2 Minute Medicine Rewind June 2, 2025
1. Frailty identified by all five commonly used frailty scales was associated with an increased risk of long-term mortality.
2. Among hospitalized patients, the comprehensive geriatric assessment-frailty index (CGA-FI) had the highest accuracy in predicting 5-year all-cause mortality, whereas the Clinical Frailty Scale (CFS) was the most sensitive.
Evidence Rating Level: 2 (Good)
The prevalence of frailty is rising globally with the aging population. Frailty is associated with adverse health outcomes events and all-cause mortality. Despite the availability of various scales to assess frailty, no studies have compared these scales to determine their long-term prognostic value in older hospitalized patients in non-Western populations. This study thus evaluated five commonly used frailty scales to determine the frailty scale that most accurately predicts long-term all-cause mortality in hospitalized patients. This prospective cohort study enrolled 917 inpatients aged ≥ 65 years in a hospital in Beijing, China between September 2018 and February 2019. During hospitalization, the five scales used to screen or assess frailty were the Clinical Frailty Scale (CFS), The FRAIL Scale (FRAIL), The Fried Frailty Phenotype (Fried), The Edmonton Frail Scale (Edmonton), and the comprehensive geriatric assessment-frailty index (CGA-FI). Telephone follow-ups at 3 months, 6 months, and annually were conducted for 5 years. The primary outcome was 5-year all-cause mortality. In total, 917 patients completed the 5-year follow-up (mean age [SD] = 75.3 [6.8] years, female [%] = 422 females [48.2%]). The prevalence of frailty was 36.5% (CFS), 19.5% (FRAIL), 31.9% (Fried), 25.4% (Edmonton), and 35.8% (CGA-FI). Patients with frailty had a higher mortality risk across all scales. After multivariate adjustment, the hazard ratios (HR) from highest to lowest, were: CGA-FI (HR = 3.284, 95%CI 1.819–5.929), FRAIL (HR = 3.254, 95%CI 1.951–5.426), Fried (HR = 2.668, 95%CI 1.591–4.473), CFS (HR = 1.8, 95%CI 1.051–3.082), and Edmonton (HR = 1.699, 95%CI 1.033–2.796). CFS, FRAIL, Fried, and CGA-FI had area under the curves (AUCs) ranging from 0.70 to 0.75 (all p < 0.001), demonstrating moderate performance in predicting mortality. CGA-FI had the largest AUC of 0.724, revealing the best predictive value, while FRAIL had the smallest AUC of 0.666 revealing the worst predictive value. Although the AUCs of Fried, Edmonton, and CFS gradually decreased (0.726, 0.71, and 0.708, respectively), the differences were not statistically significant. Furthermore, CFS had the highest sensitivity at 0.775. Overall, this study found that frailty identified by all scales was associated with an increased risk of long-term mortality. CGA-FI was the most accurate assessment scale, whereas CFS was the most sensitive and may be more suitable for frailty screening. As this study was conducted in a Chinese population, future research should confirm study findings in other populations.
Hydrocortisone and Risk Factors for Kidney Replacement Therapy in Septic Shock
1. Intravenous hydrocortisone treatment was associated with reduced odds of new kidney replacement in patients with septic shock.
Evidence Rating Level: 2 (Good)
The incidence of sepsis-associated acute kidney injury (SA-AKI) is increasing among patients admitted to the intensive care unit (ICU). SA-AKI is associated with an increased risk of mortality and kidney impairment among survivors. Although extensive research exists on the corticosteroid hydrocortisone as an adjunctive therapy in septic shock, research on its impact on SA-AKI and kidney replacement therapy (KPT) requirement is limited. This study thus examined the association between intravenous hydrocortisone and the incidence of subsequent KRT requirement. This cohort study was a post hoc analysis of the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) randomized clinical trial (RCT). This multicenter placebo-controlled RCT of hydrocortisone included patients from ICUs in Australia, the United Kingdom, New Zealand, Saudi Arabia, and Denmark recruited between 2013 and 2017. The post-hoc analysis included all patients enrolled in the ADRENAL study with septic shock who did not require KRT in the 24 hours prior to randomization and who did not have a prior longstanding dialysis requirement. The primary outcome was the incidence of new KRT requirement following randomization. Out of the 3,161 patients included (median [IQR] age = 65 [53-74] years, male [%] = 1,921 [61%]), 1,589 patients were randomized to receive hydrocortisone and 1,572 received the placebo. Patients in the hydrocortisone group had a reduced incidence of new KRT requirement compared with those in the placebo group (329 patients [21%] vs 372 patients [24%]; odds ratio [OR], 0.84 [95% CI, 0.70 to 0.99]; P = .04). Hydrocortisone treatment remained associated with reduced odds of new KRT requirement (OR, 0.79 [95% CI, 0.66 to 0.95]; P = .01), even after adjusting for factors associated with KRT requirement. Among patients who started KRT after randomization, hydrocortisone treatment was not associated with reduced days alive and free of KRT (mean difference, 1.28 [95% CI, −4.31 to 6.87] days; P = .65). Overall, this study found that use of adjunctive hydrocortisone was associated with reduced risk of new KRT requirement. Future studies are needed to confirm these findings.
1. Non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) was independently associated with early cognitive impairment in patients with mild acute ischemic stroke.
Evidence Rating Level: 3 (Average)
Patients with acute ischemic stroke (AIS) commonly exhibit early cognitive impairment, which adversely impacts their quality of life and functional recovery. Dyslipidemia is an independent risk factor for AIS and plays an important role in cognitive impairment. Although evidence suggests that non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is more effective than traditional lipid parameters in predicting the risk of various cardiometabolic conditions, limited research exists on its relationship with early cognitive function in patients with AIS. This study thus examined the association between NHHR and early cognitive impairment in patients with AIS. This cross-sectional study included patients with AIS admitted to a hospital in China between January 2023 and January 2025. Cognitive function was evaluated within two weeks of acute cerebral infarction using the Mini-Mental State Examination (MMSE), with cognitive impairment determined by education-stratified thresholds. NHHR was calculated as total cholesterol—HDL-C)/HDL-C. Patients were stratified by NHHR into quartiles: Q1 (0.544–2.072), Q2 (2.072–2.904), Q3 (2.904–3.918), Q4 (3.918–15.591). Out of the 817 patients included in the study, 473 had cognitive impairment (mean age [SD] = 66.12 [9.62] years, male [%] = 312 [65%]) and 344 had normal cognition (mean age [SD] = 59.54 [9.77] years, male [%] = 234 [68%]). There was a dose-response relationship between NHHR quartiles and the incidence of cognitive impairment, with rates increasing from 51.7% in Q1 to 63.7% in Q4 (trend test P = 0.021). Multivariate regression analysis revealed each unit increase in NHHR was associated with a 13.2% increased risk of cognitive impairment (OR = 1.13, 95% confidence interval (CI) 1.02–1.25, P = 0.018). Overall, this study found NHHR to be a risk factor for early cognitive impairment in patients with AIS, highlighting its importance as a potential biomarker for cognitive decline in this population. Future longitudinal studies are needed to confirm these findings.
Weight Loss in Midlife, Chronic Disease Incidence, and All-Cause Mortality During Extended Follow-Up
1. Participants with sustained midlife weight loss from nonsurgical and nonpharmacological intervention had a decreased risk of chronic diseases beyond type 2 diabetes, and decreased risk of all-cause mortality, compared to participants with persistent overweight.
Evidence Rating Level: 2 (Good)
Although behavioral weight loss among individuals with overweight and obesity has been linked to decreased risk of diabetes, there are conflicting findings on its long-term association with other major diseases. This study thus investigated the long-term association between nonsurgical and nonpharmacological weight reduction in healthy midlife (aged 40-50 years) and later-life morbidity and mortality. This cohort included participants without chronic disease at baseline from three cohorts: the Whitehall II study (WHII; baseline, 1985-1988), Helsinki Businessmen Study (HBS; baseline, 1964-1973), and Finnish Public Sector study (FPS; baseline, 2000). Based on the first two BMI assessments, participants were categorized into four groups: persistent healthy weight (BMI <25), weight loss from overweight to healthy weight (BMI change from ≥25 to <25), weight gain from healthy weight to overweight (BMI change from <25 to ≥25), and persistent overweight (BMI ≥25). Weight loss was presumed to be intentional, as BMI measurements were taken during a period when surgical and pharmacological weight-loss interventions were nearly non-existent, and participants were of midlife age and with no diagnosed disease. The outcome in WHII and FPS was the incidence of chronic disease, including type 2 diabetes, myocardial infarction, stroke, cancer, asthma, or chronic obstructive pulmonary disease. The outcome in HBS was all-cause mortality. Among the 23,149 participants included from all three cohorts, there were 4,118 participants from WHII (median [IQR] age at first visit = 39 [37-42] years; men [%] = 2,968 [72.1%]), 2,335 men from HBS (median [IQR] age at first visit = 42 [38-45] years), and 16,696 participants from FPS (median [IQR] age at first visit = 39 [34-43] years; 13,785 women [82.6%]). The median (IQR) follow-up for WHII, FPS, and HBS were 22.8 (16.9-23.3) years, 12.2 (8.2-12.2) years, and 35 (23-43) years, respectively. WHII participants with weight loss had a decreased risk of developing chronic disease (hazard ratio [HR], 0.52; 95% CI, 0.35-0.78) compared with participants with persistent overweight. This association remained after excluding diabetes from the outcome (HR, 0.58; 95% CI, 0.37-0.90). These results were replicated in FPS, where participants with weight loss had an HR of 0.43 (95% CI, 0.29-0.66) before and 0.70 (95% CI, 0.62-0.79) after excluding diabetes, compared with those with persistent overweight. In HBS, weight loss was associated with decreased mortality (HR, 0.81; 95% CI, 0.68-0.96). Overall, this study found that sustained weight loss without surgical or pharmacological treatment was associated with a decreased risk of chronic disease beyond type 2 diabetes and decreased all-cause mortality. Future studies using alternative metrics of weight loss are needed to validate these findings.
Geriatric ocular trauma and mortality: A retrospective cohort study
1. Geriatric patients with ocular trauma had higher mortality rates within 5 years, particularly within the first year post-injury.
Evidence Rating Level: 2 (Good)
Ocular trauma is a leading cause of vision loss and may be a result of falls. In addition to contributing to severe injuries, falls are also associated with an increased risk of mortality in the elderly. Although numerous studies have examined visual deficits and the frequency of falls leading to hospitalizations or ocular morbidity, research exploring the link between ocular trauma and mortality is limited. This study thus examined the association between geriatric ocular trauma and mortality. This retrospective cohort study analyzed data from the I2B2 Carolina Data Warehouse and included patients >65 years recruited between April 2011 and June 2016, with a minimum of five years of follow-up from the time of presentation. The study group included patients with ocular trauma, which included injuries to the eye and orbit, open wounds of the eyelid and periocular area, fractures of the orbital floor, facial bones, injury to the conjunctiva, contusion of the eyeball, ocular laceration, penetrating wounds of the orbit, or avulsion of the eye. Patients who were victims of transport accidents, homicide, assault, vehicle accidents, or intentional injury were excluded. The control group consisted of patients with age-related nuclear cataracts. In total, 602 patients suffered ocular trauma (mean age = 80.7, female [%] = 391 [64.9]) and 1,066 patients of similar age had age-related nuclear cataracts (mean age = 75.6, female [%] = 624 [58.5]). Within five years, 74 (11.30%) patients died in the study group and 69 patients (6.47%) died in the control group. For the study group, the annual mortality rates were 4.15%, 2.60%, 1.96%, 2.54%, and 0.56%, respectively. For the control group, the annual mortality rates were 1.03%, 1.70%, 1.64%, 0.88%, and 1.38% respectively. Overall, the study finding suggests that geriatric patients with ocular trauma are at a higher risk of mortality compared to age-matched controls without such injuries, particularly within the first year post-injury. These findings underscore the importance of multidisciplinary interventions such as fall prevention strategies and post-trauma geriatric assessments to reduce mortality risk.
Image: PD
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