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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.

Background Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL. Methods GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale. Results Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P Conclusions GOSAFE shows that older adults’ preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients’ expectations.

Manufacturing has been the key factor limiting rollout of vaccination during the COVID‐19 pandemic, requiring rapid development and large‐scale implementation of novel manufacturing technologies. ChAdOx1 nCoV‐19 (AZD1222, Vaxzevria) is an efficacious vaccine against SARS‐CoV‐2, based upon an adenovirus vector. We describe the development of a process for the production of this vaccine and others based upon the same platform, including novel features to facilitate very large‐scale production. We discuss the process economics and the “distributed manufacturing” approach we have taken to provide the vaccine at globally‐relevant scale and with international security of supply. Together, these approaches have enabled the largest viral vector manufacturing campaign to date, providing a substantial proportion of global COVID‐19 vaccine supply at low cost., Well over a billion doses of the ChAdOx1 nCoV‐19 vaccine developed by The University of Oxford and AstraZeneca have been produced and distributed at low cost. This represents a substantial proportion of global COVID‐19 vaccine supply to date, especially in low‐ and middle‐income countries. The authors report on the development of the manufacturing process for the vaccine, and the process economics and distributed manufacturing approach involving bulk vaccine (drug substance) production on five continents.

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

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.