Cumulative deficit model of geriatric assessment to predict the postoperative outcomes of older patients with solid abdominal cancer. The feasibility of inpatient geriatric assessment for older adults receiving induction chemotherapy for acute myelogenous leukemia. Geriatric Assessment Improves Prediction of Surgical Outcomes in Older Adults Undergoing Pancreaticoduodenectomy: A Prospective Cohort Study Geriatric assessment predicts survival for older adults receiving induction chemotherapy for acute myelogenous leukemia. Evaluation of geriatric assessment in patients with chronic lymphocytic leukemia: Results of the CLL9 trial of the German CLL study group Screening for frailty among older patients with cancer that qualify for abdominal surgery. The use of goal attainment scaling in a geriatric care setting. Frailty is an independent predictor of survival in older patients with colorectal cancer. Abridged geriatric assessment is a better predictor of overall survival than the Karnofsky Performance Scale and Physical Performance Test in elderly patients with cancer. Frailty and malnutrition predictive of mortality risk in older patients with advanced colorectal cancer receiving chemotherapy. A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people. Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment. Evaluation of the Quality of Prognosis Studies in Systematic Reviews Continuous paravertebral block for postoperative pain compared to general anaesthesia and wound infiltration for major oncological breast surgery Prognostic significance of geriatric assessment in combination with laboratory parameters in elderly patients with aggressive non-Hodgkin lymphoma Predicting falls in older patients using components of a comprehensive geriatric assessment AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both The influence of a dietary protocol on cone beam CT-guided radiotherapy for prostate cancer patients. Geriatric assessment to predict survival in older allogeneic hematopoietic cell transplantation recipients PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies Xenon for the prevention of postoperative delirium in cardiac surgery: study protocol for a randomized controlled clinical trial Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology Nutritional Intervention as a Preventive Approach for Cognitive-Related Outcomes in Cognitively Healthy Older Adults: A Systematic Review. Systematic literature review of domains assessed in psoriatic arthritis to inform the update of the psoriatic arthritis core domain set Role of geriatric intervention in the treatment of older patients with cancer: rationale and design of a phase III multicenter trial Progression of geographic atrophy in age-related macular degeneration imaged with spectral domain optical coherence tomography. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. Can trial quality be reliably assessed from published reports of cancer trials: evaluation of risk of bias assessments in systematic reviews Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients Drugs prescribed for patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and impact of a clinical pharmacist. End points and trial design in geriatric oncology research: a joint European organisation for research and treatment of cancer--Alliance for Clinical Trials in Oncology--International Society Of Geriatric Oncology position article. Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions
OBJECTIVE The geriatric assessment ( GA ) has proven to be of great value for clinicians treating older patients . However , a clear consensus on the optimal set of GA instruments is lacking , particularly for surgical patients . Therefore , the aim of this prospect i ve study was to compare the prevalence of frailty , depending on the number of incorporated GA domains , and to evaluate its accuracy in predicting postoperative outcome . MATERIAL S AND METHODS Seventy-five patients aged 65 years and older , qualified for abdominal surgery due to solid cancer , were enrolled . The GA included a wide variety of vali date d tools that evaluate functional , mobility , nutritional , co-morbidity , polypharmacy , and psychosocial domains .  RESULTS Depending on the number of incorporated GA domains the frequency of frailty was 23 - 97 % . The cumulative score rather than individual components of the GA , turned out to be an independent risk factor of 30-day postoperative morbidity . In predicting 30-day " any " and " major " morbidities , the area under the curve was 0.67 - 0.72 and 0.70 - 0.82 ( model including the severity of the surgery ) vs. 0.57 - 0.66 and 0.50 - 0.65 ( model not including the severity of the surgery ) , respectively . CONCLUSION The number of incorporated GA domains has a great influence on the prevalence of frailty and on adequate surgical risk assessment . The summary deficit score based on Pre-operative Assessment of Cancer in the Elderly ( PACE ) or the GA consisting of functional , mobility , cognitive , depression , nutritional , co-morbidity , polypharmacy , and social support assessment domains can predict 30-day postoperative morbidity . However , only models with addition of the severity of surgery show moderate to good predictive value OBJECTIVES To test the feasibility and utility of a bedside geriatric assessment ( GA ) to detect impairment in multiple geriatric domains in older adults initiating chemotherapy for acute myelogenous leukemia ( AML ) . DESIGN Prospect i ve observational cohort study . SETTING Single academic institution . PARTICIPANTS Individuals aged 60 and older with newly diagnosed AML and planned chemotherapy . MEASUREMENTS Bedside GA was performed during inpatient exmination for AML . GA measures included the modified Mini-Mental State Examination ; Center for Epidemiologic Studies Depression Scale ; Distress Thermometer , Pepper Assessment Tool for Disability ( includes self- reported activities of daily living ( ADLs ) , instrumental ADLs , and mobility questions ) ; Short Physical Performance Battery ( includes timed 4-m walk , chair st and s , st and ing balance ) ; grip strength , and Hematopoietic Cell Transplantation Comorbidity Index . RESULTS Of 54 participants ( mean age 70.8 ± 6.4 ) eligible for this analysis , 92.6 % completed the entire GA battery ( mean time 44.0 ± 14 minutes ) . The following impairments were detected : cognitive impairment , 31.5 % ; depression , 38.9 % ; distress , 53.7 % ; impairment in ADLs , 48.2 % ; impaired physical performance , 53.7 % ; and comorbidity , 46.3 % . Most were impaired in one ( 92.6 % ) or more ( 63 % ) functional domains . For the 38 participants rated as having good performance status according to st and ard oncologic assessment ( Eastern Cooperative Oncology Performance Scale score ≤1 ) , impairments in individual GA measures ranged from 23.7 % to 50 % . Significant variability in cognitive , emotional , and physical status was detected even after stratification according to tumor biology ( cytogenetic risk group classification ) . CONCLUSION Inpatient GA was feasible and added new information to st and ard oncology assessment , which may be important for stratifying therapeutic risk in older adults with AML Objective : To prospect ively evaluate the additional value of geriatric assessment ( GA ) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy ( PD ) for pancreatic tumors . Background : Older patients are less often referred for possible PD . St and ard preoperative assessment s may underestimate the likelihood of significant adverse outcomes . The prospect i ve utility of vali date d GA has not been studied in this group . Methods : PD-eligible patients were enrolled in a prospect i ve outcome study . St and ard preoperative assessment s were recorded . Elements of vali date d GA were also measured , including components of Fried 's model of frailty , the Vulnerable Elders Survey ( VES-13 ) , and the Short Physical Performance Battery ( SPPB ) . All postoperative adverse events were recorded , systematic ally review ed , and grade d using the Clavien-Dindo system by a surgeon blinded to the GA results . Multivariate regression analyses were conducted . Results : Seventy-six older patients underwent a PD . Significant unrecognized vulnerability was identified at the baseline : Fried 's “ exhaustion ” ( 37.3 % ) , SPPB < 10 ( 28.5 % ) , and VES-13 > 3 ( 15.4 % ) . Within 30 days of PD , 46 % experienced a severe complication ( Clavien-Dindo grade ≥III ) . In regression analyses controlling for age , the body mass index , the American Society of Anesthesiologists score , and comorbidity burden , Fried 's “ exhaustion ” predicted major complications [ odds ratio ( OR ) = 4.06 ; P = 0.01 ] , longer hospital stays ( & bgr ; = 0.27 ; P = 0.02 ) , and surgical intensive care unit admissions ( OR = 4.30 ; P = 0.01 ) . Both SPPB ( OR = 0.61 ; P = 0.04 ) and older age predicted discharge to a rehabilitation facility ( OR = 1.1 ; P < 0.05 ) and age correlated with a lower likelihood of hospital readmission ( OR = 0.94 ; P = 0.02 ) . Conclusions : Controlling for st and ard preoperative assessment s , worse scores on GA prospect ively and independently predicted important adverse outcomes  . Geriatric assessment may help identify older patients at high risk for complications from PD We investigated the predictive value of geriatric assessment ( GA ) on overall survival ( OS ) for older adults with acute myelogenous leukemia ( AML ) . Consecutive patients ≥ 60 years with newly diagnosed AML and planned intensive chemotherapy were enrolled at a single institution . Pretreatment GA included evaluation of cognition , depression , distress , physical function ( PF ) ( self-reported and objective ly measured ) , and comorbidity . Objective PF was assessed using the Short Physical Performance Battery ( SPPB , timed 4-m walk , chair st and s , st and ing balance ) and grip strength . Cox proportional hazards models were fit for each GA measure as a predictor of OS . Among 74 patients , the mean age was 70 years , and 78.4 % had an Eastern Cooperative Oncology Group ( ECOG ) score ≤ 1 . OS was significantly shorter for participants who screened positive for impairment in cognition and objective ly measured PF . Adjusting for age , gender , ECOG score , cytogenetic risk group , myelodysplastic syndrome , and hemoglobin , impaired cognition ( Modified Mini-Mental State Exam < 77 ) and impaired objective PF ( SPPB < 9 ) were associated with worse OS . GA methods , with a focus on cognitive and PF , improve risk stratification and may inform interventions to improve outcomes for older AML patients Abstract Multidimensional geriatric assessment ( GA ) has been demonstrated to predict outcomes in older patients with cancer . This study evaluated GA in a cohort of older patients with chronic lymphocytic leukemia ( CLL ) . Seventy-five of 97 subjects with CLL who were enrolled in a clinical trial of the German CLL Study Group underwent GA prior to the start of study treatment ( low-dose chemotherapy with fludarabine ) . GA included  cumulative illness rating scale ( CIRS ) , timed-up- and -go ( TUG ) test , dementia detection ( DEMTECT ) test and instrumental activities of daily living ( IADL ) index . There was little correlation between CIRS , TUG , DEMTECT or IADL results and treatment toxicity , feasibility or efficacy in this study . CIRS and IADL had no statistically significant impact on overall prognosis . However , under-performance in TUG or DEMTECT test was strongly associated with poor survival . The latter findings provide a rationale to further investigate geriatric  assessment in CLL and in the context with other CLL treatments OBJECTIVE The Geriatric Assessment ( GA ) is an established method for evaluating and optimizing diagnostic and treatment plans . However , it requires experience and is time-consuming . Therefore , a variety of screening methods have been developed . The aim of this study was to compare their accuracy for predicting frailty among older patients with cancer qualified for abdominal surgery based on comparison to the GA . MATERIAL AND METHODS One hundred and thirty five consecutive patients ≥65years of age were prospect ively enrolled . The diagnostic performance of eight screening tests was evaluated : The Vulnerable Elderly Survey ( VES-13 ) , Triage Risk Screening Tool ( TRST ) , Geriatric 8 ( G8 ) , Groningen Frailty Index ( GFI ) , abbreviated Comprehensive Geriatric Assessment ( aCGA ) , Rockwood , Balducci and Fried score . RESULTS The prevalence of frailty as diagnosed by the GA was 73 % . Screening methods identified frail patients in 40 - 75.5 % of cases . The sensitivity and specificity of these tests in predicting frailty were 52%-97 % ( Fried score-G8 ) and 44 - 100 % ( G8-Rockwood score ) , respectively . The positive and negative predictive values were 82 - 100 % ( Balducci-Rockwood ) and 43 - 84 % ( TRST-G8 ) , respectively . Age significantly influenced the predictive value of the screening tests whereas gender and type of cancer did not . CONCLUSION At present , there is no universal screening test that adequately identifies frailty in at risk older patients . The results of this study showed that the aCGA and G8 were the best screens for older patients with cancer that qualified for elective abdominal surgery ; the G8 had the highest sensitivity and negative predictive value and the aCGA was a good overall assessment tool OBJECTIVE  Goal attainment scaling ( GAS ) is a measurement approach used extensively in mental health . It accommo date s multiple individual patient goals , yet retains mathematical properties allowing comparisons between patients . This study was carried out to investigate the feasibility and measurement properties of GAS in a geriatric care setting . DESIGN Prospect i ve descriptive study . SETTING The geriatric restorative care service and geriatric assessment unit at Camp Hill Hospital , a 350-bed tertiary care facility in Halifax , Canada . PATIENTS Fifteen patients aged 65 to 94 who were consecutively admitted to the two geriatric services ( mean age 79 years , mean length of stay 37 days , 9 females ) . INTERVENTION Goal Attainment follow-up guides were developed independently for each patient by two geriatricians after a comprehensive assessment of the patient . These guides were later compared to assess level of agreement in goal setting and scale development . A single goal attainment follow-up guide was then developed for each patient by consensus of the two geriatricians . At the end of the follow-up , the guides were scored independently for each patient by one of the geriatricians and by the patient 's primary care nurse . MAIN OUTCOME MEASURES  GAS scores were determined on admission and discharge . Each patient also received admission and discharge ratings on the Barthel Index as well as a global rating of outcome ( on a subjective 10-point scale ) by a geriatrician who was blinded to the Goal Attainment follow-up score . RESULTS GAS proved feasible , requiring 15 - 20 minutes to scale an average of six goals per patient . GAS also appears reliable . Of 87 goals , 71 ( 82 % ) were identified independently by two geriatricians , and the remainder were determined by consensus . This is also a measure of content validity . The physician-nurse inter-rater reliability was 0.87 ( intraclass correlation ) . Concurrent validity was assessed by correlation with the Barthel Index ( r = 0.86 ) and the global clinical outcome rating ( r = 0.82 ) . Content validity was also assessed by comparing our goal areas with those identified in recent consensus reports on geriatric assessment . Of these 13 assessment areas , 12 appeared to be reasonably well covered while one assessment area ( sexual problems ) was not identified for any of the 15 patients . CONCLUSIONS GAS appears to be a feasible method of goal setting and outcome evaluation in geriatric care setting s , with promising reliability and validity BACKGROUND Colorectal cancer ( CRC ) is prevalent in the older population .  Geriatric assessment ( GA ) has previously been found to predict treatment tolerance and postoperative complications in older cancer patients . The aim of this study was to explore whether GA also predicts 1-year and 5-year survival after  CRC surgery in older patients and to compare the predictive power of GA with that of established prognostic factors such as TNM classification of malignant tumors ( TNM ) stage and age . MATERIAL S AND METHODS A cohort of 178 CRC patients aged 70 and older were followed prospect ively . All patients went through elective surgery , and GA was performed presurgery . The GA result ed in patients being divided into two groups : frail or nonfrail . All patients were followed for 5 years or until death . Data were analyzed by Kaplan-Meier plots and the Cox proportional hazards model . RESULTS Seventy-six patients ( 43 % ) were frail , and one hundred and two ( 57 % ) were nonfrail . Twenty-three patients ( 13 % ) died during the first year after surgery . One-year survival was 80 % in the frail group and 92 % in the nonfrail group . Five-year survival was significantly lower in frail ( 24 % ) than nonfrail patients ( 66 % ) , and this difference was apparent both within the stratums of TNM stages 0-II and TNM stage III . In multivariable analysis adjusting for TNM stage , age , and sex , frailty was an independent prognostic factor for survival . CONCLUSION A GA-based frailty assessment predicts 1-year and 5-year survival in older patients after surgery for CRC . In localized and regional disease , the impact of frailty upon 5-year survival is comparable with that of TNM stage OBJECTIVES Comprehensive geriatric assessment ( CGA ) is a complex and interdisciplinary approach to evaluate the health status of elderly patients . The Karnofsky Performance Scale ( KPS ) and Physical Performance Test ( PPT ) are less time-consuming tools that measure functional status . This study was design ed to assess and compare abridged geriatric assessment ( GA ) , KPS and PPT as predictive tools of mortality in elderly patients with cancer . MATERIAL S AND METHODS This prospect i ve interventional study included all individuals aged > 70years who were diagnosed with cancer during the study period . Subjects were interviewed directly using a procedure that included a clinical test and a question naire composed of the KPS , PPT and abridged GCA .  Overall survival ( OS ) was the primary endpoint . The log rank test was used to compare survival curves , and Cox 's regression model ( forward procedure ) was used for multivariate survival analysis . RESULTS One hundred patients were included in this study . Abridged GA was the only tool found to predict mortality [ median OS for unfit patients ( at least two impairments ) 467days vs 1030days for fit patients ; p=0.04 ] . Patients defined as fit by mean PPT score ( > 20 ) had worse median OS ( 560 vs 721days ) ; however , this difference was not significant ( p=0.488 on log rank ) . Although median OS did not differ significantly between patients with low ( ≤80 ) and high ( > 80 ) KPS scores ( 467 and 795days , respectively ; p=0.09 ) , survival curves diverged after nearly 120days of follow-up . Visual and hearing impairments were the only components of abridged GA of prognostic value . CONCLUSION Neither KPS nor PPT were shown to predict mortality in elderly patients with cancer whereas abridged GA was predictive . This study suggests a possible role for visual and hearing assessment as screening for patients requiring CGA INTRODUCTION In general , geriatric assessment ( GA ) provides the combined information on comorbidity and functional , nutritional and psychosocial status and may be predictive for mortality outcome of cancer patients . The impact of geriatric assessment on the outcome of older patients with colorectal cancer treated with chemotherapy is largely unknown . METHODS In a prospect i ve study , 143 patients with colorectal cancer who were 70years and older were assessed before chemotherapy  by Mini Nutritional Assessment ( MNA ) , Informant Question naire on Cognitive Decline in the Elderly ( IQCODE ) , Groningen Frailty Indicator ( GFI ) and Mini Mental State Examination ( MMSE ) . RESULTS Fifty-four ( 38 % ) patients received adjuvant chemotherapy and 89 ( 62 % ) patients received palliative chemotherapy .  Malnutrition and frailty were prevalent in 39 ( 27 % , assessed by MNA ) and 34 ( 24 % , by GFI ) patients , respectively ; whereas cognitive impairment was prevalent in 19 ( 13 % , by IQCODE ) and 11 ( 8 % , by MMSE ) patients , respectively . In patients with palliative chemotherapy , poor MNA scores were associated with receiving less than 4cycles of chemotherapy ( p=0.008 ) . Poor MNA and GFI scores were associated with increased hazard ratios ( HR ) for mortality for patients with palliative chemotherapy : HR=2.76 ( 95 % confidence interval [ CI ] : 1.60 - 4.77 ; p<0.001 ) and HR=2.72 ( 95 % CI : 1.58 - 4.69 ; p<0.001 ) , respectively , after adjustment for several clinical parameters . CONCLUSIONS Malnutrition and frailty were strongly associated with an increased mortality risk in patients who underwent palliative chemotherapy . Furthermore , a poor score on MNA was predictive for less tolerance of chemotherapy . Our findings may help the oncologist in future decision making and advice for elderly patients with colorectal cancer OBJECTIVE To test Comprehensive Geriatric Assessment ( CGA ) as an adjunct to usual care . DESIGN A r and omized controlled trial with 3 , 6 , and 12 months follow-up . SETTING Rural communities . PATIENTS A total of 182 of 265 frail older patients ( 52 refused , 2 withdrawn , 27 ineligible , 2 deaths ) referred by family practitioners with allocation to intervention ( n = 95 ) or usual care ( n = 87 ) . INTERVENTION Three-month implementation of CGA recommendations by a Mobile Geriatric Assessment Team ( MGAT ) with follow-up assessment s at 3 , 6 , and 12 months . Geriatric nurse assessors , blinded to group assignment , performed each assessment . MAIN OUTCOME MEASURE Goal Attainment Scaling ( GAS ) . RESULTS Baseline characteristics were comparable between groups . At 3 months , the intervention group was more likely to attain their goals ( GAS total : chi = 46.4 + /- 5.9 ; GAS outcome chi = 48.0 + /- 6.6 ) compared with controls ( total : chi = 38.7 + /- 4.1 ; outcome chi = 40.8 + /- 5.6 ) ( P < .001 ) . St and ard assessment s of function ( Barthel index , instrumental activities of daily living ) , cognition ( Mini-Mental State Examination ) , and quality of life ( modified Spitzer quality of life index ) showed no difference over 12 months . No difference in survival ( intervention : chi = 320 days , SE = 6 ; control : chi = 294 days , SE = 6 ; P = .257 ) or time to institutionalization ( intervention : 340 days , SE = 9 ; control : 342 days , SE = 8 ; log rank = 0.661 ; P = .416 ) were observed . CONCLUSIONS A MGAT can target rural dwelling , frail older persons , perform in-home CGA , and develop an intervention strategy . Although the intervention did not prolong life or delay institutionalization , clinical ly important benefits were observed BACKGROUND AND OBJECTIVE Frail elderly patients have complex problems that require a multidimensional assessment and a range of treatment goals . Goal Attainment Scaling ( GAS ) measures multiple , individualized goals , but its responsiveness in comparative clinical trials has not been established . METHODS We assessed the responsiveness of GAS in a r and omized , controlled trial of an interdisciplinary Mobile Geriatric Assessment Team ( MGAT ) in 265 rural frail older adults . Sensitivity to change was compared with st and ard measures ; clinical meaningfulness was assessed in relation to a patient and a blinded physician global measure . RESULTS At 3 months follow-up , GAS was the most responsive measure ( st and ardized response mean 1.22 , Norman 's responsiveness statistic 0.58 ) compared with the Barthel Index ( 1.13 , 0.46 ) , Physical Self-Maintenance Scale ( 0.10 , 0.16 , 0.02 ) , Instrumental Activities of Daily Living ( 0.23 , 0.00 ) , and modified Spitzer Quality of Life Index ( -0.04 , 0.00 ) . CONCLUSIONS Only GAS detected clinical ly important change associated with the MGAT intervention in these frail elderly patients . Clinometric measures can offer a responsive means of evaluating complex interventions Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items We hypothesized that improved acute postoperative pain relief will be achieved using general anaesthesia ( GA ) either in combination with continuous thoracic paravertebral block ( GA-cPVB ) or single shot ( GA-sPVB ) as compared to GA supplemented by local wound infiltration ( GA-LWI ) after unilateral major breast cancer surgery . A r and omised controlled trial was conducted in 46 adult women in a day-care or short-stay hospital setting after major breast cancer surgery .  Pain-intensity was measured using an 11-point visual analogue scale ( VAS ) until postoperative day 2 . GA-sPVB was stopped due to slow inclusion .No significant difference in VAS score was noted between GA-LWI ( VAS median 0.5 ( interquartile range 0.18–2.00 ) ) and GA-cPVB , ( VAS 0.3 ( 0.00–1.55 , p = 0.195 ) ) 24 hours after surgery or at any point postoperatively until postoperative day 2.We conclude that both GA-LWI and GA-cPVB anaesthetic techniques are equally effective in treatment of acute postoperative pain after major oncological breast surgery . As GA-LWI is easily to perform with fewer complications and it is more cost-effective it should be preferred over GA-cPVB Abstract The age-adjusted International Prognostic Index ( IPI ) is an important prognostic factor for patients with non-Hodgkin lymphoma ( NHL ) . We investigated whether a geriatric assessment ( GA ) is of additional prognostic value in NHL . In this prospect i ve cohort study of 44 patients aged 70 years or older with NHL receiving rituximab , cyclophosphamide , doxorubicin , vincristine and prednisone ( R-CHOP )  , a GA was administered before the start of chemotherapy . GA was composed of the  Mini Nutritional Assessment ( MNA ) , Groningen Frailty Indicator ( GFI ) , Informant Question naire on Cognitive Decline in the Elderly ( IQCODE ) , Mini Mental State Examination ( MMSE ) and levels of albumin , creatinine , lactate dehydrogenase ( LDH ) and hemoglobin . Multivariate analyses were performed using logistic regression and the Cox regression model . After adjustment for sex , age , comorbidity and univariate laboratory values with p ≤ 0.1 , abnormal MNA and GFI scores and low hemoglobin level were associated with not being able to complete the intended chemotherapy : odds ratio ( OR ) 8.29 ( 95 % confidence interval [ CI ] : 1.24–55.6 ; p = 0.03 ) , 9.17 ( 95 % CI : 1.51–55.8 ; p = 0.02 ) and 5.41 ( 95 % CI : 0.99–29.8 ; p = 0.05 ) , respectively . Adjusted for sex , age , comorbidity , age-adjusted IPI and univariate laboratory values with p ≤ 0.1 , frailty by GFI and low hemoglobin were associated with worse survival , with a hazard ratio ( HR ) of mortality of 2.55 ( 95 % CI : 1.07–6.10 ; p = 0.04 ) and 4.90 ( 95 % CI : 1.76–13.7 ; p = 0.002 ) , respectively . We conclude that ( risk of ) malnutrition , measured with the MNA , frailty , measured with the GFI , and low hemoglobin level had additional predictive value for early treatment withdrawal , and GFI and hemoglobin were , independent of the age-adjusted IPI , predictive for an increased mortality risk This prospect i ve study evaluated components of a comprehensive geriatric assessment ( CGA ) to identify rates and predictors of falls in older patients . Fall rates and scores on components of the CGA were compared among adults aged 70 or older in three groups : patients with cancer receiving chemotherapy , patients with cancer not receiving chemotherapy , and community-dwelling adults without cancer . Older adults in the chemotherapy group were hypothesized to fall significantly more often than those in the nonchemotherapy group . Among the patients with cancer , scores on the Activities of Daily Living Scale were a significant predictor of falls . The scores were the only domain of the CGA found to be a significant predictor ; therefore , more research is needed to better underst and fall risk assessment among older patients with cancer . Nurses should conduct fall risk assessment s with measures of functional status as included in a CGA The number of published systematic review s of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions . Systematic review s are subject to a range of biases and increasingly include non-r and omised studies of interventions . It is important that users can distinguish high quality review s. Many instruments have been design ed to evaluate different aspects of review s , but there are few comprehensive critical appraisal instruments . AMSTAR was developed to evaluate systematic review s of r and omised trials . In this paper , we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic review s that include r and omised or non-r and omised studies of healthcare interventions , or both . With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic review s , including those based on non-r and omised studies of healthcare interventions PURPOSE To evaluate the influence of a dietary protocol on cone beam computed tomography ( CBCT ) image quality , which is an indirect indicator for short-term ( intrafraction ) prostate motion , and on interfraction motion . Image quality is affected by motion ( e.g. , moving gas ) during imaging and influences the performance of automatic prostate localization on CBCT scans . METHODS AND MATERIAL S Twenty-six patients ( 336 CBCT scans ) followed the dietary protocol and 23 patients ( 240 CBCT scans ) did not .  Prostates were automatically localized by using three dimensional ( 3D ) gray-value registration ( GR ) . Feces and ( moving ) gas occurrence in the CBCT scans , the success rate of 3D-GR , and the statistics of prostate motion data were assessed . RESULTS Feces , gas , and moving gas significantly decreased from 55 % , 61 % , and 43 % of scans in the nondiet group to 31 % , 47 % , and 28 % in the diet group ( all p < 0.001 ) . Since there is a known relation between gas and short-term prostate motion , intrafraction prostate motion probably also decreased . The success rate of 3D-GR improved from 83 % to 94 % ( p < 0.001 ) . A decrease in r and om interfraction prostate motion also was found , which was not significant after Bonferroni 's correction . Significant deviations from planning CT position for rotations around the left-right axis were found in both groups . CONCLUSIONS The dietary protocol significantly decreased the incidence of feces and ( moving ) gas . As a result , CBCT image quality and the success rate of 3D-GR significantly increased . A trend exists that r and om interfraction prostate motion decreases . Using a dietary protocol therefore is advisable , also without CBCT-based image guidance Allogeneic hematopoietic cell transplantation is increasingly utilized in older adults . This study prospect ively evaluated the prognostic utility of geriatric assessment domains prior to allogeneic transplantation  in recipients aged 50 years and over .  Geriatric assessment was performed prior to transplant , and included vali date d measures across domains of function and disability , comorbidity , frailty , mental health , nutritional status , and systemic inflammation . A total of 203 patients completed geriatric assessment and underwent transplant . Median age was 58 years ( range 50–73 ) . After adjusting for established prognostic factors , limitations in instrumental activities of daily living ( HR 2.38 , 95%CI : 1.59–3.56 ; P<0.001 ) , slow walk speed ( HR 1.80 , 95%CI : 1.14–2.83 ; P=0.01 ) , high comorbidity by hematopoietic cell transplantation-specific comorbidity index ( HR 1.56 , 95%CI : 1.07–2.28 ; P=0.02 ) , low mental health by short-form-36 mental component summary ( HR 1.67 , 95%CI : 1.13–2.48 ; P=0.01 ) , and elevated serum C-reactive protein ( HR 2.51 , 95%CI : 1.54–4.09 ; P<0.001 ) were significantly associated with inferior overall survival . These associations were more pronounced in the cohort 60 years and over . Geriatric assessment measures confer independent prognostic utility in older allogeneic transplant recipients . Implementation of geriatric assessment prior to allogeneic transplantation may aid appropriate selection of older adults Prediction relates to estimating the probability of something currently unknown . In the context of medical research , prediction typically concerns either diagnosis ( probability of a certain condition being present but not yet detected ) or prognosis ( probability of an outcome developing in the future ) ( 13 ) . Prognosis applies not only to sick persons or those with an established diagnosis but also to , for example , pregnant women at risk for diabetes ( 4 ) . Prediction research includes predictor finding studies , prediction model studies ( development , validation , and extending or updating ) , and prediction model impact studies ( 1 ) . Predictor finding studies ( also known as risk factor or prognostic factor studies ) aim to identify which predictors ( such as age , disease stage , or biomarkers ) independently contribute to the prediction of a diagnostic or prognostic outcome ( 1 , 5 ) . Prediction model studies aim to develop , vali date , or up date ( for example , extend ) a multivariable prediction model . A prediction model uses multiple predictors in combination to estimate probabilities to inform and often guide individual care ( 2 , 6 , 7 ) . These models can predict an individual 's probability of either currently having a particular outcome or disease ( diagnostic prediction model ) or having a particular outcome in the future ( prognostic prediction model ) . Both types of model are widely used in various medical domains and setting s ( 810 ) , as evidence d by the large number of models developed in cancer ( 11 , 12 ) , neurology ( 13 , 14 ) , and cardiovascular disease ( 15 ) . Prediction models are sometimes described as  risk prediction models , predictive models , prediction indices or rules , or risk scores ( 2 , 7 ) . An example is QRISK2 for predicting cardiovascular risk ( 16 ) . Prediction model impact studies evaluate the effect of using a model to guide patient care compared with not using such a model . They use a comparative design , such as a r and omized trial , to study the model 's effect on clinical decision making , patient outcomes , or costs of care ( 1 ) . Systematic review s have a key role in evidence -based medicine and the development of clinical guidelines ( 1719 ) . They are considered to provide the most reliable form of evidence for the effects of an intervention or diagnostic test ( 20 , 21 ) . Systematic review s of prediction models are a relatively new and evolving area but are increasingly undertaken to systematic ally identify , appraise , and summarize evidence on the performance of prediction models ( 1 , 6 , 22 ) . Assessing the quality of included studies is a crucial step in any systematic review ( 20 , 21 ) . The QUIPS ( Quality In Prognosis Studies ) tool has been developed to assess risk of bias ( ROB ) in predictor finding ( prognostic factor ) studies ( 23 ) . Research ers can use the revised Cochrane ROB Tool ( ROB 2.0 ) ( 24 ) to investigate the method ological quality of prediction model impact studies that use a r and omized comparative design , or ROBINS-I ( Risk Of Bias In Nonr and omized Studies of Interventions ) for those that use a nonr and omized comparative design ( 25 ) . As more prediction model studies and systematic review s of such studies are used as evidence for clinical guidance , a tool facilitating quality assessment for individual prediction model studies is urgently needed . We present PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) , a tool to assess the ROB and concerns regarding the applicability of diagnostic and prognostic prediction model studies . PROBAST can be used to assess studies of model development and model validation , including those updating a prediction model ( Box 1 [ 26 ] ) . We refer to the accompanying explanation and elaboration document ( 27 ) , for detailed explanations of how to use PROBAST and how to judge ROB and applicability . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 7 , 26 ) . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Methods : Development of PROBAST Development of PROBAST was based on a 4-stage approach for developing health research reporting guidelines : define the scope , review the evidence base , use a Web-based Delphi procedure , and refine the tool through piloting ( 28 ) . Guidelines explicitly aim ed at the development of quality assessment tools were not available at the time ( 29 ) . Development Stage 1 : Scope and Definitions A steering group of 9 experts in prediction model studies and development of quality assessment tools agreed on key features of the desired scope of PROBAST . A panel of 38 experts with different background s further refined the scope during the Web-based Delphi procedure . PROBAST was design ed mainly to assess primary studies included in a systematic review . The group agreed that PROBAST would assess both risk of bias and concerns regarding applicability of a study evaluating a multivariable prediction model to be used for individualized diagnosis or prognosis . A domain-based structure was adopted , similar to that used in other ROB tools , such as ROB 2.0 ( 24 ) , ROBINS-I ( 25 ) , QUADAS-2 ( Quality Assessment of Diagnostic Accuracy Studies 2 ) ( 30 ) , and ROBIS ( 31 ) . We agreed that PROBAST should cover primary studies that develop , vali date , or up date multivariable prediction models aim ing to make individualized predictions of a diagnostic or prognostic outcome ( Box 1 ) . Studies that use multivariable modeling techniques to identify predictors ( such as risk or prognostic factors ) associated with an outcome but do not attempt to develop , vali date , or up date a model for making individualized predictions are not covered by PROBAST ( 5 ) . Therefore , PROBAST is not intended for predictor finding studies or prediction model impact studies . Studies of diagnostic and prognostic models often use different terms for predictors and outcomes ( Box 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors for estimating probability or risk for an individual ( 6 , 7 , 3234 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Development Stage 2 : Review of Evidence We used the following 3 approaches to build an evidence base to inform the development of PROBAST : identifying relevant method ological review s in the area of prediction model research ( November 2012 to January 2013 ) , asking members of the steering group to identify relevant method ological studies ( January 2013 to March 2013 ) , and using the Delphi procedure to ask members of the wider group to identify additional evidence ( February 2012 to July 2014 ) . Identified literature was used to guide the scope and produce an initial list of signaling questions to consider for inclusion in PROBAST ( 1 , 2 , 57 , 26 , 3340 ) . We grouped signaling questions into common themes to identify possible domains . Additional literature provided as part of the Web-based surveys informed development of the explanation and elaboration document . Development Stage 3 : Web-Based Delphi Procedure We used a modified Delphi process to gain feedback and agreement on the scope , structure , and content of PROBAST . Web-based surveys were developed to gather structured feedback for each round . The 38-member Delphi group comprised method ological experts in prediction model research and development of quality assessment tools , experienced systematic review ers , commissioners , and representatives of reimbursement agencies . We included various stakeholders to ensure that the views of end users , method ological experts , and decision makers were represented . The Delphi process consisted of 7 rounds . Round 1 asked about the scope of the tool , and participants agreed to focus on prediction model studies and follow a domain-based structure . Round 2 aim ed to identify relevant domains and agree on which to include . The signaling questions for domains were refined in rounds 3 to 5 . Respondents used a 1-to-5 Likert scale to rate each proposed signaling question for inclusion . They could also suggest rephrasing , provide supporting evidence ( such as references to relevant studies ) , and suggest missing signaling questions . Round 6 refined the domains and introduced further optional guidance for using PROBAST . In the last round , participants received the agreed draft version of PROBAST and had the opportunity to provide any final feedback . Development Stage 4 : Piloting and Refining the Tool We held 6 workshops on PROBAST at consecutive annual Cochrane Colloquia ( Quebec , Canada , 2013 ; Hyderabad , India , 2014 ; Vienna , Austria , 2015 ; Seoul , South Korea , 2016 ; Cape Town , South Africa , 2017 ; and Edinburgh , United Kingdom , 2018 ) . We also held numerous consecutive workshops with MSc and PhD students ( for example , the master 's program in epidemiology at Utrecht University [ Utrecht , the Netherl and s ] and the Evidence -Based Health Care program at Oxford University [ Oxford , United Kingdom ] ) . In these workshops , we piloted the then-current version of PROBAST to gather feedback on practical issues associated with using the tool so that we could further refine and subsequently vali date it . Finally , more than 50 review groups have already piloted PROBAST versions , including the final version , in their review s. Topics included cancer , cardiology , endocrinology , pulmonology , and orthopedics . All feedback received from these initiatives was used to further inform the content and structure of PROBAST , wording of the signaling questions , and content of the guidance documents ( 27 ) . Results : The PROBAST Tool What Does PROBAST Assess ? PROBAST assesses both risk of bias and concerns regarding applicability of primary studies that developed or vali date d multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 ) Background Postoperative delirium ( POD ) is a manifestation of acute postoperative brain dysfunction that is frequently observed after cardiac surgery . POD is associated with short-term complications such as an increase in mortality , morbidity , costs and length of stay , but can also have long-term sequelae , including persistent cognitive deficits , loss of independence , and increased mortality for up to 2 years . The noble gas xenon has been demonstrated in various models of neuronal injury to exhibit remarkable neuroprotective properties . We therefore hypothesize that xenon anesthesia reduces the incidence of POD in elderly patients undergoing cardiac surgery with the use of cardiopulmonary bypass . Methods / Design One hundred and ninety patients , older than 65 years , and scheduled for elective cardiac surgery , will be enrolled in this prospect i ve , r and omized , controlled trial . Patients will be r and omized to receive  general anesthesia with either xenon or sevoflurane . Primary outcome parameter will be the incidence of POD in the first 5 postoperative days . The occurrence of POD will be assessed by trained research personnel , blinded to study group , with the vali date d 3-minute Diagnostic Confusion Assessment Method ( 3D-CAM ) ( on the intensive care unit in its version specifically adapted for the ICU ) , in addition to chart review and the results of delirium screening tools that will be performed by the bedside nurses ) . Secondary outcome parameters include duration and severity of POD , and postoperative cognitive function as assessed with the Mini-Mental State Examination . Discussion Older patients undergoing cardiac surgery are at particular risk to develop POD .  Xenon provides remarkable hemodynamic stability and has been suggested in pre clinical studies to exhibit neuroprotective properties . The present trial will assess whether the promising profile of xenon can be translated into a better outcome in the geriatric population .Trial registration EudraCT Identifier : 2014 - 005370 - 11 ( 13 May 2015 ) Objectives : The comprehensive geriatric assessment ( CGA ) can detect geriatric problems and potentially improve survival , physical , and cognitive state of patients , as well as increase an older person ’s chances of staying at home longer . In older people , the number and severity of comorbidity increase with age and are an important determinant of survival . The aim of the study was to assess to which extent CGA and comorbidities could be seen as determinants of survival . Material s and methods : This study analyzed data from two hospitals that included geriatric assessment s of patients aged 70 years and more with cancer linked to mortality .  Logistic regression was used to model survival predictors . Results : Two hundred and five various cancer patients ( 47 % females ) with a median age of 79 were included . They presented with a lot of undiagnosed geriatric problems . Screening scales ( G8 , SEGA ) , cognitive , and psychological disorders , and low albumin levels appeared to be independent survival factors . A frailty profile classification was associated with higher mortality . The average comorbidity was grade d 2 according to the Charlson scale . By the geriatric cumulative illness rating scale ( CIRS-G ) , the arithmetic average number of affected organ systems was 5 ( range 0–10 ) in all patients . Cardiovascular disorders were the most common comorbidity . Renal insufficiency and anaemia were negatively associated with survival . Conclusion : Old cancer patients present a lot of comorbidities and newly diagnosed geriatric problems . Several tools provide determinants of survival in old cancer patients . Prospect i ve trials evaluating the utility of a CGA to guide interventions to improve quality of cancer care in older adults are justified The link diet-cognitive function/dementia has been largely investigated in observational studies ; however , there was a lack of evidence from r and omized clinical trials ( RCTs ) on the prevention of late-life cognitive disorders though dietary intervention in cognitively healthy older adults . In the present article , we systematic ally review ed RCTs published in the last four years ( 2014 - 2017 ) exploring nutritional intervention efficacy in preventing the onset of late-life cognitive disorders and dementia in cognitively healthy subjects aged 60 years and older using different levels of investigation ( i.e. , dietary pattern changes/medical food/nutraceutical supplementation/multidomain approach and dietary macro- and micronutrient approaches ) as well as possible underlying mechanisms of nutritional prevention . From the 35 included RCTs , there was moderate evidence that intervention through dietary pattern changes , medical food/nutraceutical supplementation , and multidomain approach improved specific cognitive domains or cognitive-related blood biomarkers . There was high evidence that protein supplementation improved specific cognitive domains or functional status in prefrail older adults without effect on cognitive function . For fatty acid supplementation , mainly long-chain polyunsaturated fatty acids , there was emerging evidence suggesting an impact of this approach in improving specific cognitive domains , magnetic resonance imaging ( MRI ) findings , and /or cognitive-related biomarkers also in selected subgroups of older subjects , although some results were conflicting . There was convincing evidence of an impact of non-flavonoid polyphenol and flavonoid supplementations in improving specific cognitive domains and /or MRI findings . Finally , there was only low evidence suggesting efficacy of intervention with homocysteine-related and antioxidant vitamins in improving cognitive functions , dementia incidence , or cognitive-related biomarkers in cognitively healthy older subjects The objectives of this systematic literature review ( SLR ) were to identify domains and outcome measures used in psoriatic arthritis ( PsA ) studies in the past 5 years , and to compare the measurement of the Outcome Measures in Rheumatology ( OMERACT ) 2006 PsA Core Domain Set in studies published in 2010–2015 vs those published in 2006–2010 . We performed a systematic literature search in two data bases , PubMed and Embase , to identify r and omised controlled trials ( RCTs ) in PsA. We also identified PsA longitudinal observational studies ( LOS ) . Three patient research partners provided input into study conception , and data collection and interpretation . We identified 41 studies representing 22 unique RCTs , 27 LOS and 12 registries . Across all studies , we identified 24 domains and 169 outcome measures . In addition to the PsA Core Domain Set ( 6 domains ) , the following domains were also assessed in more than 30 % of RCTs : acute phase reactants , dactylitis , enthesitis , fatigue and work productivity . We identified a range of 1–15 outcome measures per domain with a mean ( SD ) of 7 ( 4.7 ) per domain . The complete PsA Core Domain Set was assessed in 59 % of RCTs in 2010–2015 compared to 23.5 % RCTs in 2006–2010 . There has been increased measurement of the PsA Core Domain Set in RCTs and LOS in the past 5 years . Numerous additional outcomes were also measured . The PsA Core Domain Set needs an up date to st and ardise PsA outcome assessment s. This SLR will inform the development of an up date d PsA Core Domain Set with patient research partner input Background In the general geriatric population , programs linking geriatric evaluation with interventions are effective for improving functional status and survival of the patients . Whether or not these interventions improve health related quality of life ( HRQoL ) or overall survival ( OS ) in older patients with cancer is not yet clear . Indeed , r and omized data on the effect of such interventions on survival and HRQoL are rare and conflicting . We describe the rationale and design of a phase III multicenter trial aim ed at assessing the efficacy of geriatric intervention in the management of elderly patients with cancer . Methods / design Approximately 1200 patients , 70 years and older , considered in need of a geriatric intervention based on the G8 screening tool will be r and omized into two intervention arms . The ‘ Usual-care ’ arm involves st and ard oncological care based on pre-defined oncological protocol s. In addition to the st and ard oncological care , the ‘ Case-management ’ arm involves a multidimensional geriatric assessment and interventions tailored for the patient . Efficacy will be assessed using a co- primary endpoint encompassing OS and HRQoL. Discussion This trial has been design ed to assess whether focused geriatric case management can either improve OS or HRQoL in elderly cancer patients considered in need of geriatric assessment .Trial registration Clinical trials.gov ID : NCT02704832 PURPOSE To determine the area and enlargement rate ( ER ) of geographic atrophy ( GA ) in patients with age-related macular degeneration ( AMD ) using the spectral domain optical coherence tomography ( SD-OCT ) fundus image . DESIGN Prospect i ve , longitudinal , natural history study . PARTICIPANTS Eighty-six eyes of 64 patients with ≥6 months of follow-up . METHODS Patients with GA secondary to AMD were enrolled in this study . Macular scans were performed using the Cirrus SD-OCT ( Carl Zeiss Meditec , Dublin , CA ) . The areas of GA identified on the SD-OCT fundus images were quantified using a digitizing tablet . Reproducibility of these measurements was assessed and the ER of GA was calculated . The usefulness of performing square root transformations of the lesion area measurements was explored . MAIN OUTCOME MEASURES Enlargement rate of GA . RESULTS At baseline , 27 % of eyes had a single area of GA . The mean total area at baseline was 4.59 mm(2 ) ( 1.8 disc areas [ DA ] ) . The mean follow-up time was 1.24 years . Reproducibility , as assessed with the intraclass correlation coefficient ( ICC ) , was excellent on both the original area scale ( ICC = 0.995 ) and the square root scale ( ICC = 0.996 ) . Inter grade r differences were not an important source of variability in lesion size measurement ( ICC = 0.999 , 0.997 ) . On average , the ER of GA per year was 1.2 mm(2 ) ( 0.47 DA ; range , 0.01 - 3.62 mm(2)/year ) . The ER correlated with the initial area of GA ( r = 0.45 ; P<0.001 ) , but there were variable growth rates for any given baseline area . When the square root transformation of the lesion area measurements was used as a measure of lesion size , the ER ( 0.28 mm/yr ) was not correlated with baseline size ( r = -0.09 ; P = 0.40 ) . In this cohort of lesions , no correlation was found between ER and length of follow-up . Square root transformation of the data helped to facilitate sample size estimates for controlled clinical trials involving GA . CONCLUSIONS The SD-OCT fundus image can be used to visualize and quantify GA . Advantages of this approach include the convenience and assurance of using a single imaging technique that permits simultaneous visualization of GA along with the loss of photoreceptors and the retinal pigment epithelium that should correlate with the loss of visual function OBJECTIVES To integrate the principles of geriatric assessment into the care of older patients with cancer in order to identify vulnerable older adults and develop interventions to optimize cancer treatment . DESIGN A brief , comprehensive , self-administered question naire and intervention algorithm were developed consisting of measures of  geriatric assessment  that are brief , reliable , vali date d , and predictive of mortality and morbidity in older patients . SETTING Academic tertiary care cancer center and community-based satellite practice . PARTICIPANTS Patients aged 65 and older with cancer . MEASUREMENTS The question naire solicits information about the patient 's functional status , comorbidity , psychological status , nutritional status , and social support . A scoring algorithm for referral to a multidisciplinary team was developed . RESULTS Two hundred forty-five of 250 patients completed the question naire ( mean age 76 , range 65 - 95 ) . The majority of patients were women ( 71 % ) , white ( 95 % ) , married ( 52 % ) , and retired ( 90 % ) , with a variety of tumor types and stages . Most patients ( 78 % ) completed the question naire on their own and reported acceptance of question naire length ( 91 % ) , no difficult questions ( 94 % ) , no up setting questions ( 96 % ) , and no missing questions ( 89 % ) . The mean time to completion was 15 minutes , with a median of 12.5 ( st and ard deviation 10 , range 2 - 60 ) . Information from this question naire helped identify physical and psychological impairments , poor nutrition , lack of social support , and untreated comorbidities . Appropriate referrals to a multidisciplinary team were made . CONCLUSION This brief , comprehensive , self-administered question naire is feasible for use in the outpatient oncology setting and helped identify the needs of geriatric oncology patients . Prospect i ve trials are needed to determine the effectiveness of the interventions offered Objective To evaluate the reliability of risk of bias assessment s based on published trial reports , for determining trial inclusion in meta-analyses . Design Reliability evaluation of risk of bias assessment s. Data sources 13 published individual participant data ( IPD ) meta-analyses in cancer were used to source 95 r and omised controlled trials . Review methods Risk of bias was assessed using the Cochrane risk of bias tool ( RevMan5.1 ) and accompanying guidance . Assessment s were made for individual risk of bias domains and overall for each trial , using information from either trial reports alone or trial reports with additional information collected for IPD meta-analyses . Percentage agreements were calculated for individual domains and overall ( < 66%=low , ≥66%=fair , ≥90%=good ) . The two approaches were considered similarly reliable only when agreement was good . Results Percentage agreement between the two methods for sequence generation and incomplete outcome data was fair ( 69.5 % ( 95 % confidence interval 60.2 % to 78.7 % ) and 80.0 % ( 72.0 % to 88.0 % ) , respectively ) . However , percentage agreement was low for allocation concealment , selective outcome reporting , and overall risk of bias ( 48.4 % ( 38.4 % to 58.5 % ) , 42.1 % ( 32.2 % to 52.0 % ) , and 54.7 % ( 44.7 % to 64.7 % ) , respectively ) . Supplementary information reduced the proportion of unclear assessment s for all individual domains , consequently increasing the number of trials assessed as low risk of bias ( and therefore available for inclusion in meta-analyses ) from 23 ( 23 % ) based on publications alone to 66 ( 66 % ) based on publications with additional information . Conclusions Using cancer trial publications alone to assess risk of bias could be unreliable ; thus , review ers should be cautious about using them as a basis for trial inclusion , particularly for those trials assessed as unclear risk . Supplementary information from trialists should be sought to enable appropriate assessment s and potentially reduce or overcome some risks of bias . Furthermore , guidance should ensure clarity on what constitutes risk of bias , particularly for the more subjective domains PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options Context Many Americans 65 years of age and older are at risk for functional decline , yet we know little about the quality of care for geriatric conditions . Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline .  Quality of care was highly variable from condition to condition but was generally better for general medical conditions , such as diabetes , than for geriatric conditions , such as incontinence . Implication s Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status . The Editors The quality of care among patients 65 years of age and older has not been extensively investigated , and most existing studies have focused on general adult medical conditions . This is surprising , considering that more than 40 % of all medical expenditures are for persons 65 years of age and older ( 1 ) . The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 ( 2 ) . Care for acute myocardial infa rct ion , heart failure , stroke , and pneumonia was evaluated by using inpatient medical records . Pneumonia , breast cancer , and diabetes indicators were evaluated by using survey and Medicare cl aims data . The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state . Several other studies of older patients evaluated cardiovascular conditions , diabetes , or aspects of preventive care and medication use ( 3 - 10 ) . No study , however , has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients . Furthermore , surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life ( 11 ) . Quality -of-care measurement for older patients that examines only a few conditions and only indicators aim ed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients . For this reason , we developed a  quality assessment system  that assesses more conditions . Together , these conditions account for a majority of all of the care older patients receive ( 12 ) and include several geriatric syndromes . We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline . Methods The Assessing Care of Vulnerable Elders ( ACOVE ) project developed and applied a quality assessment system for vulnerable older persons . The assessment system aim ed to develop quality indicators ( QIs ) that cover the spectrum of care for these patients . Indicators were implemented by using medical record abstract ion and patient interview . The ACOVE Quality -of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues . This system focused on processes ( care behaviors ) rather than outcomes for 2 reasons . First , although most agree that outcomes should be adjusted for risk when quality is measured , there is little consensus regarding the best severity measurement system ( 13 ) . Second , measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes ( 14 ) . The process measures were selected to represent the various domains of care : screening and prevention , diagnosis , treatment , and follow-up . The development of the assessment system was guided by a Policy Advisory Committee , which helped to direct the focus toward practical applications , and by a Clinical Committee , which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system ( 15 ) . The methods for selecting conditions and developing the QIs have been described in detail elsewhere ( 12 , 16 ) . In brief , the Clinical Committee used the criteria of prevalence , impact , effectiveness of prevention or treatment , need for quality improvement , feasibility of measurement , and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement ( 12 ) . For each of the 22 conditions , we developed a set of  evidence -based QIs  for vulnerable elders using a combination of systematic review s and expert judgment ( 16 ) . Of 420 proposed QIs , the 2 expert panels , the Clinical Committee , and the American College of Physicians Task Force on Aging accepted 236 as valid indicators ; these were assembled into the ACOVE QI set ( 17 ) . The 236 QIs covered the domains of care as follows : Sixty-one ( 26 % ) focused on screening and prevention , 50 ( 21 % ) focused on diagnosis , 84 ( 36 % ) focused on treatment , and 41 ( 17 % ) focused on follow-up and continuity of care . Examples of ACOVE QIs for each condition are presented in Table 1 . Table 1 . Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set , we assessed care provided to seniors who were enrolled in 2 managed care organizations . These patients were defined as vulnerable on the basis of self-report or proxy report on a brief , 13-item screening survey ( Vulnerable Elders-13 [ VE-13 ] Survey [ 18 ] ) . Vulnerable elders , identified by this function-based survey , are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable ( 18 ) . Each managed care organization , 1 in the northeastern United States and the other in the southwestern United States , had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care . Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions ( excluding nonmelanoma skin cancer ) during this period . A r and om sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a r and om-number generator . Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview . Patients who did not speak English were not eligible to participate . The R AND Institutional Review Board approved the study protocol . Medical Record Review Using administrative data , we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999 . Medical records were requested from primary care and specialist providers ( including eye care and mental health providers ) , acute care hospitals , skilled-nursing facilities , home health agencies , and facilities providing outpatient services ( for example , physical therapy ) . Identifying information of patients and providers was removed from the medical records . Trained nurses with previous experience in quality assessment performed medical record abstract ion . Abstract ors were provided with written abstract ion guidelines and real-time consultation with a senior nurse review er . The abstract or considered all of a patient 's records when assessing whether he or she was eligible for and received the indicated care processes . In other words , information on eligibility for a QI could have been derived from 1 record ( such as an outpatient note ) while the care process was delivered and documented in another setting ( for example , inpatient medical record ) . If the care process was performed in the defined time interval , care was scored as complying with the QI . The senior nurse review er also assessed each completed medical record abstract ion . Physicians review ed QIs that required a more detailed level of clinical assessment . Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia . An ophthalmologist evaluated selected data elements addressing vision care . Ten percent of all records were re abstract ed to evaluate reliability of the abstract ion process . Exact agreement on QI eligibility and score was 95 % . ( For details of abstract or preparation and abstract ion material s , see the Appendix . ) Quality -of-Care Interview A quality -of-care interview was conducted to ask study participants ( or , if participants were incapable of responding , their proxies ) about aspects of their care that might not be captured in the medical record ( for example , physicianpatient counseling ) . On the basis of conditions and medications reported during the interview , patients were asked about specific processes of care they had received . Patients were also asked about care preferences that might affect the applicability of QIs . In addition , the interview included demographic questions and functional status items . The quality -of-care interview was conducted by telephone between August and October 2000 and required , on average , 44 minutes to complete . Statistical Analysis Of the 236 QIs , we were able to evaluate 207 using chart abstract ion ( n = 185 [ 89 % ] ) or interview ( n = 22 [ 11 % ] ) . Interview was used to score  QIs  for data elements that we did not collect from the medical record . A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process ( Table 1 ) . A score of 1 was awarded if the care process was carried out , and a score of 0 was assigned if it was not . For QIs that included several triggering events , a score between 0 and 1 was possible . If the medical record indicated that the patient declined the care process , the QI was considered to be passed ( the care was credited in both the numerator and the denominator of the indicator score ) . On the other h and , if the patient had a OBJECTIVES The aim of this study was to assess the prevalence of potentially inappropriate medication ( PIM ) use upon admission and at discharge in a geriatric oncology unit after involving a clinical pharmacist . Although the few studies conducted in geriatric oncology units used the 2003 Beers criteria , this study used START and STOPP criteria , a more appropriate tool for European formularies . MATERIAL S AND METHODS Prospect i ve study in older ( ≥70years ) patients consecutively admitted to a geriatric oncology unit in a cancer center from July 2011 to April 2012 .  Clinical pharmacist conducted a complete comprehensive medication review including non-prescription and complementary ( herbals ) medications . This information coupled with the patient 's medical history allows identifying PIMs using the STOPP and START criteria . The number of PIMs at admission and at discharge from the hospital was compared after clinical pharmacist intervention . RESULTS Ninety-one older patients with cancer ( mean age±SD=79±6years ) were included in the study . START criteria identified 41 PIMs for 31 persons ( 34 % ) at admission compared to 7 PIMs for 6 persons ( 7 % ) at discharge . STOPP criteria identified 50 PIMs at admission for 29 persons ( 32 % ) compared to 16 PIMs at discharge for 14 persons ( 16 % ) . Results showed significantly lower START scores at discharge than at admission ( p<0.001 ) ; similarly , STOPP criteria demonstrated fewer PIMs at discharge than at admission ( p<0.001 ) . CONCLUSION The use of START and STOPP criteria by a clinical pharmacist allows identifying PIMs and changing prescriptions for older patients with cancer in agreement with the oncologist and geriatrician of the team Selecting the most appropriate end points for clinical trials is important to assess the value of new treatment strategies . Well-established end points for clinical research exist in oncology but may not be as relevant to the older cancer population because of competing risks of death and potentially increased impact of therapy on global functioning and quality of life . This article discusses specific clinical end points and their advantages and disadvantages for older individuals . R and omized or single-arm phase II trials can provide insight into the range of efficacy and toxicity in older population s but ideally need to be confirmed in phase III trials , which are unfortunately often hindered by the severe heterogeneity of the older cancer population , difficulties with selection bias depending on inclusion criteria , physician perception , and barriers in willingness to participate . All clinical trials in oncology should be without an upper age limit to allow entry of eligible older adults . In setting s where so-called st and ard therapy is not feasible , specific trials for older patients with cancer might be required , integrating meaningful measures of outcome . Not all questions can be answered in r and omized clinical trials , and large observational cohort studies or registries within the community setting should be established ( preferably in parallel to r and omized trials ) so that treatment patterns across different setting s can be compared with impact on outcome . Obligatory integration of a comparable form of geriatric assessment is recommended in future studies , and regulatory organizations such as the European Medicines Agency and US Food and Drug Administration should require adequate collection of data on efficacy and toxicity of new drugs in fit and frail elderly sub population Background Interventions for preventing  falls in older people often involve several components , multidisciplinary teams , and implementation in a variety of setting s. We have developed a classification system ( taxonomy ) to describe interventions used to prevent falls in older people , with the aim of improving the design and reporting of clinical trials of fall-prevention interventions , and synthesis of evidence from these trials . Methods Thirty three international experts in falls prevention and health services research participated in a series of meetings to develop consensus . Robust techniques were used including literature review s , expert presentations , and structured consensus workshops moderated by experienced facilitators . The taxonomy was refined using an international test panel of five health care practitioners . We assessed the chance corrected agreement of the final version by comparing taxonomy completion for 10 r and omly selected published papers describing a variety of fall-prevention interventions . Results The taxonomy consists of four domains , summarized as the " Approach " , " Base " , " Components " and " Descriptors " of an intervention . Sub-domains include ; where participants are identified ; the theoretical approach of the intervention ; clinical targeting criteria ; details on assessment s ; descriptions of the nature and intensity of interventions . Chance corrected agreement of the final version of the taxonomy was good to excellent for all items . Further independent evaluation of the taxonomy is required . Conclusions The taxonomy is a useful instrument for characterizing a broad range of interventions used in falls prevention . Investigators are encouraged to use the taxonomy to report their interventions
All eight domains were predictive for at least one of the investigated outcomes but the results were quite variable across studies .
Physical function and nutritional status were the domains most often associated with mortality and systemic treatment-related outcomes , and the domain physical function was most often associated with postoperative complications .
Overall , this review demonstrates that the GA should minimally consist of physical function and nutritional status , when the aim is to predict patients -related outcomes of older patients with cancer , although the results are quite heterogeneous .
BACKGROUND A geriatric assessment ( GA ) is increasingly used to help guide treatment decisions in older patients with cancer .
However , there is no consensus regarding which domains should be included in the GA .
In addition , the field of geriatric oncology moves very fast and as a result many new studies have been published since the last review in 2015 .
Therefore , the objective of this systematic review is to evaluate which domains of the GA could predict patient-related treatment outcomes of older patients with cancer and thereby should be included in a GA .