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Nickel CH, Kellett J. Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change? Clin Geriatr Med 2023; 39:475-489. [PMID: 37798060 DOI: 10.1016/j.cger.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.
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Affiliation(s)
- Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Denmark
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Shehadeh AA, McLaren GW, Collins JT, Munene G, Sawyer RG, Shebrain SA. Frailty as a Predictor of Surgical Outcomes Following Femoral Hernia Repair. Am Surg 2023; 89:2254-2261. [PMID: 35428419 DOI: 10.1177/00031348221084085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Femoral hernias are associated with significant morbidity and mortality due to risk of strangulation. Frailty has shown to be strongly associated with adverse outcomes. A modified five-factor frailty index (mFI-5) is a simple validated predictor of postoperative complications and mortality within the ACS-NSQIP® database. This study aims to evaluate the impact of frailty and age on 30-day outcomes after femoral hernia repair. METHODS Patients who underwent femoral hernia repair were queried using the ACS-NSQIP database (2017) and divided into two groups based on frailty score (FS): Frail (FS = 1-5) and Non-frail (FS = 0). We evaluated the association between postoperative outcomes and frailty, age, sex, presentation, ASA class, timing of surgery, and surgical approaches. Univariate analysis followed by a multivariable logistic regression model was performed to evaluate postoperative morbidity. RESULTS Of a total of 1,295 patients, 540 (42.7%) were in the Frail group. No differences in sex and race proportions were observed between groups. The Frail group had a higher rate of serious morbidity (4.4% vs 1.9%, P < .001), overall morbidity (7.8% vs 3.4%, P < .010), readmission rate (5.4% vs 2.3%, P = .003), and median (IQR) hospital length of stay (1 [0, 4] vs 0 [0, 1] days, P < .001). In multivariable analysis, male sex, presentation with complication, emergency surgery, and FS were associated with increased odds of overall morbidity. All deaths were in the Frail group. CONCLUSION(S) Frailty, male sex, presentation with obstruction/strangulation, and emergency surgery are independent predictors of increased 30-day morbidity. Thirty-day mortality was noted in the Frail group.
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Affiliation(s)
- Ayman A Shehadeh
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Graham W McLaren
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - John T Collins
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga Munene
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Saad A Shebrain
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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Chin M, Kendzerska T, Inoue J, Aw M, Mardiros L, Pease C, Andrew MK, Pakhale S, Forster AJ, Mulpuru S. Comparing the Hospital Frailty Risk Score and the Clinical Frailty Scale Among Older Adults With Chronic Obstructive Pulmonary Disease Exacerbation. JAMA Netw Open 2023; 6:e2253692. [PMID: 36729458 PMCID: PMC9896302 DOI: 10.1001/jamanetworkopen.2022.53692] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Frailty is associated with severe morbidity and mortality among people with chronic obstructive pulmonary disease (COPD). Interventions such as pulmonary rehabilitation can treat and reverse frailty, yet frailty is not routinely measured in pulmonary clinical practice. It is unclear how population-based administrative data tools to screen for frailty compare with standard bedside assessments in this population. OBJECTIVE To determine the agreement between the Hospital Frailty Risk Score (HFRS) and the Clinical Frailty Scale (CFS) among hospitalized individuals with COPD and to determine the sensitivity and specificity of the HFRS (vs CFS) to detect frailty. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was conducted among hospitalized patients with COPD exacerbation. The study was conducted in the respiratory ward of a single tertiary care academic hospital (The Ottawa Hospital, Ottawa, Ontario, Canada). Participants included consenting adult inpatients who were admitted with a diagnosis of acute COPD exacerbation from December 2016 to June 2019 and who used a clinical care pathway for COPD. There were no specific exclusion criteria. Data analysis was performed in March 2022. EXPOSURE Degree of frailty measured by the CFS. MAIN OUTCOMES AND MEASURES The HFRS was calculated using hospital administrative data. Primary outcomes were the sensitivity and specificity of the HFRS to detect frail and nonfrail individuals according to CFS assessments of frailty, and the secondary outcome was the optimal probability threshold of the HFRS to discriminate frail and nonfrail individuals. RESULTS Among 99 patients with COPD exacerbation (mean [SD] age, 70.6 [9.5] years; 56 women [57%]), 14 (14%) were not frail, 33 (33%) were vulnerable, 18 (18%) were mildly frail, and 34 (34%) were moderately to severely frail by the CFS. The HFRS (vs CFS) had a sensitivity of 27% and specificity of 93% to detect frail vs nonfrail individuals. The optimal probability threshold for the HFRS was 1.4 points or higher. The corresponding sensitivity to detect frailty was 69%, and the specificity was 57%. CONCLUSIONS AND RELEVANCE In this cross-sectional study, using the population-based HFRS to screen for frailty yielded poor detection of frailty among hospitalized patients with COPD compared with the bedside CFS. These findings suggest that use of the HFRS in this population may result in important missed opportunities to identify and provide early intervention for frailty, such as pulmonary rehabilitation.
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Affiliation(s)
- Melanie Chin
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jiro Inoue
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael Aw
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Linda Mardiros
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Pease
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Melissa K. Andrew
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Smita Pakhale
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan J. Forster
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
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Role of Endothelial Progenitor Cells in Frailty. Int J Mol Sci 2023; 24:ijms24032139. [PMID: 36768461 PMCID: PMC9916666 DOI: 10.3390/ijms24032139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Frailty is a clinical condition closely related to aging which is characterized by a multidimensional decline in biological reserves, a failure of physiological mechanisms and vulnerability to minor stressors. Chronic inflammation, the impairment of endothelial function, age-related endocrine system modifications and immunosenescence are important mechanisms in the pathophysiology of frailty. Endothelial progenitor cells (EPCs) are considered important contributors of the endothelium homeostasis and turn-over. In the elderly, EPCs are impaired in terms of function, number and survival. In addition, the modification of EPCs' level and function has been widely demonstrated in atherosclerosis, hypertension and diabetes mellitus, which are the most common age-related diseases. The purpose of this review is to illustrate the role of EPCs in frailty. Initially, we describe the endothelial dysfunction in frailty, the response of EPCs to the endothelial dysfunction associated with frailty and, finally, interventions which may restore the EPCs expression and function in frail people.
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Leblanc A, Diab N, Backman C, Huang S, Pulfer T, Chin M, Kobewka DM, McIsaac DI, Lawson J, Forster AJ, Mulpuru S. Development and assessment of an educational intervention to improve the recognition of frailty on an acute care respiratory ward. BMJ Open Qual 2022; 11:bmjoq-2022-001935. [PMID: 36454710 PMCID: PMC9362820 DOI: 10.1136/bmjoq-2022-001935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Frailty is a robust predictor of poor outcomes among patients with chronic obstructive pulmonary disease yet is not measured in routine practice. We determined barriers and facilitators to measuring frailty in a hospital setting, designed and implemented a frailty-focused education intervention, and measured accuracy of frailty screening before and after education. METHODS We conducted a pilot cross-sectional mixed-methods study on an inpatient respiratory ward over 6 months. We recruited registered nurses (RNs) with experience using the Clinical Frailty Scale (CFS). RNs evaluated 10 clinical vignettes and assigned a frailty score using the CFS. A structured frailty-focused education intervention was delivered to small groups. RNs reassigned frailty scores to vignettes 1 week after education. Outcomes included barriers and facilitators to assessing frailty in hospital, and percent agreement of CFS scores between RNs and a gold standard (determined by geriatricians) before and after education. RESULTS Among 26 RNs, the median (IQR) duration of experience using the CFS was 1.5 (1-4) months. Barriers to assessing frailty included the lack of clinical directives to measure frailty and large acute workloads. Having collateral history from family members was the strongest perceived facilitator for frailty assessment. The median (IQR) percent agreement with the gold-standard frailty score across all cases was 55.8% (47.2%-60.6%) prior to the educational intervention, and 57.2% (44.1%-70.2%) afterwards. The largest increase in agreement occurred in the 'mildly frail' category, 65.4%-81% agreement. CONCLUSIONS Barriers to assessing frailty in the hospital setting are external to the measurement tool itself. Accuracy of frailty assessment among acute care RNs was low, and frailty-focused rater training may improve accuracy. Subsequent work should focus on health system approaches to empower health providers to assess frailty, and on testing the effectiveness of frailty-focused education in large real-world settings.
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Affiliation(s)
- Aaron Leblanc
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nermin Diab
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Chantal Backman
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley Huang
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Melanie Chin
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel M Kobewka
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lawson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Roberts MH, Mapel DW, Ganvir N, Dodd MA. Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes. Int J Chron Obstruct Pulmon Dis 2022; 17:701-717. [PMID: 35411140 PMCID: PMC8994612 DOI: 10.2147/copd.s348714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/12/2022] [Indexed: 12/14/2022] Open
Abstract
Rationale Frailty prevalence estimates among individuals with COPD have varied widely, and few studies have investigated relationships between frailty and adverse outcomes in a COPD population. Objective(s) Describe frailty prevalence among individuals with and without COPD and examine associations between frailty and mortality and other adverse outcomes in the next two years. Methods This was an observational cohort study using Health and Retirement Study data (2006–2018) of community living individuals ages 50–64 and ≥65 with and without COPD (non-COPD). Frailty (Fried phenotype [5 items], and a modified Frailty Index-Comprehensive Geriatric Assessment [Enhanced FI-CGA] [37 items], and debility (modified BODE Index [4 items]) were assessed. Two-year post-assessment outcomes (mortality, ≥1 inpatient stay, home health and skilled nursing facility (SNF) use) were reviewed in a population matched 3:1 (non-COPD: COPD) on age, sex, race, and year using univariate and multivariate logistic regression (adjusted for morbidities). Area-under-the-curve (AUC) was used to evaluate regressions. Results The study included 18,979 survey observations for age 50–64, and 24,162 age ≥65; 7.8% and 12.0% respectively reporting a diagnosis of COPD. Fried phenotype frailty prevalence for age ≥65 was 23.1% (COPD) and 9.4% (non-COPD), and for the Enhanced FI-CGA, 45.9% (COPD) and 22.4% (non-COPD). Two-year mortality for COPD was more than double non-COPD for age 50–64 (95% CI: 3.8–5.9% vs 0.7–1.3%) and age ≥65 (95% CI: 11.9–14.3% vs 5.6–6.6%). Inpatient utilization, home health care use, or at least temporary SNF placement were also more frequent for COPD. Measures were predictive of adverse outcomes. In adjusted models, the Fried phenotype and modified BODE score performed similarly, and both performed better than the Enhanced FI-CGA index. AUC values were higher for morality regressions. Conclusion Frailty prevalence among individuals with COPD in this national survey is substantially greater than without COPD, even at pre-retirement (50–64 years). These measures identify patients with increased risk of poor outcomes.
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Affiliation(s)
- Melissa H Roberts
- College of Pharmacy, The University of New Mexico, Albuquerque, NM, USA
- Correspondence: Melissa H Roberts, College of Pharmacy, The University of New Mexico, 2502 Marble Ave, Albuquerque, NM, 87106, USA, Tel +1 505 925 0953, Fax +1 505 272 6749, Email
| | - Douglas W Mapel
- College of Pharmacy, The University of New Mexico, Albuquerque, NM, USA
- Northern Arizona Pulmonary Associates/Critical Care Consultants of Arizona, Flagstaff, AZ, USA
| | - Nikhil Ganvir
- Department of Economics, The University of New Mexico, Albuquerque, NM, USA
| | - Melanie A Dodd
- College of Pharmacy, The University of New Mexico, Albuquerque, NM, USA
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Iles KA, Duchesneau E, Strassle PD, Chrisco L, Howell TC, King B, Williams FN, Nizamani R. Higher Admission Frailty Scores Predict Increased Mortality, Morbidity, and Healthcare Utilization in the Elderly Burn Population. J Burn Care Res 2021; 43:315-322. [PMID: 34794175 DOI: 10.1093/jbcr/irab221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The Rockwood Clinical Frailty Scale is a validated rapid assessment of frailty phenotype and predictor of mortality in the geriatric population. Using data from a large tertiary care burn center, we assessed the association between admission frailty in an elderly burn population and inpatient outcomes. This was a retrospective analysis of burn patients ≥ 65 years from 2015-2019. Patients were assigned to frailty subgroups based on comprehensive medical, social work, and therapy assessments. Cox proportional hazards regression was used to estimate associations between admission frailty and 30-day inpatient mortality. Our study included 644 patients (low frailty: 262, moderate frailty: 345, and high frailty: 37). Frailty was associated with higher median TBSA and age at admission. The 30-day cumulative incidence of mortality was 2.3%, 7.0%, and 24.3% among the low, moderate, and high frailty strata, respectively. After adjustment for age, TBSA, and inhalation injury, high frailty was associated with increased 30-day mortality, compared to low (HR 5.73; 95% CI 1.86, 17.62). Moderate frailty also appeared to increase 30-day mortality, although estimates were imprecise (HR 2.19; 95% CI 0.87-5.50). High frailty was associated with increased morbidity and healthcare utilization, including need for intensive care stay (68% vs 37% and 21%, p<0.001) and rehab or care facility at discharge (41% vs 25% and 6%, p<0.001), compared to moderate and low frailty subgroups. Our findings emphasize the need to consider pre-injury physiological state and the increased risk of death and morbidity in the elderly burn population.
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Affiliation(s)
- Kathleen A Iles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Emilie Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paula D Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health, Bethesda, Maryland
| | - Lori Chrisco
- Department of Burn Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - T Clark Howell
- Department of Surgery, Duke University, Durham, North Carolina
| | - Booker King
- Department of Burn Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Felicia N Williams
- Department of Burn Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rabia Nizamani
- Department of Burn Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Supportive and palliative care for people with chronic respiratory disease and frailty. Curr Opin Support Palliat Care 2021; 14:206-212. [PMID: 32740274 DOI: 10.1097/spc.0000000000000523] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Frailty is a multidimensional syndrome associated with increased risk of poor outcomes. It is estimated that at least one in five people with chronic respiratory disease is also living with frailty. In this review, we consider recent advances in how frailty can be recognized, and its associated impact on people with chronic respiratory disease. We then discuss advances in supportive and palliative care for those with both chronic respiratory disease and frailty. RECENT FINDINGS The interconnectedness of chronic respiratory disease and frailty is being better understood. An increasing number of factors associated with frailty in respiratory disease have been identified, from increased symptom burden (e.g. breathlessness, fatigue) to increased exacerbations and higher mortality. These contribute to accumulating multidimensional losses in reserve, and unpredictable health. Recent advances in respiratory research, while not always with people with frailty, may inform supportive and palliative care to address frailty in chronic respiratory disease. These include rehabilitation interventions to strengthen reserves, advance care planning interventions to help manage unpredictable trajectories, and integrated models of care (e.g. incorporating respiratory, geriatric, and palliative care) to address multidimensional needs. SUMMARY Recent evidence supporting the role of rehabilitation, advance care planning, and early palliative care, may be of benefit to people living with chronic respiratory disease and frailty. Models showing integration across multiple specialities and professionals may have the most potential to meet the multidimensional needs of this group. Future research should develop and test models of care that address frailty and/or explore the role of frailty in triggering integrated multidisciplinary input.
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Laugesen SKN, Nissen SK, Kellett J, Brabrand M, Cooksley T, Nickel CH. Impaired Mobility, Rather Than Frailty, Should Be a Vital Sign. Chest 2019; 155:877-878. [PMID: 30955577 DOI: 10.1016/j.chest.2018.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sune K N Laugesen
- Department of Emergency Medicine, Odense University Hospital, Odense.
| | | | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense; Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg
| | - Tim Cooksley
- Department of Acute Medicine, University Hospital of South Manchester
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