Commentary on the EMA reflection paper on the pharmaceutical development of medicines for use in the older population.

Older people are often affected by impaired organ and bodily functions resulting in multimorbidity and polypharmacy, turning them into the main user group of many medicines. Very often, medicines have not specifically been developed for older people, causing practical medication problems for them like limited availability of easy to swallow formulations, easy to open packaging and dosing instructions for enteral administration. In 2020, the European Medicines Agency (EMA) published a reflection paper 'Pharmaceutical development of medicines for use in the older population', which discusses how the emerging needs of an ageing European population can be addressed by medicines regulation. The paper intends to help industry to better consider the needs of older people during pharmaceutical/clinical medicines development by summarising data on the most relevant topics, providing early suggestions on how to move forward and prompting expert discussions and studies into knowledge gaps. Topics include patient acceptability, (dis)advantages of an administration route, formulation, dosage form, packaging, dosing device and user instruction. While the paper is directed at older people and the pharmaceutical industry, the reflections are also relevant to younger patients with similar disease-related needs and of value to other stakeholders parties, e.g., healthcare professionals, academics, patients and caregivers, as the paper makes clear what can be expected from industry and where collaborative work is needed. This commentary provides an overview of the different steps in the development of the reflection paper, discusses points considered most controversial and/or subject to (multidisciplinary) expert discussions and indicates their value for real world clinical practice.

Ionization Energy of the Metastable 2

In a recent breakthrough in first-principles calculations of two-electron systems, Patkós, Yerokhin, and Pachucki [Phys. Rev. A 103, 042809 (2021)PLRAAN2469-992610.1103/PhysRevA.103.042809] have performed the first complete calculation of the Lamb shift of the helium 2 ^{3}S_{1} and 2 ^{3}P_{J} triplet states up to the term in α^{7}m. Whereas their theoretical result of the frequency of the 2 ^{3}P←2 ^{3}S transition perfectly agrees with the experimental value, a more than 10σ discrepancy was identified for the 3 ^{3}D←2 ^{3}S and 3 ^{3}D←2 ^{3}P transitions, which hinders the determination of the He^{2+} charge radius from atomic spectroscopy. We present here a new measurement of the ionization energy of the 2 ^{1}S_{0} state of He [960 332 040.491(32) MHz] which we use in combination with the 2 ^{3}S_{1}←2 ^{1}S_{0} interval measured by Rengelink et al. [Nat. Phys. 14, 1132 (2018).NPAHAX1745-247310.1038/s41567-018-0242-5] and the 2 ^{3}P←2 ^{3}S_{1} interval measured by Zheng et al. [Phys. Rev. Lett. 119, 263002 (2017)PRLTAO0031-900710.1103/PhysRevLett.119.263002] and Cancio Pastor et al. [Phys. Rev. Lett. 92, 023001 (2004)PRLTAO0031-900710.1103/PhysRevLett.92.023001] to derive experimental ionization energies of the 2 ^{3}S_{1} state [1152 842 742.640(32) MHz] and the 2 ^{3}P centroid energy [876 106 247.025(39) MHz]. These values reveal disagreements with the α^{7}m Lamb shift prediction by 6.5σ and 10σ, respectively, and support the suggestion by Patkós et al. of an unknown theoretical contribution to the Lamb shifts of the 2 ^{3}S and 2 ^{3}P states of He.

Precision Measurements in Few-Electron Molecules: The Ionization Energy of Metastable

Molecular helium represents a benchmark system for testing ab initio calculations on few-electron molecules. We report on the determination of the adiabatic ionization energy of the a ^{3}Σ_{u}^{+} state of He_{2}, corresponding to the energy interval between the a ^{3}Σ_{u}^{+} (v^{''}=0, N^{''}=1) state of He_{2} and the X^{+} ^{2}Σ_{u}^{+} (v^{+}=0, N^{+}=1) state of He_{2}^{+}, and of the lowest rotational interval of He_{2}^{+}. These measurements rely on the excitation of metastable He_{2} molecules to high Rydberg states using frequency-comb-calibrated continuous-wave UV radiation in a counterpropagating laser-beam setup. The observed Rydberg states were extrapolated to their series limit using multichannel quantum-defect theory. The ionization energy of He_{2} (a ^{3}Σ_{u}^{+}) and the lowest rotational interval of He_{2}^{+} (X^{+} ^{2}Σ_{u}^{+}) are 34 301.207 002(23)±0.000 037_{syst} cm^{-1} and 70.937 589(23)±0.000 060_{syst} cm^{-1}, respectively.

A Unified Framework for Understanding Nucleophilicity and Protophilicity in the SN 2/E2 Competition.

The concepts of nucleophilicity and protophilicity are fundamental and ubiquitous in chemistry. A case in point is bimolecular nucleophilic substitution (SN 2) and base-induced elimination (E2). A Lewis base acting as a strong nucleophile is needed for SN 2 reactions, whereas a Lewis base acting as a strong protophile (i.e., base) is required for E2 reactions. A complicating factor is, however, the fact that a good nucleophile is often a strong protophile. Nevertheless, a sound, physical model that explains, in a transparent manner, when an electron-rich Lewis base acts as a protophile or a nucleophile, which is not just phenomenological, is currently lacking in the literature. To address this fundamental question, the potential energy surfaces of the SN 2 and E2 reactions of X- +C2 H5 Y model systems with X, Y = F, Cl, Br, I, and At, are explored by using relativistic density functional theory at ZORA-OLYP/TZ2P. These explorations have yielded a consistent overview of reactivity trends over a wide range in reactivity and pathways. Activation strain analyses of these reactions reveal the factors that determine the shape of the potential energy surfaces and hence govern the propensity of the Lewis base to act as a nucleophile or protophile. The concepts of "characteristic distortivity" and "transition state acidity" of a reaction are introduced, which have the potential to enable chemists to better understand and design reactions for synthesis.

Prescribing medicines to older people-How to consider the impact of ageing on human organ and body functions.

Ageing is associated with several changes in human organs, which result in altered medication pharmacokinetics and pharmacodynamics. Ageing is also associated with changes in human body functions, such as impaired vision, hearing, swallowing, motor and cognitive functions, which can affect the adequate intake and administration of drugs. As a consequence, older people, and especially patients older than 75 years, are the main users of many drugs and they frequently use 5 drugs or more long-term (i.e. polypharmacy). All this increases the complexity of adequate drug intake, administration and adherence. However, there is a lack of evidence on the considerations that should be taken into account to ensure appropriate drug prescribing to older people. This review article summarizes the most clinically relevant changes in human organ and body functions and the consequential changes in pharmacokinetics and pharmacodynamics in older people, along with possible dosing consequences or alternatives for drugs frequently prescribed to this patient population. Recommendations are given on how ageing could be considered in clinical drug development, drug authorization and appropriate prescribing.

Effects of Pharmacogenetic Screening for CYP2D6 Among Elderly Starting Therapy With Nortriptyline or Venlafaxine: A Pragmatic Randomized Controlled Trial (CYSCE Trial).

PURPOSE/BACKGROUND: The duration of untreated depression is a predictor for poor future prognosis, making rapid dose finding essential. Genetic variation of the CYP2D6 isoenzyme can influence the optimal dosage needed for individual patients. The aim of this study was to determine the effectiveness of CYP2D6 pharmacogenetic screening to accelerate drug dosing in older patients with depression initiating nortriptyline or venlafaxine. METHODS/PROCEDURES: In this randomized controlled trial, patients were randomly allocated to one of the study arms. In the intervention arm (DG-I), the specific genotype accompanied by a standardized dosing recommendation based on the patients' genotype and the prescribed drug was directly communicated to the physician of the participant. In both the deviating genotype control arm (DG-C) and the nonrandomized control arm, the physician of the participants was not informed about the genotype and the associated dosing advise. The primary outcome was the time needed to reach adequate drug levels: (1) blood levels within the therapeutic range and (2) no dose adjustments within the previous 3 weeks. FINDINGS/RESULTS: No significant difference was observed in mean time to reach adequate dose or time to adequate dose between DG-I and DG-C. Compared with the nonrandomized control arm group, adequate drug levels were reached significantly faster in the DG-I group (log-rank test; P = 0.004), and there was a similar nonsignificant trend for the DG-C group (log-rank test; P = 0.087). IMPLICATIONS/CONCLUSIONS: The results of this study do not support pharmacogenetic CYP2D6 screening to accelerate dose adjustment for nortriptyline and venlafaxine in older patients with depression.

International core outcome set for clinical trials of medication review in multi-morbid older patients with polypharmacy.

BACKGROUND: Comparisons of clinical trial findings in systematic reviews can be hindered by the heterogeneity of the outcomes reported. Moreover, the outcomes that matter most to patients might be underreported. A core outcome set can address these issues, as it defines a minimum set of outcomes that should be reported in all clinical trials in a particular area of research. The objective in this study was to develop a core outcome set for clinical trials of medication review in multi-morbid older patients with polypharmacy. METHODS: Firstly, eligible outcomes were identified through a systematic review of trials of medication review in older patients (≥65 years) and interviews with 15 older patients. Secondly, an international three-round Delphi survey in four countries involving patients, healthcare professionals, and experts was conducted to validate outcomes to be included in the core outcome set. Consensus meetings were conducted to validate the results. RESULTS: Of the 164 participants invited to take part in the Delphi survey, 150 completed Round 1, including 55 patients or family caregivers, 55 healthcare professionals, and 40 experts. A total of 129 participants completed all three rounds. Sixty-four eligible outcomes were extracted from 47 articles, 32 clinical trial protocols, and patient interviews. Thirty outcomes were removed and one added after Round 1, 18 outcomes were removed after Round 2, and seven after Round 3. Results were discussed during consensus meetings. Consensus was reached on seven outcomes, which constitute the core outcome set: drug-related hospital admissions; drug overuse; drug underuse; potentially inappropriate medications; clinically significant drug-drug interactions; health-related quality of life; pain relief. CONCLUSIONS: We developed a core outcome set of seven outcomes which should be used in future trials of medication review in multi-morbid older patients with polypharmacy.

Determination of the Spin-Rotation Fine Structure of He_{2}

Measuring spin-rotation intervals in molecular cations is challenging, particularly so when the ions do not have electric-dipole-allowed rovibrational transitions. We present a method, based on an angular-momentum basis transformation, to determine the spin-rotational fine structure of molecular ions from the fine structure of high Rydberg states. The method is illustrated by the determination of the so far unknown spin-rotation fine structure of the fundamentally important He_{2}^{+} ion in the X ^{2}Σ_{u}^{+} state. The fine-structure splittings of the v^{+}=0, N^{+}=1, 3, and 5 levels of He_{2}^{+} are 7.96(14), 17.91(32), and 28.0(6) MHz, respectively. The experiment relies on the use of single-mode cw radiation to record spectra of high Rydberg states of He_{2} from the a ^{3}Σ_{u}^{+} metastable state.

Fundamental vibration frequency and rotational structure of the first excited vibrational level of the molecular helium ion ( He 2 + ).

The term values of the rotational levels of the first excited vibrational state of the electronic ground state of He 2 + with a rotational quantum number N + ≤ 13 have been determined with an accuracy of 1.2 × 10-3 cm-1 (∼35 MHz) by multichannel-quantum-defect-theory-assisted Rydberg spectroscopy of metastable He2. Comparison of the experimental term values with the most accurate ab initio results for He 2 + available in the literature [W.-C. Tung, M. Pavanello, and L. Adamowicz, J. Chem. Phys. 136, 104309 (2012)] reveals inconsistencies between the theoretical and experimental results that increase with increasing rotational quantum numbers. The fundamental vibrational wavenumber of He 2 + was determined to be 1628.3832(12) cm-1 by fitting effective molecular constants to the obtained term values.

Molecular Fountain.

The resolution of any spectroscopic or interferometric experiment is ultimately limited by the total time a particle is interrogated. Here we demonstrate the first molecular fountain, a development which permits hitherto unattainably long interrogation times with molecules. In our experiments, ammonia molecules are decelerated and cooled using electric fields, launched upwards with a velocity between 1.4 and 1.9 m/s and observed as they fall back under gravity. A combination of quadrupole lenses and bunching elements is used to shape the beam such that it has a large position spread and a small velocity spread (corresponding to a transverse temperature of <10 µK and a longitudinal temperature of <1 µK) when the molecules are in free fall, while being strongly focused at the detection region. The molecules are in free fall for up to 266 ms, making it possible, in principle, to perform sub-Hz measurements in molecular systems and paving the way for stringent tests of fundamental physics theories.

Precision measurement of the rotational energy-level structure of the three-electron molecule He2.

The term values of all rotational levels of the 4He2+ X+ 2Σu+ (ν+=0) ground vibronic state with rotational quantum number N+ ≤ 19 have been determined with an accuracy of 8 × 10-4 cm-1 (∼25 MHz) by multichannel-quantum-defect-theory-assisted Rydberg spectroscopy of metastable He2∗. Comparison of these term values with term values recently calculated ab initio by Tung et al. [J. Chem. Phys. 136, 104309 (2012)] reveals discrepancies that rapidly increase with increasing rotational quantum number and reach values of 0.07 cm-1 (∼2.1 GHz) at N+ = 19.

Efficiency of Clinical Decision Support Systems Improves with Experience.

Efficiency, or the resources spent while performing a specific task, is widely regarded as one the determinants of usability. In this study, the authors hypothesize that having a group of users perform a similar task over a prolonged period of time will lead to improvements in efficiency of that task. This study was performed in the domain of decision-supported medication reviews. Data was gathered during a randomized controlled trial. Three expert teams consisting of an independent physician and an independent pharmacist conducted 150 computerized medication reviews on patients in 13 general practices located in Amsterdam, the Netherlands. Results were analyzed with a linear mixed model. A fixed effects test on the linear mixed model showed a significant difference in the time required to conduct medication reviews over time; F(31.145) = 14.043, p < .001. The average time in minutes required to conduct medication reviews up to the first quartile was M = 20.42 (SD = 9.00), while the time from the third quartile up was M = 9.81 (SD = 6.13). This leads the authors to conclude that the amount of time users needed to perform similar tasks decreased significantly as they gained experience over time.

Precision Spectroscopy in Cold Molecules: The Lowest Rotational Interval of He_{2}

Multistage Zeeman deceleration was used to generate a slow, dense beam of translationally cold He_{2} molecules in the metastable a ^{3}Σ_{u}^{+} state. Precision measurements of the Rydberg spectrum of these molecules at high values of the principal quantum number n have been carried out. The spin-rotational state selectivity of the Zeeman-deceleration process was exploited to reduce the spectral congestion, minimize residual Doppler shifts, resolve the Rydberg series around n=200 and assign their fine structure. The ionization energy of metastable He_{2} and the lowest rotational interval of the X^{+} ^{2}Σ_{u}^{+} (ν^{+}=0) ground state of ^{4}He_{2}^{+} have been determined with unprecedented precision and accuracy by Rydberg-series extrapolation. Comparison with ab initio predictions of the rotational energy level structure of ^{4}He_{2}^{+} [W.-C. Tung, M. Pavanello, and L. Adamowicz, J. Chem. Phys. 136, 104309 (2012)] enabled us to quantify the magnitude of relativistic and quantum-electrodynamics contributions to the fundamental rotational interval of He_{2}^{+}.

Implementation of the WHO-6-step method in the medical curriculum to improve pharmacology knowledge and pharmacotherapy skills.

AIM: The only validated tool for pharmacotherapy education for medical students is the 6-step method of the World Health Organization. It has proven effective in experimental studies with short term interventions. The generalizability of this effect after implementation in a contextual-rich medical curriculum was investigated. METHODS: The pharmacology knowledge and pharmacotherapy skills of cohorts of students, from years before, during and after implementation of a WHO-6-step-based integrated learning programme were tested using a standardized assessment containing 50 items covering knowledge of basic (n = 25) and clinical (n = 24) pharmacology, and pharmacotherapy skills (n = 1 open question). All scores are expressed as a percentage of the maximum score possible per (sub)domain. RESULTS: In total, 1652 students were included between September 2010 and July 2014 (participation rate 89%). The WHO-6-step-based learning programme improved students' knowledge of basic pharmacology (mean score ± SD, 60.6 ± 10.5% vs. 63.4 ± 10.9%, P < 0.01) and clinical or applied pharmacology (63.7 ± 10.4% vs. 67.4 ± 10.3%, P < 0.01), and improved their pharmacotherapy skills (68.8 ± 26.1% vs. 74.6% ± 22.9%, P 0.02). Moreover, satisfaction with education increased (5.7 ± 1.3 vs. 6.3 ± 1.0 on a 10-point scale, P < 0.01) and as did students' confidence in daily practice (from -0.81 ± 0.72 to -0.50 ± 0.79 on a -2 to +2 scale, P < 0.01). CONCLUSIONS: The WHO-6-step method was successfully implemented in a medical curriculum. In this observational study, the integrated learning programme had positive effects on students' knowledge of basic and applied pharmacology, improved their pharmacotherapy skills, and increased satisfaction with education and self-confidence in prescribing. Whether this training method leads to better patient care remains to be established.

Education on prescribing for older patients in the Netherlands: a curriculum mapping.

PURPOSE: Pharmacology and pharmacotherapy education is being increasingly integrated in medical curricula, which might lead to a specific loss of knowledge in these subjects. This, in turn, could lead to harmful prescribing errors, especially in vulnerable older patients. METHODS: Teachers who coordinated education in Dutch medical schools completed a structured interview on (geriatric) pharmacology and pharmacotherapy education. A list of core learning goals was developed. Pharmacology and pharmacotherapy education in general was compared to geriatric pharmacology and pharmacotherapy education. RESULTS: All Dutch medical schools participated. Contact hours for education in pharmacology and pharmacotherapy ranged from 39 to 107 h; ECTSs (representing 28 study hours) ranged from 0 to 3. The various curricula covered, on average, 79% of all learning goals for these subjects: knowledge 85%, skills 76%, and attitudes 66%; the curricula also covered specific geriatric goals: knowledge 87% and skills 65%. All geriatric learning goals were met if a geriatrician was among the coordinators. Half (4 of 8) of the medical schools lacked appropriate assessment procedures. Evaluation was mostly based on students' opinions. Teachers rated students as being moderately well prepared for daily practice. CONCLUSIONS: There are large differences in the quantity and quality of (geriatric) pharmacology and pharmacotherapy education in Dutch medical schools. In general, more time should be devoted to skills and attitude, and the assessment procedures should be optimized with high priority. Other curricula with a problem-based approach might benefit from the points of improvement described in this article.

Effects of a Six-Month Local Vibration Training on Bone Density, Muscle Strength, Muscle Mass, and Physical Performance in Postmenopausal Women.

The aim of the study was to investigate the effect of 6 months' local vibration training on bone mineral density (BMD), muscle strength, muscle mass, and physical performance in postmenopausal women (66-88 years). The study was organized as a randomized controlled trial for postmenopausal women who lived in daily care service flats and rest homes. Thirty-five postmenopausal women were randomly assigned to either a vibration (n = 17) or a control group (n = 18). The vibration group received 6-month local vibration treatment with frequency between 30 and 45 Hz and acceleration between 1.71 and 3.58g. The vibration was applied on the midthigh and around the hip in supine-lying position once per day, 5 d·wk. The participants of the control group continued their usual activities and were not involved in any additional training program. The primary outcome variables were the isometric and dynamic quadriceps muscle strength and the BMD of the hip. We assessed the muscle mass of the quadriceps and physical performance. Additionally, the feasibility, side effects, and compliance were evaluated after 6 months of local vibration training. Overall, the results showed a net benefit of 13.84% in isometric muscle strength at 60° knee angle in favor of the vibration group compared with controls (p < 0.01). No changes in BMD, muscle mass, or physical performance were found in both groups (p > 0.05). Six months of local vibration training improved some aspects of muscle strength but had no effect on BMD, muscle mass, and physical performance in postmenopausal women. The specific vibration protocol used in this study can be considered as safe and suitable for a local vibration training program.

A comparison of medical and pharmacy students' knowledge and skills of pharmacology and pharmacotherapy.

AIM: Pharmacotherapy might be improved if future pharmacists and physicians receive a joint educational programme in pharmacology and pharmacotherapeutics. This study investigated whether there are differences in the pharmacology and pharmacotherapy knowledge and skills of pharmacy and medical students after their undergraduate training. Differences could serve as a starting point from which to develop joint interdisciplinary educational programmes for better prescribing. METHODS: In a cross-sectional design, the knowledge and skills of advanced pharmacy and medical students were assessed, using a standardized test with three domains (basic pharmacology knowledge, clinical or applied pharmacology knowledge and pharmacotherapy skills) and eight subdomains (pharmacodynamics, pharmacokinetics, interactions and side-effects, Anatomical Therapeutic Chemical Classification groups, prescribing, prescribing for special groups, drug information, regulations and laws, prescription writing). RESULTS: Four hundred and fifty-one medical and 151 pharmacy students were included between August 2010 and July 2012. The response rate was 81%. Pharmacy students had better knowledge of basic pharmacology than medical students (77.0% vs. 68.2% correct answers; P < 0.001, δ = 0.88), whereas medical students had better skills than pharmacy students in writing prescriptions (68.6% vs. 50.7%; P < 0.001, δ = 0.57). The two groups of students had similar knowledge of applied pharmacology (73.8% vs. 72.2%, P = 0.124, δ = 0.15). CONCLUSIONS: Pharmacy students have better knowledge of basic pharmacology, but not of the application of pharmacology knowledge, than medical students, whereas medical students are better at writing prescriptions. Professional differences in knowledge and skills therefore might well stem from their undergraduate education. Knowledge of these differences could be harnessed to develop a joint interdisciplinary education for both students and professionals.

Perspective: tipping the scales: search for drifting constants from molecular spectra.

Transitions in atoms and molecules provide an ideal test ground for constraining or detecting a possible variation of the fundamental constants of nature. In this perspective, we review molecular species that are of specific interest in the search for a drifting proton-to-electron mass ratio µ. In particular, we outline the procedures that are used to calculate the sensitivity coefficients for transitions in these molecules and discuss current searches. These methods have led to a rate of change in µ bounded to 6 × 10(-14)/yr from a laboratory experiment performed in the present epoch. On a cosmological time scale, the variation is limited to âˆ£Δµ∕µâˆ£ < 10(-5) for look-back times of 10-12× 10(9) years and to âˆ£Δµ∕µâˆ£ < 10(-7) for look-back times of 7× 10(9) years. The last result, obtained from high-redshift observation of methanol, translates into µÌ‡/µ=(1.4±1.4)×10(-17)/yr if a linear rate of change is assumed.

Variability between nursing homes in prevalence of antipsychotic use in patients with dementia.

BACKGROUND: Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics. METHODS: A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health. RESULTS: In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with a high prevalence of APD use behavioral symptoms were present in 62% of their patients. In facilities with medium APD use behavioral problems remained frequent (57%), and in facilities with low prevalence of APD use 54% of the patients had behavioral symptoms. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities. CONCLUSIONS: There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicates potential inappropriate prescribing because of differences in institutional prescribing culture.

Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND: Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined. METHODS: Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI. RESULTS: Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status). CONCLUSIONS: C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.