The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis.

BACKGROUND: Both frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD. METHODS: We searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05. RESULTS: Nine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias. CONCLUSIONS: This meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.

Student curriculum review team, 8 years later: Where we stand and opportunities for growth.

BACKGROUND: The Student Curriculum Review Team (SCRT) was founded at the Johns Hopkins University School of Medicine (JHUSOM) in 2012 to refine pre-clinical courses. Since then, SCRT has provided a voice for student feedback - offering forums for discussion through 'Town Hall meetings' and confidential avenues for peer-to-peer comments. Here, we assess the perceived efficacy and utility of SCRT among the student body and faculty course directors. METHODS: A cross-sectional analysis was conducted in 2019 using an anonymous survey distributed to second- (MS2) and third-year (MS3) medical students as well as faculty course directors at JHUSOM. RESULTS: A total of 113 student surveys and 13 faculty surveys were returned. The majority of students (97%) endorsed SCRT as effective in enabling them to express their concerns. Most faculty (69%) reported SCRT's impact on their respective course as positive and found SCRT suggestions to be 'realistic and actionable.' Students (84%) and faculty (62%) alike considered SCRT to meet needs not met by other curricular organizations at JHUSOM. CONCLUSION: Students and faculty find that SCRT satisfies an unfilled position in the landscape of curricular feedback at JHUSOM. This study may be beneficial for other academic institutions considering ways to better engage students in curricular reform.

Immune checkpoint inhibitors: maximizing benefit whilst minimizing toxicity.

INTRODUCTION: The advent of immunotherapy has revolutionized the treatment of cancer; anti-tumor efficacy has been observed with immune checkpoint inhibitors (ICI) in ~20 different cancer types with durable responses in some cases. However, the risk of toxicity in the form of immune-related adverse events (irAE) partially counterbalances these benefits, and there are no FDA-approved biomarkers to categorize patients by likelihood of response or risk of irAEs. AREAS COVERED: We conducted a thorough review of the literature of clinical studies regarding ICI and their toxicities. In this review, we synthesize the current body of literature about ICI treatment and irAE by summarizing the classes and uses of ICI, how to identify patients at risk for irAE, present the current understanding of irAE development, describe ongoing research into biomarkers of irAE, examine opportunities for irAE prevention, described management of steroid refractory irAE, and highlight future directions for development of prevention and management strategies. EXPERT OPINION: While ongoing biomarker studies are promising, it is unlikely that there will be a 'one-size-fits-all' approach to categorizing irAE risk. In contrast, improved management and irAE prophylaxis are potentially in reach, and ongoing trials will help elucidate best practices.

A 4-year old presenting with fever and achiness.

In children under the age of 5 who have abnormalities in history, physical examination, and laboratory studies indicating multi-system disease, uncovering the correct diagnosis is challenging. Here, we report the course of a 4-year-old girl who presented with a change in behavior, fever, arthralgia, arthritis, and hematuria following three recent hospitalizations for pneumonia and impetigo. Serologic findings were suggestive of a rheumatologic etiology and a renal biopsy was consistent with Membranous Lupus Nephritis Class V which helped secure the diagnosis of pediatric systemic lupus erythematosus. We review the clinical features and diagnostic criteria of early-onset systemic lupus erythematosus and discuss diagnostic considerations and prognosis.