BACKGROUND: Pneumococcal disease is a leading cause of morbidity and mortality worldwide, with older adults aged 65 and above at particularly high risk for invasive pneumococcal infections. In Canada, pneumococcal vaccination has been recommended for this age group since 1989, yet coverage remains below national targets. Currently, only about 55% of older adults report being vaccinated, falling short of the 80% target. This study assessed knowledge, attitudes, willingness, and barriers to pneumococcal vaccination among unvaccinated older adults. METHODS: We used baseline data from a randomized controlled trial conducted as a cross-sectional survey among community-dwelling adults aged 65 years and older, residing in any of the ten Canadian provinces, and who self-identified as unvaccinated against pneumococcal disease. The survey was administered online using a tailored web-based electronic data capture system. Data were collected between June 20, 2024, and December 12, 2024, capturing data on participants’ knowledge, attitudes, and willingness to receive the vaccine, along with perceived barriers. Ordinal logistic regression was used to identify factors associated with willingness to be vaccinated, categorized as “willing”, “not willing”, and “I don’t know”. RESULTS: A total of 720 participants completed the baseline survey. Ninety percent of the respondents had moderate to good knowledge, and 47% reported positive attitudes toward the vaccine. 59% of respondents reported willingness to be vaccinated, 20% were unwilling, and 21% were unsure. We also found that positive attitudes were the strongest predictor of willingness to be vaccinated (aOR 14.8, 95% CI: 9.2-23.9), followed by good knowledge of pneumococcal vaccines and pneumococcal disease (aOR 2.6, 95% CI: 1.4-5.0). Regional differences emerged, with significantly higher willingness among those residing in the Prairies versus Ontario. Commonly reported barriers included affordability concerns and lack of awareness about where to get vaccinated. CONCLUSION: Our findings underscore the need to address attitudes alongside knowledge in public health efforts to improve pneumococcal vaccine uptake among older adults. Tailored interventions that reduce logistical and informational barriers may help close the coverage gap and support national immunization goals.

Background and Purpose: Vasospasm is an important complication of subarachnoid hemorrhage (SAH) resulting in significant morbidity and mortality. Risk stratification attempts designed to identify patients most at risk of developing vasospasm have not led to significant practice changes. We sought to validate a prognostic utility criterion to identify patients at lowest risk of vasospasm. Methods: We conducted a single-centre retrospective observational study using transcranial doppler (TCD) readings of patients with SAH from 2018 to 2024. Through chart review, we extracted patient’s mean blood flow velocities in the bilateral middle cerebral artery (MCAs) throughout their admission. We defined patients at low-risk of vasospasm as: MCA velocities on TCD had to remain below 120 cm/s and velocities had to have peaked and started to decrease by the 7th day post SAH. Our primary outcome was to analyze the predictive ability of our low-risk criteria to identify patients less at risk of developing vasospasm, defined as the presence of moderate to severe vasospasm (mean velocity in the middle cerebral artery exceeding 160 cm/s). Results: We collected data on 210 consecutive patients, of whom 196 met inclusion criteria; 107 (55%) met our low-risk criteria. Only 3 (2.8%) patients meeting our low-risk criteria developed vasospasm (p < 0.001), while 46 (52%) patients not meeting our low-risk criteria developed vasospasms (RR 18.4). The Positive Predictive Value (PPV) for not developing vasospasm in our low-risk group was 97.2% (95% CI: 92.0% − 99.4%). Conclusion: Our low-risk criteria based on TCD patterns in the first 7 days since SAH can identify a cohort of patients at very low risk of moderate to severe vasospasm. Our low-risk criteria for vasospasm could be used in future prospective studies to evaluate the safety of early discharge from the intensive care unit.

Background: Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of vascular-related mortality. While VTE prophylaxis (VTEp) is well established in acute care settings, its value in postacute care units, such as transitional care units (TCUs) at our institution, remains unclear. Objectives: This study therefore aimed to characterize current VTEp use in TCUs at a tertiary care hospital and to evaluate associated thrombotic and hemorrhagic outcomes. Methods: We conducted a retrospective electronic health record review of patients admitted to TCUs at The Ottawa Hospital between March 1, 2021, and March 1, 2022. Patients on therapeutic anticoagulation for indications other than VTEp or with repeat TCU admissions were excluded. Data were collected with standardized forms and analyzed descriptively; logistic regression was used to explore associations between VTEp and thrombotic or hemorrhagic complications. Results: Among 1218 patients (mean age, 76 years; 56% female), 72% received VTEp during their TCU stay—primarily enoxaparin (85%) or unfractionated heparin (12%); 75% of these patients remained on prophylaxis for their entire TCU admission. VTEp recipients more often had recent surgery or active cancer, whereas patients in the non-VTEp group more commonly had dementia or previous gastrointestinal bleeding. The overall PE incidence and DVT incidence within 90 days were low (0.8% and 0.9%, respectively) and similar between the groups. Hemorrhagic complications, intracranial hemorrhage (0.4%), and gastrointestinal bleeding (0.9%) were likewise infrequent and comparable. Adjusted odds ratios for these outcomes included 1.0 with wide CIs. Conclusion: VTEp was used frequently and was usually continued for the full TCU stay. The number of VTE and bleeding events were low, limiting the ability to determine the optimal risk-benefit balance of VTEp use in this population.

To assess the durability of SARS-CoV-2-specific immunity following three doses of COVID-19 vaccine in children with inborn errors of immunity (IEI). In this multi-center observational study, we compared SARS-CoV-2 specific humoral and T-cell immunity 24 weeks after the third dose of monovalent mRNA COVID-19 vaccine in children (5–18 years) with IEI and healthy controls (HC). Participants with IEI were categorized into predominant antibody deficiency (PAD) or non-PAD subgroups. Forty-three children with IEI (26 with PAD and 17 with non-PAD; 16 females, mean age 10.5 ± 4 years) and 12 HC (7 females, mean age 14.1 ± 3 years) were included. Anti-RBD IgG and anti-S IgG seropositivity was 100

BACKGROUND:Method comparison studies are conducted to examine the level of agreement between two instruments measuring physiological continuous parameters. The inclusion of repeated measurements in such studies poses additional challenges. The Bland & Altman limits of agreement (LOA) approach has been adapted to account for the correlation between repeated measurements and is widely used in method comparison studies. Alternate statistical methods are not always appropriate for the analysis of such data, and there is a paucity of evidence and guidelines pertaining to statistical methods that inform the analysis of method comparison studies that include repeated measurements. This scoping review aimed to identify methodological publications that propose statistical methods to inform the analysis of method comparison studies that include repeated measurements of continuous clinical data and that may be compared with the LOA method. METHODS:Six online databases were searched from inception to November 2022 using a peer-reviewed search strategy. Searching of grey literature and books, as well as backward citation searching were performed to identify additional sources of evidence. Screening and data abstraction were done by two independent reviewers. Results were synthesized narratively. RESULTS:Twenty-nine publications were included in this review. Thirty-two independent statistical methods were identified from the included publications, including variants of the LOA method. Four included publications compared findings from different versions of the LOA method. Four different approaches to handling repeated measurements in the context of method comparison studies were identified and were used to group findings from the included publications. Reported strengths and limitations of the LOA method were summarized. CONCLUSION:This scoping review provides a synthesis of existing statistical approaches to inform the analysis of method comparison studies with repeated measurements of clinical data, as well as how the various statistical methods perform when compared with various version of the LOA method. Based on the findings, it is generally advisable to consider using adjusted LOAs or modified mixed-effect LOAs in analyzing method comparison studies with repeated measurements. TRIAL REGISTRATION:The protocol was registered on Open Science Framework ( https://osf.io/4p8ut ).

BACKGROUND:Whether a hospital policy of tranexamic acid administration for patients undergoing major noncardiac surgery safely reduces the need for red-cell transfusion is uncertain. METHODS:We conducted a multicenter, double-blind, cluster-randomized, placebo-controlled trial involving patients undergoing noncardiac surgery who were at high risk for red-cell transfusion. Hospitals were randomly assigned at 4-week intervals to a hospital-wide policy of intraoperative tranexamic acid or placebo. The coprimary effectiveness and safety outcomes were transfusion of red cells during the index hospitalization and diagnosis of venous thromboembolism within 90 days, respectively. The safety outcome was assessed for noninferiority, with a prespecified noninferiority margin defined as an upper boundary of 1.46 for the 95% confidence interval of the relative risk. Analyses used mixed-effects models that accounted for the cluster-crossover design. RESULTS:A total of 8273 patients enrolled across 10 Canadian hospitals could be evaluated for the coprimary outcomes. Oncologic surgery accounted for 60.5% of the surgical procedures (5002 of 8273). The percentage of patients who received a red-cell transfusion during hospitalization was 7.4% (306 of 4156) in the tranexamic acid group and 9.8% (403 of 4117) in the placebo group (relative risk, 0.73; 95% confidence interval [CI], 0.61 to 0.86; adjusted difference, -2.7 percentage points; 95% CI, -4.2 to -1.4). Venous thromboembolism within 90 days occurred in 2.1% of patients (86 of 4128) in the tranexamic acid group and 2.1% of patients (85 of 4052) in the placebo group (relative risk, 0.96; 95% CI, 0.65 to 1.38; adjusted difference, -0.1 percentage points; 95% CI, -0.9 to 0.7), which met the criterion for noninferiority. CONCLUSIONS:Among patients undergoing major noncardiac surgery, a hospital policy of tranexamic acid administration resulted in a lower incidence of red-cell transfusion than placebo administration, and tranexamic acid was noninferior to placebo with regard to diagnosis of venous thromboembolism. (Funded by the Canadian Institutes of Health Research and others; TRACTION ClinicalTrials.gov number, NCT04803747.).

KEY POINTS:This prospective study of 976 adults measured the association between subclinical primary aldosteronism and kidney outcomes. Among a general healthy adult population, subclinical primary aldosteronism was associated with steeper decline in eGFR over time. Primary aldosteronism pathophysiology spans a wide unrecognized continuum that parallels the risk for kidney disease. BACKGROUND:Primary aldosteronism, an overt form of renin-independent aldosterone production, leads to steeper eGFR decline compared with primary hypertension. Mounting evidence suggests that milder forms of renin-independent aldosterone production (subclinical primary aldosteronism) are highly prevalent; however, the link between subclinical primary aldosteronism and eGFR decline remains unknown. METHODS:This prospective cohort study included 976 Canadian adults aged 40-69 years, with predominantly normal BP or mild untreated hypertension, from the randomly sampled, population-based CARTaGENE cohort. Aldosterone and renin concentrations were measured at enrollment (2009-2010). Creatinine and cystatin C were measured at enrollment and 5-7 years postenrollment. Multivariable linear mixed regression models were used to measure the associations of aldosterone, renin, and the aldosterone-to-renin ratio (ARR) with eGFR decline over time. RESULTS:The mean (SD) age of participants was 53 (7) years; 51% were female. Mean BP was 121 (15)/72 (10) mm Hg, and 11% had BP ≥140/90 mm Hg. Mean eGFR CrCysC was 109 (16) ml/min per 1.73 m 2 . At higher ARR levels, there was steeper mean eGFR decline over time (Tertile 1 [ARR, ≤0.49 ng/dl per mU/L]: -1.40 [1.77] ml/min per 1.73 m 2 /yr, Tertile 2 [ARR, 0.50-0.87 ng/dl per mU/L]: -1.48 [1.75] ml/min per 1.73 m 2 /yr, Tertile 3 [ARR, >0.87 ng/dl per mU/L]: -1.57 [1.79] ml/min per 1.73 m 2 /yr; P = 0.01), representing 11% steeper decline in the highest versus lowest ARR tertile. At lower renin levels, there was steeper mean eGFR decline over time (Tertile 1 [renin, ≤9.2 mU/L]: -1.59 [1.80] ml/min per 1.73 m 2 /yr, Tertile 2 [renin, 9.3-15.9 mU/L]: -1.53 [1.77] ml/min per 1.73 m 2 /yr, Tertile 3 [renin, >15.9 mU/L]: -1.33 [1.72] ml/min per 1.73 m 2 /yr; P = 0.04), representing 16% steeper eGFR decline in the lowest versus highest renin tertile. There was no significant association between aldosterone and eGFR change over time ( P = 0.50). All aforementioned associations were independent of BP and were consistent among participants with normal BP in isolation. CONCLUSIONS:Independent of BP, elevated ARR and suppressed renin were associated with steeper eGFR decline over time. PODCAST:This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2026_04_30_ASN0000001039.mp3.

Background: Non-inferiority trials can be used for efficacy endpoints or safety endpoints, with indirect and direct comparison to placebo. A less common application of this design involves using placebo as the proposed intervention to challenge standard practices that lack evidence of efficacy. However, the methodology of using a placebo in a non-inferiority trial is poorly described in the literature. We performed a scoping review to map how placebo is utilized in randomized controlled trials with a non-inferiority design, with particular attention to studies positioning placebo as a proposed alternative to existing, but unproven, interventions. Methods: We conducted a scoping review of randomized controlled trials using non-inferiority designs with a placebo arm, searching six databases without date or language restrictions. Eligible studies were primary randomized controlled trials with at least one placebo arm evaluated under a non-inferiority hypothesis. Data extraction focused on study characteristics, design elements, rationale for non-inferiority design and margin, and analytical practices. Results: Of 6897 studies screened, 94 met inclusion criteria. Three primary study types were identified: safety (63%), deprescription (20%), and shorter-course (13%) trials. There has been increased use of deprescription and shorter-course studies since 2017. One-third (35%) hypothesized that placebo was non-inferior to active treatment, predominantly in deprescription and shorter-course trials focused on antibiotic use. Most studies (94%) applied non-inferiority analysis to primary outcomes, yet only 22% provided a rationale for non-inferiority design, and despite 96% prespecifying non-inferiority margin, only 41% justified the margin. While 71% used intention-to-treat analysis, only 53% conducted per-protocol analysis. Graphical representation of non-inferiority margins and confidence intervals was reported in 23% of studies. Conclusion: Placebo is increasingly used in non-inferiority trials aimed at evaluating the necessity of standard interventions, including safety, deprescription, and shorter-course designs. However, many trials lack critical methodological transparency. Future studies should clearly justify non-inferiority designs and margins, use both intention-to-treat and per-protocol analyses, and adhere to the Consolidated Standards of Reporting Trials reporting guidelines to enhance interpretability and rigor.

Background and Objectives: Adverse medication events significantly contribute to emergency department visits, unplanned hospitalizations, and in-hospital morbidity and mortality, particularly in older adults. Identifying potentially inappropriate prescribing is essential to improve safety, care quality, and medication management. The objective of this study was to identify and codify the Screening Tool of Older People's Prescriptions (STOPP)-Screening Tool to Alert to Right Treatment (START) and Beers criteria for large, population-level health databases to detect potentially inappropriate prescribing at the population level. Methods: A subset of the 2014 STOPP/START and 2015 Beers criteria applicable to health administrative data was codified using diagnostic (ICD; International Classification of Diseases) and medication (DIN; Drug Identification Number) codes using provincial health administrative databases in Ontario, Canada, which comprise individual-level linked information on medication dispensation, physician services use, emergency room visits, hospitalizations, mortality, and sociodemographic data. Results: Overall, 103 of 177 (58.2%) criteria were codable (76.5% of 81 STOPP, 23.5% of 34 START, and 53.2% of 62 Beers). Some criteria could not be coded because the population health data used were missing information necessary to the operationalization of these criteria. This included laboratory values (renal function) and diagnostic or clinical information (such as blood pressure, body mass index) that could not be indirectly derived from the population health data. Conclusions: Applying a large subset of codified and well-established clinical criteria to health administrative data offers a promising and potentially cost-effective approach to detect potentially inappropriate prescribing at the population level. The present study contributes the required coding which constitutes the core of this approach. (c) 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Importance:Individuals with chronic kidney disease (CKD) are disproportionately admitted to the intensive care unit (ICU); however, the association between CKD severity and outcomes after ICU admission remains uncertain. Objective:To evaluate the association between CKD severity and health outcomes after ICU admission. Design, Setting, and Participants:This population-based cohort study was conducted from November 1, 2008, to February 28, 2021. Participants included 531 090 consecutive adult (≥18 years) residents of Ontario, Canada, admitted to an ICU during the study period who had a baseline outpatient serum creatinine measurement within 7 to 365 days prior to admission. Statistical analyses were conducted from July 23, 2025, to April 16, 2026. Exposure:CKD severity was classified according to the baseline outpatient estimated glomerular filtration rate (eGFR) Kidney Disease Improving Global Outcomes criteria. Main Outcomes and Measures:Mortality (ICU, hospital, and 90-day mortality) and kidney replacement therapy (KRT) requirement in the ICU and dependence at 90 days. Results:The study included 531 090 adults (mean [SD] age, 67 [15] years; 57% men) admitted to the ICU. One in 4 individuals had preexisting CKD: stage 3a CKD, eGFR 45 to 59 mL/min/1.73 m2 (12% of adults); stage 3b CKD, eGFR 30 to 44 mL/min/1.73 m2 (7% of adults); stage 4 CKD, eGFR 15 to 29 mL/min/1.73 m2 (3% of adults); non-dialysis-dependent stage 5 CKD, eGFR less than 15 mL/min/1.73 m2 (1% of adults); and undergoing maintenance dialysis (2% of adults). Compared with individuals without CKD, the severity of the disease among individuals with CKD was progressively associated with increased mortality risk up to non-dialysis-dependent stage 5 CKD. However, the risk of mortality was lower for individuals receiving maintenance dialysis (odds ratio [OR], 1.92 [95% CI, 1.82-2.04]) compared with those with non-dialysis-dependent stage 5 CKD (OR, 2.32 [95% CI, 2.14-2.52]). Risk for KRT initiation in the ICU increased with CKD severity relative to individuals without CKD: stage 3a (adjusted OR [AOR], 1.79 [95% CI, 1.68-1.90]), stage 3b (AOR, 3.02 [95% CI, 2.83-3.22]), stage 4 (AOR, 6.71 [95% CI, 6.23-7.22]), and non-dialysis-dependent stage 5 (AOR, 32.00 [95% CI, 29.07-35.22]). Among those who initiated KRT in the ICU and survived to 90 days, KRT dependence at day 90 increased progressively by CKD stage: no CKD, 7.2%; stage 3a, 14.2%; stage 3b, 22.5%; stage 4, 50.3%; and previously non-dialysis-dependent stage 5, 83.8%. Conclusions and Relevance:In this cohort study of consecutive adults admitted to the ICU, the presence and severity of CKD were associated with adverse health outcomes. These findings can inform risk prognostication, discussions about goals of care, resource allocation, and health policy initiatives for this large portion of the ICU population.

ABSTRACT Background Effective screening for Parkinson disease (PD) is important for both symptomatic treatment and recruitment into intervention trials. We recently developed a toolkit to quantify PD risk. Here, we examined the P R EDIGT model’s diagnostic performance when deployed at home. Methods We contacted 613 subjects following outpatient clinic encounters. Between 2022-2024, 305 participants (range, 40-85 years) were recruited: 93 with typical PD; 66 had other neurological diseases (OND); 146 were neurologically healthy. Two versions of the toolkit were completed: First, an original , 69-item-long questionnaire paired with a 40-scent smell test; thereafter, a simplified , 11-item-long questionnaire and a newly developed, 8-scent smell test. P R EDIGT summary scores were calculated for each subject to examine diagnostic classifications. Area-under-the-ROC-curve, sensitivity, specificity, and likelihood ratios were used to evaluate performances and to determine clinically relevant thresholds. Results In both versions, PD patients had higher questionnaire scores and lower smell test scores than neurologically healthy controls (p<0.001); scores for OND subjects ranked at intermediate levels. The simplified questionnaire outperformed the original version in diagnostic accuracy. The abbreviated smell test performed as well as the 40-item version in identifying hyposmia. At a value of 22.94 (range 0-100) for the threshold that separates PD subjects from other participants, the simplified P R EDIGT summary score showed a sensitivity of 0.98, a specificity of 0.83, and revealed positive and negative likelihood ratios of 5.88 and 0.02, respectively. Interpretation Our study reveals that unsupervised screening for typical PD can be effectively carried out at home using an 11-item questionnaire and 8-scent smell test.

The presence and severity of acute kidney injury (AKI) upon ICU admission provides important short- and long-term prognostic information. Existing reports have been limited by inadequate baseline kidney function assessment, incomplete outcome capture, limited adjustment for illness severity, and small sample sizes. We conducted a population-level study of all adult (≥ 18 years) Ontario, Canada residents with available outpatient baseline creatinine measurements admitted to the ICU from 2009–2021. AKI at the time of ICU admission was determined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Outcomes included death and kidney replacement therapy (KRT). Multivariable logistic regression modeling was used to estimate adjusted odds ratios (aOR). The study cohort included 484,956 adults (43

Background Individuals with ulcerative colitis (UC) are frequently re-hospitalized for persistent or recurrent severe disease flares. Accurate prediction of the risk of early re-hospitalization at the time of discharge could promote targeted outpatient interventions to reduce this risk.Methods We conducted a retrospective study in adults with UC admitted to The Ottawa Hospital between 2009 and 2016 for an acute UC-related indication. We ascertained candidate demographic, clinical, and health services predictors through medical records and administrative health databases. We derived and bootstrap validated a multivariable logistic regression model of 90-day UC-related re-hospitalization risk. We chose a probability cut point that maximized Youden's index to differentiate high-risk from low-risk individuals and assessed model performance.Results Among 248 UC-related hospitalizations, there were 27 (10.9%) re-hospitalizations within 90 days of discharge. Our multivariable model identified gastroenterologist consultation within the prior year (adjusted odds ratio [aOR] 0.11, 95% confidence interval [CI], 0.04-0.39), male sex (aOR 3.27, 95% CI, 1.33-8.05), length of stay (OR 0.94, 95% CI, 0.88-1.01), and narcotic prescription at discharge (OR 1.96, 95% CI, 0.73-5.27) as significant predictors of 90-day re-hospitalization. The optimism-corrected c-statistic value was 0.78, and the goodness-of-fit test P-value was .09. The chosen probability cut point produced a sensitivity of 77.8%, specificity of 80.9%, positive predictive value (PPV) of 33.0%, and negative predictive value (NPV) of 96.7% in the derivation cohort.Conclusions A limited set of variables accessible at the point of hospital discharge can reasonably discriminate re-hospitalization risk among individuals with UC. Future studies are required to validate our findings. People with ulcerative colitis (UC), a condition that causes swelling in the colon, often need to go to the hospital because their disease is severe. After they leave the hospital, some patients have to be re-admitted quickly because their condition worsens or they have problems with their treatment. If doctors could predict which patients are most likely to be re-admitted, they could focus on giving them better care after they leave the hospital. In this study, we looked at the medical records of adults with UC who were hospitalized at The Ottawa Hospital between 2009 and 2016. We wanted to find out what factors might predict if someone would end up back in the hospital within 90 days. We used this information to create a mathematical model to predict the risk of re-admission and tested how accurate it was. We found that things like seeing a gastroenterologist in the past year, the patient's gender, how long they stayed in the hospital, and if they were prescribed narcotics at discharge all helped predict the risk of being re-admitted. Combining all these factors helped make the prediction even more accurate.

Importance:Care decisions for long-term care (LTC) residents should be frailty-informed to maximize well-being and avoid burdensome treatments that do not align with patient wishes. Objective:To investigate the incidence and time spent living with severe impairment among LTC residents to help inform person-centered decision-making. Design, Setting, and Participants:This retrospective cohort study was conducted among a population-based cohort of incident admissions to LTC facilities between April 1, 2013, and March 31, 2018, determined using administrative health data in Ontario, Canada. Ontario residents aged 65 years or older who were admitted to LTC were included. Participants were followed up until death, discharge, or April 1, 2023. Data analysis was completed from October 17, 2023, to March 31, 2024. Main Outcomes and Measures:Outcomes were states of impairment that care partners identified as meaningful and some considered worse than death. The incidence of total care dependence, inability to make any decisions, inability to communicate, and incontinence of stool or urine was described. Survival after becoming impaired, characteristics of residents when they became impaired, and characteristics of those who survived for more than 1 year with each impairment were described. Residents at risk of a specific impairment (at-risk residents) were those who did not already have the impairment at admission. Results:A total of 120 238 residents admitted to LTC (mean [SD] age, 84.3 [7.7] years; 77 868 female [64.8%]) were included. By the end of follow-up, 22 018 of 109 830 at-risk residents (20.0%) had become permanently unable to make decisions, 9138 of 118 132 at-risk residents (7.7%) had become permanently unable to communicate, 15 711 of 116 848 at-risk residents (13.4%) had developed total care dependence, and 30 449 of 92 974 at-risk residents (32.8%) had developed incontinence of stool or urine. Median (IQR) survival time was shortest for residents who entered a state of total care dependence (45 [5-310] days) and longest for those with newly developed incontinence of stool or urine (356 [79-1031] days). Younger residents (eg, median [IQR] survival after developing total care dependence, 133 (17-735) days for ages <80 years vs 30 (4-217) days for ages ≥80 years) and those with dementia at admission (eg, median [IQR] survival after developing the inability to make decisions, 318 [40-1020] days with dementia vs 74 [4-474] days without dementia) had longer median survival after entering a state of severe impairment. Conclusions and Relevance:In this study, severe permanent impairment in function and cognition were common and often present near the end of life for LTC residents, but a minority of residents lived in these states for years. These results suggest that building shared understanding and open communication about the natural course of frailty trajectories for LTC residents may support resident-centered medical decision-making.

To develop a simplified smell test for identifying patients with Parkinson’s disease (PD), we reevaluated the Sniffin’-Sticks-Identification-Test (SST-ID) and University-of-Pennsylvania-Smell-Identification-Test (UPSIT), using three case-control studies. These included 301 patients with PD or dementia with Lewy bodies (DLB), 68 subjects with multiple-system atrophy (MSA) or progressive supranuclear palsy (PSP), and 281 healthy controls (HC). Scents were ranked by area-under-the-curve values for group classification and results leveraged by 8 published studies with 5853 individuals. PD/DLB patients showed markedly worse olfaction than controls, whereas scores for MSA/PSP subjects were intermediate. We identified and validated a subset of 7 shared odorants that performed similarly to the traditional 16-scent SST-ID and 40-scent UPSIT tests in distinguishing PD/DLB from HC. There, the identification of 4 or fewer scents out of 7 served as an effective cut-off between the two groups. We also identified a critical role for distractors (from correct answers) and age on olfaction performance.

PURPOSE:This systematic review evaluated the efficacy of postoperative rehabilitation for patients at risk of poorer outcomes after total knee arthroplasty. METHODS:Six databases were searched, and only randomised controlled trials were included. Two reviewers independently screened, extracted data, and appraised the quality of the studies. RESULTS:Twenty-three studies were included. Insufficient evidence supports cognitive behavioural therapy for patients with kinesiophobia, while continuous passive motion may not be effective for range of motion deficits. The impact of exercise therapy on functional recovery is conflicting; however, longer durations tend to be more effective for older patients and those with functional limitations. Limited evidence suggests that exercise may not alleviate pain. Outpatient exercise therapy improves health-related quality of life more than home-based programs for older patients and those with functional limitations. The efficacy of other rehabilitation aspects remains inconclusive due to high heterogeneity in interventions and outcome measures, and high or unclear risk of bias in most studies. CONCLUSION:While limited evidence suggests benefits for specific rehabilitation interventions, there is insufficient data to assess the efficacy of most interventions on postoperative recovery in those at risk of poorer outcomes. More robust evidence is needed to guide clinical practice and standardise outcome measures. TRAIL REGISTRATION:PROSPERO CRD42022355574.

Background: Point-of-care testing devices to measure haemoglobin (Hgb) frequently inform transfusion decision-making in surgery. This study aimed to examine their accuracy in surgery, focusing on Hgb concentrations of 60-100 g L-1, a range with higher potential for transfusion. Methods: This was a prospective diagnostic cohort study focused on method comparison, conducted at two academic hospitals. Consecutive patients undergoing noncardiac surgery and requiring point-of-care Hgb measurements were eligible. Hgb concentrations from arterial and central venous blood samples were measured concurrently using three devices and compared with laboratory Hgb. The primary outcome was individual pairwise comparisons between point- of-care and laboratory Hgb values; agreement was determined based on a threshold of within 4 g L-1. The primary analysis consisted of computing limits of agreement. Results: A total of 1735 intraoperative blood samples were collected (1139 participants); 680 samples had a laboratory Hgb <100 g L-1. The limits of agreement among those with Hgb <100 g L-1 were-9.5 to 8.0 g L-1 for HemoCue (R),-16.2 to 11.5 g L-1 for i-STAT (R), and-14.7 to 40.5 g L-1 for Rad-67 (R). HemoCue was associated with a 5.8% incidence of potentially clinically significant transfusion error, whereas i-STAT and Rad-67 were associated with 25.3% and 28.2%, respectively. HemoCue yielded Hgb measurements within 10 g L-1 in 98% of intraoperative blood samples. Conclusions: No point-of-care Hgb device demonstrated limits of agreement that were smaller than the agreement difference of 4 g L-1. Despite this, HemoCue can be safely used to inform transfusion decisions in surgery, given its error probability of <4% in transfusion scenarios.

Background: There is a paucity of real-world data on the treatments naturopathic doctors (NDs) use for supportive cancer care. We conducted an observational cohort study to comprehensively describe the treatments NDs with experience in cancer care recommend to their patients. Methods: Patients with advanced breast, colorectal, ovarian, or pancreatic cancer were recruited from 12 North American naturopathic clinics and followed for 2 to 3 years. Therapeutic recommendations were abstracted from clinic records. Results: 384 participants (154 breast, 112 colorectal, 71 ovarian, 47 pancreatic) were included in the analyses. The median number of ND visits was 5. The most common types of recommendations were natural health products (NHPs, 99% of participants), nutrition guidance (88%), and parenteral therapies (81%). Mental health (33%) and Traditional Chinese Medicine (29%) were least common. Participants were recommended a median of 11 NHPs throughout the study, with 430 unique products recommended across all participants. Nutrition guidance heavily favoured encouraging foods rather than discouraging them (83% vs. 17% of all dietary recommendations, respectively). Vitamin D, curcumin, intravenous vitamin C, increasing protein intake, and exercise were recommended to at least 50% of participants across each cancer type. Other common recommendations included melatonin, fish oil, Trametes versicolor, subcutaneous mistletoe, increasing vegetable intake, and eating behaviour changes. Recommendations were fairly uniform between cancer types, with the most variation seen in NHPs. Conclusion: NDs frequently recommend NHPs, nutrition guidance, and parenteral therapies for people with advanced cancer. The diversity of unique recommendations suggests individualized care, yet some commonly used treatments demonstrate a degree of consistency.