Comparison of an Automated Plate Assessment System (APAS Independence) and Artificial Intelligence (AI) to Manual Plate Reading of Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus CHROMagar Surveillance Cultures.

The automated plate assessment system (APAS Independence; Clever Culture System, Bäch, Switzerland) is an automated imaging station linked with interpretive software that detects target colonies of interest on chromogenic media and sorts samples as negative or presumptive positive. We evaluated the accuracy of the APAS to triage methicillin-resistant Staphylococcus aureus (MRSA) and S. aureus cultures using chromogenic medium compared to that by human interpretation. Patient samples collected from the nares on ESwabs were plated onto BD BBL CHROMagar MRSA II and BD BBL CHROMagar Staph aureus and allowed to incubate for 20 to 24 h at 37°C in a non-CO2 incubator. Mauve colonies are suggestive of S. aureus and were confirmed with latex agglutination. Following incubation, samples were first interrogated by APAS before being read by a trained technologist blinded to the APAS interpretation. The triaging by both APAS and the technologists was compared for accuracy. Any discordant results required further analysis by a third reader. Over a 5-month period, 5,913 CHROMagar MRSA cultures were evaluated. Of those, 236 were read as concordantly positive, 5,525 were read as concordantly negative, and 152 required discordant analysis. Positive and negative percent agreements (PPA and NPA, respectively) were 100% and 97.3%, respectively. The APAS detected 5 positive cultures that were missed by manual reading and determined to be true positives. In a separate analysis, 744 CHROMagar Staph aureus plates were read in parallel. Of these, 133 were concordantly positive, 585 were concordantly negative, and 26 required discordant analysis. PPA and NPA were 95.7% and 96.7%, respectively. This study confirmed the high sensitivity of digital image analysis by the APAS Independence such that negative cultures can be reliably reported without technologist intervention (negative predictive values [NPVs] of 100% for CHROMagar MRSA and 99.0% for CHROMagar Staph aureus). Triaging using the APAS Independence may provide great efficiency in a laboratory with high throughput of MRSA and S. aureus surveillance cultures.

Differentiating Streptococcus pseudoporcinus from GBS: could this have implications in pregnancy?

BACKGROUND: Streptococcus agalactiae (GBS) is a common pathogen known to cause neonatal and maternal infectious morbidity. Streptococcus pseudoporcinus (S pseudoporcinus) is a separate, recently identified ß-hemolytic gram-positive coccus that can cause false-positive results on standard GBS agglutination testing assays. OBJECTIVE: To determine the prevalence and clinical implications of Streptococcus pseudoporcinus colonization in pregnancy. MATERIALS AND METHODS: This is a 2-year retrospective cohort study comparing pregnant women colonized with GBS to those colonized with S. pseudoporcinus. A proteomics method of identification, namely, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, was used to distinguish between S. pseudoporcinus and GBS colonization. Antibiotic susceptibility testing was carried out on all specimens. Maternal and neonatal chart reviews were conducted to identify predictors of S. pseudoporcinus colonization and to compare maternal and neonatal outcomes. RESULTS: S. pseudoporcinus colonization occurred in 1.6% of all pregnancies. A total of 2.5% of all GBS-positive results by agglutination assay were false positive, instead reflecting S. pseudoporcinus colonization. Clindamycin resistance among S. pseudoporcinus isolates is uncommon. S. pseudoporcinus colonization in pregnancy is independently associated with African American race, tobacco use, and body mass index ≥35. Preterm premature rupture of membranes or spontaneous preterm birth was more common in patients colonized with S. pseudoporcinus. CONCLUSION: Although the prevalence of S. pseudoporcinus colonization is low, it primarily occurs in African American women and is associated with preterm premature rupture of membranes or spontaneous preterm birth when compared to individuals colonized with GBS.

Recognition of Streptococcus pseudoporcinus Colonization in Women as a Consequence of Using Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry for Group B Streptococcus Identification.

During a 14-month period of using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for group B streptococcus (GBS) identification, we recovered 32 (1%) Streptococcus pseudoporcinus isolates from 3,276 GBS screening cultures from female genital sources (25 isolates from pregnant women and 7 from nonpregnant women). An additional two S. pseudoporcinus isolates were identified from a urine culture and a posthysterectomy wound culture. These isolates were found to cross-react with three different GBS antigen agglutination kits, PathoDx (Remel) (93%), Prolex (Pro-Lab Diagnostics) (38%), and Streptex (Remel) (53%). New approaches to bacterial identification in routine clinical microbiology laboratories may affect the prevalence of S. pseudoporcinus.

An adequate interset rest period for strength recovery during a common isokinetic test.

Isokinetic testing is used in rehabilitation settings on a regular basis; yet, there is a lack of consistency in rest period usage among protocols. Furthermore, the allotment of rest periods has been arbitrary (e.g., 30, 60, 90 seconds or more). This investigation examines the work:rest ratio as an effective method of standardizing rest periods in isokinetic testing. The purpose of this study was to establish an adequate rest period that would allow reproducibility of strength during a common isokinetic strength test. Twenty-seven healthy college-aged men (age, 23 ± 3.8 years; body weight, 79.54 ± 11.09 kg) were tested on 5 separate occasions: 2 familiarization sessions and 3 experimental sessions. Each subject performed a knee extension/flexion isokinetic strength protocol (Cybex NORM; Lumex, Inc., Ronkonkoma, NY, USA) to determine peak torque by performing 5 maximal reciprocal repetitions at each ascending velocity of 60, 180, and 300°·s. Work:rest ratios of 1:3, 1:8, and 1:12 were counterbalanced between sets. A 3 × 3 repeated measures analysis of variance was used to analyze the data. A significance level of α ≤ 0.05 was used for all tests. There was no significant difference in either knee extension or knee flexion peak torque when comparing work:rest ratios. These findings suggest that a 1:3 work:rest ratio is sufficient during a common isokinetic strength test.

Enterovirus characterized from cerebrospinal fluid in a cohort from the Eastern United States.

BACKGROUND: Enteroviruses (EVs) are predominant causes of a spectrum of neurological diseases. To better understand the origins of the outbreaks of disease associated with EV, it is essential to develop an efficient surveillance system that identifies the circulating EVs and correlate their genomic evolution with the disease presentations. METHODS: The clinical presentations of patients with positive EV from cerebrospinal fluid (CSF) between 2014 and 2022, diagnosed at the Johns Hopkins Medical Microbiology Laboratory, were compared from year to year. EV typing and whole genome sequencing were performed and correlated to the spectrum of disease. RESULTS: A total of 95 CSF specimens were positive for EV between 2014 and 2022. The percentage positivity ranged from the lowest of 1.1% in 2020 to the highest of 3.2% in 2015. The median ages declined from 22 years in 2014 to less than one year starting in 2016 to 34 in 2022. Typing using VP1 sequencing revealed that E30 and E6 were associated with meningitis in adults but coxsackieviruses (CVs-B3 and B5) were detected from pediatric patients with fever. Whole genome sequencing revealed multiple recombination events. In 2020, a recombinant CV-A9 was detected in a CSF sample associated with unusual presentation of sepsis, profound acute bilateral sensory neural hearing loss, and myofasciitis. CONCLUSIONS: EV genomic surveillance is needed for a better understanding of the genetic determinants of neurovirulence. Whole genome sequencing can reveal recombination events missed by traditional molecular surveillance methods.

A diagnostic stewardship approach to prevent unnecessary testing of an enteric bacterial molecular panel.

IMPORTANCE: Testing for enteric bacterial pathogens in patients hospitalized for more than 3 days is almost always inappropriate. Our study validates the utility of the 3-day rule and the use of clinical decision support tools to decrease unnecessary testing of enteropathogenic bacteria other than C. difficile. Overriding the restriction was very low yield. Our study highlights the importance of diagnostic stewardship and further refines the criteria for allowing providers to override the restriction while monitoring the impact of the interventions.

Multicentre genetic diversity study of carbapenem-resistant Enterobacterales: predominance of untypeable pUVA-like blaKPC bearing plasmids.

Objectives: Carbapenem-resistant Enterobacterales (CRE) are an urgent public health threat. A better understanding of the molecular epidemiology and transmission dynamics of CRE is necessary to limit their dissemination within healthcare settings. We sought to investigate the mechanisms of resistance and spread of CRE within multiple hospitals in Maryland. Methods: From 2016 to 2018, all CRE were collected from any specimen source from The Johns Hopkins Medical Institutions. The isolates were further characterized using both phenotypic and genotypic approaches, including short- and/or long-read WGS. Results: From 2016 to 2018, 302 of 40 908 (0.7%) unique Enterobacterales isolates were identified as CRE. Of CRE, 142 (47%) were carbapenemase-producing CRE with KPC (80.3%) predominating among various genera. Significant genetic diversity was identified among all CRE with high-risk clones serving as major drivers of clonal clusters. Further, we found the predominance of pUVA-like plasmids, with a subset harbouring resistance genes to environmental cleaning agents, involved in intergenus dissemination of blaKPC genes. Conclusions: Our findings provide valuable data to understand the transmission dynamics of all CRE within the greater Maryland region. These data can help guide targeted interventions to limit CRE transmission in healthcare facilities.

Clinical significance of Nosocomiicoccus ampullae isolated from blood cultures.

IMPORTANCE: Nosocomiicoccus species are recently described as members of the Staphylococcaceae family. With their inclusion in commercial matrix-assisted laser desorption/ionization-time of flight mass spectrometry databases, Nosocomiicoccus species can now be identified when Gram-positive cocci in clusters are detected in positive blood cultures. However, their clinical significance is not known, making it difficult for the clinical microbiology laboratory to decide the extent of work-up. Based on our study, Nosocomiicoccus species demonstrate low pathogenicity and opportunistic potential. If isolated from a single blood culture set, limited work-up should be performed to an extent similar to other possible blood culture contaminants.

Increasing Pediatric Infectious Diseases Consultation Rates for Staphylococcus aureus Bacteremia.

Introduction: Staphylococcus aureus bacteremia (SAB) in children is associated with significant mortality and morbidity, including recurrent bacteremia. Infectious disease consultation (IDC) improves SAB outcomes in adult patients. However, increasing IDC and impact for pediatric patients with SAB is not well described. Methods: This quality improvement project aimed to increase IDC for SAB events at a quaternary pediatric medical center. First, we evaluated the local practices regarding pediatric SAB and engaged stakeholders (July 2018-August 2020). We added an advisory comment supporting IDC for SAB to all blood culture results in September 2020. Using statistical process control charts, we monitored the number of SAB events with IDC before a SAB event without IDC. Finally, we evaluated SAB recurrences before and after initiating the advisory comment. Results: In the baseline period, 30 of 49 (61%) SAB events received an IDC with a mean of 1.4 SAB events with IDC before a SAB event without IDC. Postintervention, 22 of 23 (96%) SAB events received IDC with a mean of 14 events with IDC before 1 event without IDC. The SAB recurrence rate was 8%, with 6 events in 4 children; none of the index cases resulting in recurrence received an IDC (P = 0.0002), and all occurred before any intervention. Conclusions: An electronic advisory comment supporting IDC for SAB significantly increased the rate of pediatric IDC with no further SAB recurrence episodes following intervention. This low-resource intervention may be considered in other pediatric centers to optimize SAB management.

The effect of patient characteristics upon uptake of the influenza vaccination: a study comparing community-based older adults in two healthcare systems.

BACKGROUND: the uptake of influenza vaccination represents a simple marker of proactive care of older people. However, many still do not receive the vaccine. To understand this challenge better, we investigated the relationship between patient characteristics (demographic, physical and psychological health and health service use) and vaccination uptake in a sample of community-dwelling older people in two adjacent but differently structured healthcare systems (Northern Ireland (NI) and the Republic of Ireland (RoI)). METHODS: a total of 2,033 randomly selected community-dwelling older adults (65 years and older) were interviewed in their homes. RESULTS: rates of uptake were 78% in NI and 72% in RoI. The uptake was greater with older age (odds ratio (OR) 1.6, 95% confidence interval (CI) = 1.3-2.1, P < 0.0005), widowhood (OR = 1.5, 95% CI = 1.1-2.3, P = 0.02), living in NI (OR = 0.77, 95% CI = 0.6-0.9, P = 0.04), greater functional impairment (OR RoI 2.0, 95% CI = 0.8-3.5, P = 0.03), more frequent use of family doctor (OR RoI 0.5, 95% CI = 0.3-0.6, P = 0.0001; NI 0.6, 95% CI = 0.4-0.9, P = 0.01) and greater use of services such as chiropody (OR NI 0.6, 95% CI = 0.4-0.9, P = 0.01), meals-on-wheels (OR RoI 1.3, 95% CI = 0.4-2.2, P = 0.03), social work (OR RoI 1.2, 95% CI = 0.3-1.9, P = 0.05) and occupational therapy (OR RoI 1.3, 95% CI = 0.5-2.5, P = 0.02). CONCLUSION: the uptake rates in both healthcare systems exceeded targets. Higher rates of vaccination were found among older people, those who were married and those who made greater use of hospital and community services. Increased exposure to health services may enhance trust in health care leading to higher vaccination uptake.

Clinical performance of the GenMark Dx ePlex respiratory pathogen panels for upper and lower respiratory tract infections.

The GenMark Dx ePlex Respiratory Pathogen Panel (RP) is a multiplexed nucleic acid test for the qualitative detection of common viral and a few bacterial causes of respiratory tract infections. The ePlex RP has received FDA clearance for nasopharyngeal swab (NPS) specimens collected in viral transport media. In this study, we evaluated the performance of the ePlex RP panel in comparison to the NxTAG Respiratory Pathogen Panel (NxTAG-RPP) from Luminex in use in our laboratory, not only for NPS but also for bronchoalveolar lavage specimens (BAL). We also evaluated the impact of implementing the ePlex RP on the test turn-around time (TAT). The newest panel from GenMark Dx, the ePlex Respiratory Pathogen Panel 2 (RP2), which added the SARS-CoV-2 target to the RP was also evaluated for NPS. Verification of the performance of the ePlex RP for both NPS and BAL showed 93.3 % and 84.9 % total agreement with the NxTAG-RPP respectively. An overall comparison of the TAT after implementing the ePlex RP as compared to the NxTAG-RPP assay showed an average decrease of almost seven-fold.

Comparing the analytical performance of three SARS-CoV-2 molecular diagnostic assays.

In December 2019, a novel coronavirus (SARS-CoV-2) was first isolated from Wuhan city, China and within three months, the global community was challenged with a devastating pandemic. The rapid spread of the virus challenged diagnostic laboratories to rapidly develop molecular diagnostic methods. As SARS CoV-2 assays became available for testing on existing molecular platforms, laboratories devoted unprecedented energy and resources into evaluating the analytical performance of the new tests and in some cases developed their own diagnostic assays under FDA-EUA guidance. This study compares the validation of three different molecular assays at the Johns Hopkins Molecular Virology laboratory: the RealStar® SARS-CoV-2 RT-PCR, ePlex® SARS-CoV-2, and the CDC COVID-19 RT-PCR tests. Overall, our studies indicate a comparable analytical performance of the three assays for the detection of SARS-CoV-2.

Evaluation of flow characteristics of 3-way catheters.

PURPOSE: We evaluated the flow characteristics of various 3-way catheters. MATERIALS AND METHODS: We evaluated 14, 3-way catheters, including 18Fr, 20Fr, 22Fr and 24Fr Rusch(R), 18Fr, 20Fr, 22Fr and 24Fr Bardex(R), 18Fr, 20Fr, 22Fr and 24Fr Dover, and 20Fr and 22Fr Mentor (Mentor, Santa Barbara, California) catheters. Ten operators applied maximum 1-hand pressure with a 60 ml bladder wash syringe. Maximum and average flow rates were evaluated. The catheter was connected to an irrigation bottle and free flow irrigation speed was noted. The catheter was inserted into a latex balloon containing a prefilled volume of 100 ml and continuous irrigation characteristics were noted. Statistical analysis was performed using 1-way ANOVA and the Kruskal-Wallis test. RESULTS: Rusch catheters had the best flow characteristics when the drainage port was used for manual irrigation with 18Fr catheters (Rusch and Dover 24.8 and 19.2 ml per second, p = 0.003, vs Bardex 17.67 ml per second, p <0.001), and with 20Fr Rusch, Bardex, Mentor and Dover catheters (27.7, 21.42, 27.1 and 24 ml per second, respectively, p = 0.034). In the other categories of catheters tested there was no significant difference among 22Fr Rusch, Bardex, Dover and Mentor catheters (29.4, 28.9, 25 and 28.27 ml per second, p = 0.32), and among 24Fr Rusch, Bardex and Dover catheters (32.2, 29.79 and 29.9 ml per second, respectively, p = 0.27). Upon using the irrigation channel for manual irrigation all catheters had similar flow characteristics (no statistically significant difference). When connected to the irrigation tube with free flow, although the 18Fr, 20Fr and 22Fr Rusch, and 24Fr Dover catheters had slightly better flow than the others, this was not statistically significant. There was no marked difference in flow rate as catheter size increased above 20Fr. When the artificial bladder was used, the Rusch catheters had the maximum drainage in the 18Fr and 20Fr sizes, whereas the Mentor and Dover catheters had the maximum drainage in the 22Fr and 24Fr sizes, respectively (no statistically significant difference). CONCLUSIONS: The 18Fr and 20Fr Rusch 3-way catheters have better flow than other catheters when the drainage port is used for washout. In the 22Fr and 24Fr categories all different catheters had equivalent irrigation and drainage properties. Larger catheter size does not equate to better irrigation or drainage when continuous irrigation is used.

Do consultation charges deter general practitioner use among older people? A natural experiment.

In the Republic of Ireland, approximately 30% of the population ('medical card patients') are entitled to free general practice services. Eligibility is determined primarily on the basis of an income means test. The remaining 70% of the population ('private patients') must pay the full cost of all general practitioner (GP) consultations. From July 2001, all those over 70 years of age are also entitled to a medical card, regardless of income. This change in the pricing of GP services in the Republic of Ireland in 2001 provides a natural experiment that allows for an examination of the influence of economic incentives on GP visiting behaviour. The purpose of this paper is to examine whether this change in pricing for GP care for those over 70 years of age in Ireland led to an increase in the utilisation of GP services among this group. Using data from two nationally representative surveys of the population over the age of 65 before and after the policy change, difference-in-difference two-step models of GP visiting behaviour are estimated. The results indicate that, while there is some limited evidence in favour of an increase in the probability of seeking GP care among those over 70 years of age after the policy change, there is no significant effect on the frequency of visits. Differences in the incentives facing both patients and GPs after the policy change can explain the latter result.

Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults.

BACKGROUND: Stroke is a leading cause of death and functional impairment. While older people are particularly vulnerable to stroke, research suggests that they have the poorest awareness of stroke warning signs and risk factors. This study examined knowledge of stroke warning signs and risk factors among community-dwelling older adults. METHODS: Randomly selected community-dwelling older people (aged 65+) in Ireland (n = 2,033; 68% response rate). Participants completed home interviews. Questions assessed knowledge of stroke warning signs and risk factors, and personal risk factors for stroke. RESULTS: Of the overall sample, 6% had previously experienced a stroke or transient ischaemic attack. When asked to identify stroke risk factors from a provided list, less than half of the overall sample identified established risk factors (e.g., smoking, hypercholesterolaemia), hypertension being the only exception (identified by 74%). Similarly, less than half identified established warning signs (e.g., weakness, headache), with slurred speech (54%) as the exception. Overall, there were considerable gaps in awareness with poorest levels evident in those with primary level education only and in those living in Northern Ireland (compared with Republic of Ireland). CONCLUSION: Knowledge deficits in this study suggest that most of the common early symptoms or signs of stroke were recognized as such by less than half of the older adults surveyed. As such, many older adults may not recognise early symptoms of stroke in themselves or others. Thus, they may lose vital time in presenting for medical attention. Lack of public awareness about stroke warning signs and risk factors must be addressed as one important contribution to reducing mortality and morbidity from stroke.

Cross-sectional validation of the Aging Perceptions Questionnaire: a multidimensional instrument for assessing self-perceptions of aging.

BACKGROUND: Self-perceptions of aging have been implicated as independent predictors of functional disability and mortality in older adults. In spite of this, research on self-perceptions of aging is limited. One reason for this is the absence of adequate measures. Specifically, there is a need to develop a measure that is theoretically-derived, has good psychometric properties, and is multidimensional in nature. The present research seeks to address this need by adopting the Self-Regulation Model as a framework and using it to develop a comprehensive, multi-dimensional instrument for assessing self-perceptions of aging. This study describes the validation of this newly-developed instrument, the Aging Perceptions Questionnaire (APQ). METHODS: Participants were 2,033 randomly selected community-dwelling older (+65 yrs) Irish adults who completed the APQ alongside measures of physical and psychological health. The APQ assesses self-perceptions of aging along eight distinct domains or subscales; seven of these examine views about own aging, these are: timeline chronic, timeline cyclical, consequences positive, consequences negative, control positive, control negative, and emotional representations; the eighth domain is the identity domain and this examines the experience of health-related changes. RESULTS: Mokken scale analysis showed that the majority of items within the views about aging subscales were strongly scalable. Confirmatory factor analysis also indicated that the model provided a good fit for the data. Overall, subscales had good internal reliabilities. Hierarchical linear regression was conducted to investigate the independent contribution of APQ subscales to physical and psychological health and in doing so determine the construct validity of the APQ. Results showed that self-perceptions of aging were independently related to physical and psychological health. Mediation testing also supported a role for self-perceptions of aging as partial mediators in the relationship between indices of physical functioning and physical and psychological health outcomes. CONCLUSION: Findings support the complex and multifaceted nature of the aging experience. The good internal reliability and construct validity of the subscales suggests that the APQ is a promising instrument that can enable a theoretically informed, multidimensional assessment of self-perceptions of aging. The potential role of self-perceptions of aging in facilitating physical and psychological health in later life is also highlighted.

Effects of telephone intervention on arthritis self-efficacy, depression, pain, and fatigue in older adults with arthritis.

PURPOSE: Arthritis self-efficacy (ASE) characterizes individuals' confidence in managing their arthritis. This study's purpose was to examine the effects of a telephone intervention on ASE, depression, pain, and fatigue in older adults with arthritis. METHODS: Eighty-five elders with arthritis were randomly assigned to the intervention or control group. Participants in both groups: (a) completed baseline assessments of ASE, depression, pain, and fatigue; (b) received written information on arthritis management; and (c) received individualized action plans for achieving their own arthritis management goal over the 6-week study. Participants in the intervention group received a telephone intervention including instruction on managing arthritis and encouragement to pursue their goal. In the sixth week the assessment tools were re-administered. Quantitative and qualitative data analysis methods were employed. RESULTS: Quantitative analyses showed a significant increase in ASE and a significant reduction in depression and pain over time for both groups. Qualitative analyses revealed several themes related to benefits of telephone intervention. CONCLUSION: Study results suggest that minimal intervention (ie, written information, goal-setting, and action plans) may produce positive changes in ASE, depression, and pain in some older adults with arthritis. Furthermore, telephone intervention may assist older patients in managing their arthritis.

Effect of obesity status on heart rate peak in female youth.

The purpose of this study was to compare heart rate peak in obese (n = 43) and normal weight (n = 45) female youth. Heart rate (HR) peak was significantly lower (p < or = 0.05) in the obese group as compared to the normal weight group (192.3 +/- 9.3, 203.4 +/- 7.6), and VO2 (L x min(-1)) peak similar between groups (1.77 +/- 0.53, 1.97 +/- 0.60). Bivariate correlations for heart rate peak with body weight, percent fat, and body mass index yielded the following: -0.53, -0.54, and -0.57. These findings agree with the adult data indicating low HR peak in obese individuals. Further research is needed to explore physiologic factors that may lead to reduced HR peak in obese female youth.

Vulnerable older people in the community: relationship between the Vulnerable Elders Survey and health service use.

OBJECTIVES: The Vulnerable Elders Survey (VES), a recently developed screening tool for at-risk older people in the community, has been validated in the United States. This study evaluated its profile in older Irish people. It assessed whether those categorized as vulnerable according to the VES were likely to use health services more frequently than others. DESIGN: Nationally representative cross-sectional interviews. SETTING: Private homes in the community. PARTICIPANTS: Randomly selected older people (aged > or = 65) (N=2,033; 68% response). MEASUREMENTS: Interviews included the 13-item VES and questions on health service use. RESULTS: The proportion scoring as vulnerable was identical to the U.S. sample (32.1% vs 32.3%). At the community healthcare level, participants categorized as vulnerable visited their primary care physician more frequently (mean visits 6.7 vs 4.0, P<.001), had more home-based public health nurse visits (29% vs 5%, P<.001), and were more likely to have had preventive influenza vaccinations (81% vs 72%, P<.001) in the previous year. More-vulnerable older adults did not differ on assessment of blood pressure (97% vs 96%), cholesterol (82% vs 85%), or receipt of smoking advice (66% vs 52%). Vulnerable participants were more likely to have used emergency department (17% vs 8%, P<.05), inpatient (21% vs 12%, P<.05), and outpatient (28% vs 21%, P<.05) hospital services. Fourteen percent of those categorized as vulnerable had zero or one visit to their family physician in the previous year. CONCLUSION: This study provides further evidence, from a different healthcare system, of the potential of the VES to differentiate more-vulnerable older people. Prospective studies are needed to assess use of the VES as a clinical decision aid for community professionals such as family physicians and public health nurses.