who received primary prevention devices, only a small percentage died as a result of sudden arrhythmic death. CRT‐D should be the device of choice where appropriate in heart failure patients. Significant challenges remain to improve access to device therapy and maximize benefit to those who do get implanted.

During Bell’s first journeys into Mesopotamia, undertaken in 1909 and 1911, she had occasion to visit the ancient sites of Babylon and Assur when they were being excavated by teams of German archaeologists. This chapter discusses in particular Bell’s visit to the ruins of the Assyrian capital of Assur, and her interactions with the site’s German director, Walter Andrae. Bell greatly admired Andrae’s excavation methods, given his attention to stratigraphy, his focus on both elite and non-elite urban contexts and his comprehensive system of architectural recording. She also valued their scholarly exchanges, which included discussions of the development of architectural forms such as the vault and the Parthian iwān. In all, Andrae had a profound effect on Bell’s archaeological scholarship, especially influencing her understanding of later Islamic architectural features such as those exhibited at the castle of Ukhaidir, and her admiration for Andrae would continue up to the end of her life.

OBJECTIVES: Walking is older adults’ second most preferred mode of transport and preferred recreational activity. This leads to greater exposure to traffic, increasing their risk of pedestrian-vehicle crashes, with older adults being more likely to die as a pedestrian when compared to other modes of transport. However, less focus has been placed on this particularly vulnerable group. This review summarises issues associated with older adult pedestrian and motorised mobility scooters (MMS) safety and interventions that have been conducted. METHODS: A literature search was undertaken from Pub Med, MUARC publications, Curtin University Library Catalogue and Google Scholar. Keywords included older pedestrians, older adult road injury, mobility scooter injury, and injury prevention. Publications from 2000 onwards were used, unless an earlier publication had significant relevance and worth. CONCLUSION: Maintaining older adults’ mobility and independence during a time of decreasing physical and mental capacity is a priority. Walking provides a key mode of transport that needs to be given higher priority within the road environment by policy makers, transport planners and drivers. Therefore governments need to consider appropriate and comprehensive urban planning and road safety policies that accommodate ‘active ageing’ to provide pedestrians and MMS users with environments that facilitate active living and safe transport. In addition there is a need for community programs that raise awareness about safe road crossing for this growing vulnerable age group.

Purpose The purpose of this study was to assess the maximal dose area product (DAP) of radiation received by women during hip arthroscopy; we used computer modeling to determine the theoretical risk to a fetus. Methods We studied 116 female patients of childbearing age who underwent hip arthroscopy. We retrospectively collected data from the procedure, hip pathologic process, and dose of irradiation in milligray. We calculated the theoretical dose of radiation to the fetus and the risk of childhood hereditary disease and cancer. Results Labral tear (52%) was the most common indication for hip arthroscopy, with labral resection the most common procedure undertaken. The maximal DAP to the patient was 9.52 mGy, and the maximal DAP was estimated to be 2.99 mGy to the fetus. The risk of hereditary disease and childhood cancer for the fetus was calculated to be 1 in 14,000 and 1 in 11,000, respectively. Conclusions Fluoroscopy used in hip arthroscopy generates a maximal theoretical dose of 2.99 mGy to the fetus, which places the procedure in the low-risk category. Level of Evidence Level IV, therapeutic case series.

Letters sent from the German scholar Ernst Herzfeld to Gertrude Bell between 1909 and 1912 provide valuable information about the scholarship of these remarkable characters as they explored issues pertaining to the development of early Islamic art and architecture in Mesopotamia. Through a spirited and often fractious exchange of ideas about a range of artistic and architectural topics that included vaulting techniques, the design of early mosques and palace forms, one can track the impact each had upon the other's scholarship, and the degree to which their respective views shaped one another's conclusions about important Islamic period sites such as Samarra and Ukhaidir.

Prophylaxis for hospitalized venous-thromboembolic events (VTEs) is frequently underutilized, in part due to lack of a simple risk assessment model (RAM).To compare patient selection and administration of VTE prophylaxis according to the American College of Chest Physicians (ACCP) 2008 guidelines versus the newer 2012 guidelines, and assess the feasibility of developing simpler local RAMs.We conducted a prospective assessment of VTE risk among 300 unselected consecutive patients admitted to a medical hospital ward, using the 2008 and 2012 ACCP guidelines. The frequency and relative weight of each risk factor in the 2012 ACCP guidelines were used to develop a local VTE RAM.VTE prophylaxis was indicated by the 2008 and 2012 ACCP guidelines in 40% and 42% of the cohort respectively, and was administered in 28% and 26% of eligible patients, respectively. Contraindication to VTE prophylaxis was found in 29% of patients according to both guidelines. In comparison to the 2008 guidelines, sensitivity and specificity of the 2012 guidelines were 96% and 88%, respectively. A local RAM based on the following concise score, comprising age, malignancy and immobility, correctly identified 99% of at-risk patients based on the 2012 guidelines, with a sensitivity and specificity of 98% and 95%, respectively.Both guidelines performed to a similar degree and were poorly implemented in daily practice. A simplified RAM accurately identified the vast majority of these eligible patients. The development of local RAMs is feasible and may result in higher utilization rates.

Gilles de la Tourette syndrome is a complex neuropsychiatric disorder with a strong genetic basis. We identified a male patient with Tourette syndrome-like tics and an apparently balanced de novo translocation [46,XY,t(2;7)(p24.2;q31)]. Further analysis using array comparative genomic hybridisation (CGH) revealed a cryptic deletion at 7q31.1-7q31.2. Breakpoints disrupting this region have been reported in one isolated and one familial case of Tourette syndrome. In our case, IMMP2L, a gene coding for a human homologue of the yeast inner mitochondrial membrane peptidase subunit 2, was disrupted by the breakpoint on 7q31.1, with deletion of exons 1-3 of the gene. The IMMP2L gene has previously been proposed as a candidate gene for Tourette syndrome, and our case provides further evidence of its possible role in the pathogenesis. The deleted region (7q31.1-7q31.2) of 7.2 Mb of genomic DNA also encompasses numerous genes, including FOXP2, associated with verbal dyspraxia, and the CFTR gene.

Adenovirus (Ad) is an efficient and safe vector for CNS gene delivery since it infects non-replicating neurons and does not cause insertional mutagenesis of host cell genomes. However, the promiscuous Ad CAR receptor targets cells non-specifically and activates a host immune response. Using Ad5 containing an expression cassette encoding the gene for green fluorescent protein, gfp, regulated by the neuron specific promoter synapsin-1 and the woodchuck post-transcriptional regulatory element (WPRE), we demonstrate efficient, prolonged and promoter-restricted gfp expression in neurons of mixed primary adult rat dorsal root ganglion (DRG) and retinal cell cultures. We also demonstrate restricted gfp expression in DRG neurons after direct injections of Ad5 containing the synapsin-1(gfp)/WPRE construct into L4 DRG in vivo, while Ad5 CMV(gfp) transfected both DRG glia and neurons. Moreover, since the effective titres of delivered Ad5 are reduced with this neuron specific promoter/WPRE expression cassette, the viral immune challenge should be attenuated when used in vivo.

Background The best treatment for dorsally displaced distal radius fracture is still debated. The aim of our study is to use the patient rated wrist evaluation (PRWE) and Euroqol functional outcome scores to look at patients’ function for a minimum of 1 year from the fracture. This is our pilot study to inform a multinational randomized controlled trial (RCT).

Late graft loss (LGL) and late mortality (LM) following liver transplantation (LT) in children were analyzed from the studies of pediatric liver transplantation (SPLIT) database. Univariate and multivariate associations between pre- and postoperative factors and LGL and LM in 872 patients alive with their primary allografts 1 year after LT were reviewed. Thirty-four patients subsequently died (LM) and 35 patients underwent re-LT (LGL). Patients who survive the first posttransplant year had 5-year patient and graft survival rates of 94.2% and 89.2%, respectively. Graft loss after the first year was caused by rejection in 49% of the cases with sequelae of technical complications accounting for an additional 20% of LGL. LT for tumor, steroid resistant rejection, reoperation in the first 30 days and >5 admissions during the first posttransplant year were independently associated with LGL in multivariate analysis. Malignancy, infection, multiple system organ failure and posttransplant lymphoproliferative disease accounted for 61.8% of all late deaths after LT. LT performed for FHF and tumor were associated with LM. Patients who are at or below the mean for weight at the time of transplant were also at an increased risk of dying. Frequent readmission was also found to be associated with LM.

Child sexual exploitation has been a largely hidden but significant issue for many years. Nurses need to be aware of its effects on health so they can identify children and young people affected and work with colleagues from other disciplines and agencies to provide treatment and care.

Damage to neonatal and adult tissues always incites an influx of inflammatory neutrophils and macrophages. Besides clearing the wound of invading microbes, these cells are believed to be crucial coordinators of the repair process, acting both as professional phagocytes to clear wound debris and as a major source of wound growth factor signals. Here we report wound healing studies in the PU.1 null mouse, which is genetically incapable of raising the standard inflammatory response because it lacks macrophages and functioning neutrophils. Contrary to dogma, we show that these “macrophageless” mice are able to repair skin wounds with similar time course to wild-type siblings, and that repair appears scar-free as in the embryo, which also heals wounds without raising an inflammatory response. The growth factor and cytokine profile at the wound site is changed, cell death is reduced, and dying cells are instead engulfed by stand-in phagocytic fibroblasts. We also show that hyperinnervation of the wound site, previously believed to be a consequence of inflammation, is present in the PU.1 null wound, too.