Showing papers in "Canadian Medical Association Journal in 2004"
TL;DR: The overall incidence rate of AEs of 7.5% in this study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
Abstract: Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
2,255 citations
TL;DR: An epidemic of CDAD with an increased case-fatality rate has had important consequences on the elderly population of Quebec and the equivalence of vancomycin and metronidazole in the treatment ofCDAD needs to be questioned.
Abstract: Background: Recent reports suggest that Clostridium difficile colitis may be evolving into a more severe disease. During the second half of 2002 we noted an increase in the number of patients with severe C. difficile -associated diarrhea (CDAD) in our institution. We describe cases of CDAD at our institution over a 13-year period and investigate changes in illness severity. Methods: We undertook a retrospective chart review of all cases of CDAD diagnosed at the Centre hospitalier universitaire de Sherbrooke from Jan. 1, 1991, to Dec. 31, 2003. Because the hospital serves a well-defined population of Quebec, we were also able to calculate population-based incidence during this period. We abstracted data on individual patients from patient charts and from hospital and pharmacy computer databases. We defined cases of CDAD as having a positive C. difficile cytotoxicity assay result, or endoscopic or histopathological evidence of pseudomembranous colitis. A case was considered complicated if one or more of the following was observed: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days after diagnosis. Results: A total of 1721 cases of CDAD were diagnosed during the study period. The incidence increased from 35.6 per 100 000 population in 1991 to 156.3 per 100 000 in 2003; among patients aged 65 years or more, it increased from 102.0 to 866.5 per 100 000. The proportion of cases that were complicated increased from 7.1% (12/169) in 1991–1992 to 18.2% (71/390) in 2003 ( p p 9 /L or greater) and an elevated creatinine level (200 μmol/L or greater) were strongly associated with adverse outcomes: in 2003, 45 (40.9%) of 110 patients with a high leukocyte count or creatinine level, or both, had complicated CDAD and 28 (25.5%) died within 30 days after diagnosis. After adjustment for age and other confounding factors, patients initially given oral vancomycin therapy had a risk of progression to complicated CDAD that was 79% lower than the risk among patients initially treated with metronidazole (adjusted odds ratio 0.2, 95% confidence interval 0.06–0.8, p = 0.02). Interpretation: An epidemic of CDAD with an increased case-fatality rate has had important consequences on the elderly population of our region. Our observational data suggest that the equivalence of vancomycin and metronidazole in the treatment of CDAD needs to be questioned.
1,156 citations
TL;DR: Caregivers' depression and perceived burden increase as patients' functional status declines, and strategies are needed to help reduce the psychosocial, occupational and economic burden associated with caregiving.
Abstract: Background: The vital role played by family caregivers in supporting dying cancer patients is well recognized, but the burden and economic impact on caregivers is poorly understood. We prospectively examined the psychosocial, occupational and economic impact of caring for a person with a terminal illness. Methods: We studied 89 caregivers of women with advanced breast cancer receiving care at either the Ottawa or Hamilton regional cancer centres in Ontario. Patients were followed until their death or study completion at 3 years. Patients identified a principal caregiver to participate in the study. The Karnofsky Performance Status (KPS) index, the Medical Outcomes Study 36-item Short Form (SF-36), the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, FAMCARE and the Medical Outcomes Study Social Support Survey were administered during follow-up. Economic data were collected by means of a questionnaire administered by an interviewer. Assessments were conducted every 3 months during the palliative period (KPS score > 50) and every 2 weeks during the terminal period (KPS score ≤ 50). Results: Over half of the caregivers were male (55%) and the patient9s spouse or partner (52%), with a mean age of 53 years. At the start of the palliative period, the caregivers9 mean physical functioning score was better than the patients9 (51.3 v. 35.1, 95% confidence interval [CI] 13.3–20.0); there were similar mean mental functioning scores (46.6 and 47.1 respectively); similar proportions were depressed (11% and 12%); and significantly more caregivers than patients were anxious (35% v. 19%, p = 0.009). More caregivers were depressed (30% v. 9%, p = 0.02) and had a higher level of perceived burden (26.2 v. 19.4, p = 0.02) at the start of the terminal period than at the start of the palliative period. Burden was the most important predictor of both anxiety and depression. Of employed caregivers, 69% reported some form of adverse impact on work. In the terminal period 77% reported missing work because of caregiving responsibilities. Prescription drugs were the most important component of financial burden. Interpretation: Caregivers9 depression and perceived burden increase as patients9 functional status declines. Strategies are needed to help reduce the psychosocial, occupational and economic burden associated with caregiving.
868 citations
Journal Article•
TL;DR: Almost one-quarter of patients in this study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.
Abstract: Background: Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital. Methods: At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors9 residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified. Results: During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54–81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%–28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%–16%). Interpretation: Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.
725 citations
TL;DR: Patients in hospital who received proton pump inhibitors were at increased risk of C. difficile diarrhea, and this was associated with female sex and prior renal failure.
Abstract: Background: Antibiotic disruption of the normal intestinal flora is a well-known risk factor for Clostridium difficile -associated diarrhea. Reduced gastric acidity has been suggested as a risk factor, and we hypothesized that proton pump inhibitors, because of their potency, may be an independent risk factor for this problem. Methods: For the cohort study we identified from a pharmacy database 1187 inpatients at a Montreal teaching hospital who received antibiotics over a 9-month period beginning in August 2002. We compared patients in this group who had also received a proton pump inhibitor or an H 2 blocker with patients who had not received acid suppressive therapy. Hospital laboratory reports of positive assay results for C. difficile toxin were used to ascertain cases in the cohort.
To assess the possibility that proton pump inhibitors were prescribed to patients who were sicker and had other risk factors for C. difficile infection, we did a case–control study at a second Montreal teaching hospital. Cases were defined as patients who were positive for C. difficile toxin and who had a history of diarrhea ( n = 94). Control subjects were selected from among patients who had received an antibiotic and were matched to cases by ward, age within 5 years and class of antibiotics ( n = 94). Results: In the cohort study, C. difficile diarrhea developed in 81 (6.8%) of the 1187 patients who received antibiotics while in hospital. In a multivariate analysis, C. difficile diarrhea was significantly associated with use of proton pump inhibitors (adjusted odds ratio [OR] 2.1, 95% confidence interval [CI] 1.2– 3.5), receipt of 3 or more antibiotics (OR 2.1, 95% CI 1.3– 3.4) and admission to a medical ward (OR 4.1, 95% CI 2.3– 7.3). In the case–control study C. difficile diarrhea was associated with female sex (adjusted OR 2.1, 95% CI 1.1–4.0), prior renal failure (adjusted OR 4.3, 95% CI 1.5–11.9), hospital admission in the 3 months before the index admission (adjusted OR 2.6, 95% CI 1.4–5.2) and use of proton pump inhibitors (adjusted OR 2.7, 95% CI 1.4–5.2). Interpretation: Patients in hospital who received proton pump inhibitors were at increased risk of C. difficile diarrhea.
575 citations
TL;DR: The findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff, which differed with respect to occupation and risk perception.
Abstract: Background: The outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak. Methods: Questionnaires were distributed to all willing employees of Sunnybrook and Women9s College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12). Results: Of the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family9s health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6–9.6), living with children (adjusted OR 1.8, 95% CI 1.5–2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5–4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2–2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5–5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2–5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4–3.5) and ability to do one9s job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9–4.6). Interpretation: Our findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.
542 citations
TL;DR: The epidemiology and causes of cobalamin deficiency in elderly people, with an emphasis on food-cobalamin malabsorption syndrome, are reviewed, and diagnostic and management strategies for cobalamina deficiency are reviewed.
Abstract: VITAMIN B12 OR COBALAMIN DEFICIENCY occurs frequently (> 20%) among elderly people, but it is often unrecognized because the clinical manifestations are subtle; they are also potentially serious, particularly from a neuropsychiatric and hematological perspective. Causes of the deficiency include, most frequently, food-cobalamin malabsorption syndrome (> 60% of all cases), pernicious anemia (15%–20% of all cases), insufficent dietary intake and malabsorption. Food-cobalamin malabsorption, which has only recently been identified as a significant cause of cobalamin deficiency among elderly people, is characterized by the inability to release cobalamin from food or a deficiency of intestinal cobalamin transport proteins or both. We review the epidemiology and causes of cobalamin deficiency in elderly people, with an emphasis on food-cobalamin malabsorption syndrome. We also review diagnostic and management strategies for cobalamin deficiency.
529 citations
Journal Article•
TL;DR: Industry-funded trials are more likely to be associated with statistically significant pro-industry findings, both in medical trials and surgical interventions.
Abstract: Background: Conflicting reports exist in the medical literature regarding the association between industry funding and published research findings. In this study, we examine the association between industry funding and the statistical significance of results in recently published medical and surgical trials. Methods: We examined a consecutive series of 332 randomized trials published between January 1999 and June 2001 in 8 leading surgical journals and 5 medical journals. Each eligible study was independently reviewed for methodological quality using a 21-point index with 5 domains: randomization, outcomes, eligibility criteria, interventions and statistical issues. Our primary analysis included studies that explicitly identified the primary outcome and reported it as statistically significant. For studies that did not explicitly identify a primary outcome, we defined a “positive” study as one with at least 1 statistically significant outcome measure. We used multivariable regression analysis to determine whether there was an association between reported industry funding and trial results, while controlling for study quality and sample size. Results: Among the 332 randomized trials, there were 158 drug trials, 87 surgical trials and 87 trials of other therapies. In 122 (37%) of the trials, authors declared industry funding. An unadjusted analysis of this sample of trials revealed that industry funding was associated with a statistically significant result in favour of the new industry product (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3–3.5). The association remained significant after adjustment for study quality and sample size (adjusted OR 1.8, 95% CI 1.1–3.0). There was a nonsignificant difference between surgical trials (OR 8.0, 95% CI 1.1–53.2) and drug trials (OR 1.6, 95% CI 1.1–2.8), both of which were likely to have a pro-industry result (relative OR 5.0, 95% CI 0.7–37.5, p = 0.14). Interpretation: Industry-funded trials are more likely to be associated with statistically significant pro-industry findings, both in medical trials and surgical interventions.
486 citations
TL;DR: Imagine that you're a busy family physician and that you've found a rare free moment to scan the recent literature and notice a study comparing emergency physicians' interpretation of chest radiographs with radiologists' interpretations.
Abstract: Imagine that you're a busy family physician and that you've found a rare free moment to scan the recent literature. Reviewing your preferred digest of abstracts, you notice a study comparing emergency physicians' interpretation of chest radiographs with radiologists' interpretations.[1][1] The
467 citations
Journal Article•
TL;DR: Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes.
Abstract: Background: The provision of nutritional support for patients in intensive care units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence-based algorithms to improve nutritional support in the ICU would improve patient outcomes. Methods: A cluster-randomized controlled trial was performed in the ICUs of 11 community and 3 teaching hospitals between October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study ( n = 499). Evidence-based recommendations were introduced in the 7 intervention hospitals by means of in-service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutritional support, preferably enteral. Results: Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals ( n = 214), the patients in the intervention hospitals ( n = 248) received significantly more days of enteral nutrition (6.7 v. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 v. 35 days; p = 0.003) and showed a trend toward reduced mortality (27% v. 37%; p = 0.058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 v. 11.8 days; p = 0.7). Interpretation: Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes.
432 citations
TL;DR: Whether outcome reporting bias would be present in a cohort of government-funded trials subjected to rigorous peer review and whether primary outcomes specified in trial protocols were compared with those reported in publications is compared.
Abstract: BACKGROUND: The reporting of outcomes within published randomized trials has previously been shown to be incomplete, biased and inconsistent with study protocols. We sought to determine whether outcome reporting bias would be present in a cohort of government-funded trials subjected to rigorous peer review. METHODS: We compared protocols for randomized trials approved for funding by the Canadian Institutes of Health Research (formerly the Medical Research Council of Canada) from 1990 to 1998 with subsequent reports of the trials identified in journal publications. Characteristics of reported and unreported outcomes were recorded from the protocols and publications. Incompletely reported outcomes were defined as those with insufficient data provided in publications for inclusion in meta-analyses. An overall odds ratio measuring the association between completeness of reporting and statistical significance was calculated stratified by trial. Finally, primary outcomes specified in trial protocols were compared with those reported in publications. RESULTS: We identified 48 trials with 68 publications and 1402 outcomes. The median number of participants per trial was 299, and 44% of the trials were published in general medical journals. A median of 31% (10th-90th percentile range 5%-67%) of outcomes measured to assess the efficacy of an intervention (efficacy outcomes) and 59% (0%-100%) of those measured to assess the harm of an intervention (harm outcomes) per trial were incompletely reported. Statistically significant efficacy outcomes had a higher odds than nonsignificant efficacy outcomes of being fully reported (odds ratio 2.7; 95% confidence interval 1.5-5.0). Primary outcomes differed between protocols and publications for 40% of the trials. INTERPRETATION: Selective reporting of outcomes frequently occurs in publications of high-quality government-funded trials.
TL;DR: Treatment with oral vancomycin therapy should be reserved for patients who have contraindications or intolerance to metronidazole or who fail to respond to first-line therapy.
Abstract: CLOSTRIDIUM DIFFICILE is the most important cause of nosocomial diarrhea in adults. Illness may range from mild watery diarrhea to life-threatening colitis. An antecedent disruption of the normal colonic flora followed by exposure to a toxigenic strain of C. difficile are necessary first steps in the pathogenesis of disease. Diagnosis is based primarily on the detection of C. difficile toxin A or toxin B. First-line treatment is with oral metronidazole therapy. Treatment with oral vancomycin therapy should be reserved for patients who have contraindications or intolerance to metronidazole or who fail to respond to first-line therapy.
Journal Article•
TL;DR: A better understanding of the adverse effects of antiretroviral agents is of interest not only for HIV specialists as they try to optimize therapy, but also for other physicians who care for HIV-positive patients.
Abstract: LONG-TERM REMISSION OF HIV-1 DISEASE CAN BE READILY ACHIEVED by combinations of antiretroviral agents. The suppression of plasma viral loads to less than the limit of quantification of the most sensitive commercially available assays (i.e., less than 50 copies/mL) and the coincident improvement in CD4 T cell counts is associated with resolution of established opportunistic infections and a decrease in the risk of new opportunistic infections. However, prolonged treatment with combination regimens can be difficult to sustain because of problems with adherence and toxic effects. All antiretroviral drugs can have both short-term and long-term adverse events. The risk of specific side effects varies from drug to drug, from drug class to drug class, and from patient to patient. A better understanding of the adverse effects of antiretroviral agents is of interest not only for HIV specialists as they try to optimize therapy, but also for other physicians who care for HIV-positive patients.
TL;DR: The reporting of single-gene discoveries and associated technologies in major daily newspapers in Canada, the United States, Great Britain and Australia from January 1995 to June 2001 is reviewed to examine the accuracy and nature of media coverage of genetic research.
Abstract: Background: The public gets most of its information about genetic research from the media. It has been suggested that media representations may involve exaggeration, called “genohype.” To examine the accuracy and nature of media coverage of genetic research, we reviewed the reporting of single-gene discoveries and associated technologies in major daily newspapers in Canada, the United States, Great Britain and Australia. Methods: We used neutral search terms to identify articles about gene discoveries and associated technologies hosted on the Dow Jones Interactive and Canadian NewsDisk databases from January 1995 to June 2001. We compared the contents, claims and conclusions of the scientific journal article with those of the associated newspaper article. Coders subjectively assigned the newspaper articles to 1 of 3 categories: moderately to highly exaggerated claims, slightly exaggerated claims or no exaggerated claims. We used classification tree software to identify the variables that contributed to the assignment of each newspaper article to 1 of the 3 categories: attention structure (positioning in the newspaper and length of the article), authorship, research topic, source of information other than the scientific paper, type and likelihood of risks and benefits, discussion of controversy, valuation tone (positive or negative), framing (e.g., description of research, celebration of progress, report of economic prospects or ethical perspective), technical accuracy (either omissions or errors that changed the description of the methods or interpretation of the results) and use of metaphors. Results: We examined 627 newspaper articles reporting on 111 papers published in 24 scientific and medical journals. Only 11% of the newspaper articles were categorized as having moderately to highly exaggerated claims; the majority were categorized as having no claims (63%) or slightly exaggerated claims (26%). The classification analysis ranked the reporting of risks as the most important variable in determining the categorization of newspaper articles. Only 15% of the newspaper articles and 5% of the scientific journal articles discussed costs or risks, whereas 97% of the newspaper articles and 98% of the scientific journal articles discussed the likelihood of benefits of the research. Interpretation: Our data suggest that the majority of newspaper articles accurately convey the results of and reflect the claims made in scientific journal articles. Our study also highlights an overemphasis on benefits and under-representation of risks in both scientific and newspaper articles. The cause and nature of this trend is uncertain.
TL;DR: Logistic regression revealed that students who identified family medicine as their first choice tended to be older, to be concerned about medical lifestyle and to have lived in smaller communities at the time of completing high school; they were also less likely to be hospital oriented.
Abstract: Background: Over the last 10 years the number of medical students choosing family medicine as a career has steadily declined. Studies have demonstrated that career preference at the time that students begin medical school may be significantly associated with their ultimate career choice. We sought to identify the career preferences students have at entry to medical school and the factors related to family medicine as a first-choice career option. Methods: A questionnaire was administered to students entering medical school programs at the time of entry at the University of Calgary (programs beginning in 2001 and 2002), University of British Columbia (2001 and 2002) and University of Alberta (2002). Students were asked to indicate their top 3 career choices and to rank the importance of 25 variables with respect to their career choice. Factor analysis was performed on the variables. Reliability of the factor scores was estimated using Cronbach9s alpha coefficients; biserial correlations between the factors and career choice were also calculated. A logistic regression was performed using career choice (family v. other) as the criterion variable and the factors plus demographic characteristics as predictor variables. Results: Of 583 students, 519 (89%) completed the questionnaire. Only 20% of the respondents identified family medicine as their first career option, and about half ranked family medicine in their top 3 choices. Factor analysis produced 5 factors (medical lifestyle, societal orientation, prestige, hospital orientation and varied scope of practice) that explained 52% of the variance in responses. The 5 factors demonstrated acceptable internal consistency and correlated in the expected direction with the choice of family medicine. Logistic regression revealed that students who identified family medicine as their first choice tended to be older, to be concerned about medical lifestyle and to have lived in smaller communities at the time of completing high school; they were also less likely to be hospital oriented. Moreover, students who chose family medicine were much more likely to demonstrate a societal orientation and to desire a varied scope of practice. Interpretation: Several factors appear to drive students toward family medicine, most notably having a societal orientation and a desire for a varied scope of practice. If the factors that influence medical students to choose family medicine can be identified accurately, then it may be possible to use such a model to change medical school admission policies so that the number of students choosing to enter family medicine can be increased.
TL;DR: In Toronto, homeless women 18–44 years of age were 10 times more likely to die than women in the general population of Toronto and the risk of death among homeless women was greater than that among women inThe general population by a factor of 4.6.
Abstract: Background: Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women. We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population. Methods: A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK). Results: In Toronto, mortality rates were 515 per 100 000 person-years among homeless women 18–44 years of age and 438 per 100 000 person-years among those 45–64 years of age. Homeless women 18–44 years of age were 10 times more likely to die than women in the general population of Toronto. In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different. In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men. Interpretation: Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.
TL;DR: The opening of the safer injecting facility in Vancouver was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
Abstract: Background: North America9s first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature. Methods: Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall. Results: In stratified linear regression models, the 12-week period after the facility9s opening was independently associated with reductions in the number of drug users injecting in public ( p p p Interpretation: The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
TL;DR: Patients who had a hemispheric TIA related to internal carotid artery disease had a high risk of stroke in the first few days after the TIA, and patients with more severe stenosis appeared to be at no greaterrisk of stroke than patients with lesser degrees of stenosis.
Abstract: Background: Transient ischemic attacks (TIAs) often herald a stroke, but little is known about the acute natural history of TIAs. Our objective was to quantify the early risk of stroke after a TIA in patients with internal carotid artery disease. Methods: Using patient data from the medical arm of the North American Symptomatic Carotid Endarterectomy Trial, we calculated the risk of ipsilateral stroke in the territory of the symptomatic internal carotid artery within 2 and 90 days after a first-recorded hemispheric TIA. We also studied similar outcomes among patients in the trial who had a first-recorded completed hemispheric stroke. Results: For patients with a first-recorded hemispheric TIA (n = 603), the 90-day risk of ipsilateral stroke was 20.1% (95% confidence interval [CI] 17.0%–23.2%), higher than the 2.3% risk (95% CI 1.0%–3.6%) for patients with a hemispheric stroke (n = 526). The 2-day risks were 5.5% and 0.0%, respectively. Patients with more severe stenosis of the internal carotid artery (> 70%) appeared to be at no greater risk of stroke than patients with lesser degrees of stenosis (adjusted hazard ratio 1.1, 95% CI 0.7–1.7). Infarct on brain imaging (adjusted hazard ratio 2.1, 95% CI 1.5–3.0) and the presence of intracranial major-artery disease (adjusted hazard ratio 1.9, 95% CI 1.3-2.7) doubled the early risk of stroke in patients with a hemispheric TIA. Interpretation: Patients who had a hemispheric TIA related to internal carotid artery disease had a high risk of stroke in the first few days after the TIA. Early risk of stroke was not affected by the degree of internal carotid artery stenosis.
TL;DR: Characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing, were evaluated, finding that most occurred before the hospitalization, and most were avoidable.
Abstract: Background: Adverse events are poor patient outcomes that are due to medical care Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing Methods: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period Charts were reviewed in 2 stages If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization The reviewer also rated the preventability, severity and type of each adverse event Results: Of the 64 patients with an adverse event (incidence 127%, 95% confidence interval [CI] 101%–160%), 24 had a preventable event (48%, 95% CI 32%–70%), and 3 (06%, 95% CI 02%–17%) died because of an adverse event Most adverse events were due to drug treatment, operative complications or nosocomial infections Of the 64 patients, 39 (61%, 95% CI 49%–72%) experienced the adverse event before the index hospitalization Interpretation: Adverse events were common in this study However, only one-third were deemed avoidable, and most occurred before the hospitalization Interventions to improve safety must address ambulatory care as well as hospital-based care
TL;DR: This topical diclofenac solution can provide safe, site-specific treatment for osteoarthritic pain, with only minor local skin irritation and minimal systemic side effects.
Abstract: Background: Treatment of osteoarthritis with oral NSAID therapy provides pain relief but carries a substantial risk of adverse effects. Topical NSAID therapy offers an alternative to oral treatment, with the potential for a reduced risk of side effects. The objective of this trial was to assess the safety and efficacy of a topical diclofenac solution in relieving the symptoms of primary osteoarthritis of the knee. Methods: We identified 248 men and women from southern Ontario with primary osteoarthritis of the knee and at least moderate pain. The patients were randomly assigned to apply 1 of 3 solutions to their painful knee for 4 weeks: a topical diclofenac solution (1.5% wt/wt diclofenac sodium in a carrier containing dimethyl sulfoxide [DMSO]); a vehicle-control solution (the carrier containing DMSO but no diclofenac); and a placebo solution (a modified carrier with a token amount of DMSO for blinding purposes but no diclofenac). The primary efficacy end point was pain relief, measured by the Western Ontario and McMaster Universities (WOMAC) LK3.0 Osteoarthritis Index pain subscale. Secondary end points were improved physical function and reduced stiffness (measured by the WOMAC subscales), reduced pain on walking and patient global assessment (PGA). Safety was evaluated with clinical and laboratory assessments. Results: In the intent-to-treat group the mean change (and 95% confidence interval [CI]) in pain score from baseline to final assessment was significantly greater for the patients who applied the topical diclofenac solution (–3.9 [– 4.8 to –2.9]) than for those who applied the vehicle-control solution (–2.5 [– 3.3 to –1.7]; p = 0.023) or the placebo solution (–2.5 [–3.3 to –1.7]; p = 0.016). For the secondary variables the topical diclofenac solution also revealed superiority to the vehicle-control and placebo solutions, leading to mean changes (and 95% CIs) of –11.6 (–14.7 to –8.4; p = 0.002 and 0.014, respectively) in physical function, –1.5 (–1.9 to –1.1; p = 0.015 and 0.002, respectively) in stiffness and –0.8 (–1.1 to –0.6; p = 0.003 and 0.015, respectively) in pain on walking. The PGA scores were significantly better for the patients who applied the topical diclofenac solution than for those who applied the other 2 solutions ( p = 0.039 and 0.025, respectively). The topical diclofenac solution caused some skin irritation, mostly minor local skin dryness, in 30 (36%) of the 84 patients, but this led to discontinuation of treatment in only 5 (6%) of the cases. The incidence of gastrointestinal events did not differ between the treatment groups. No serious gastrointestinal or renal adverse events were reported or detected by means of laboratory testing. Interpretation: This topical diclofenac solution can provide safe, site-specific treatment for osteoarthritic pain, with only minor local skin irritation and minimal systemic side effects.
TL;DR: Evidence is found that higher initial viral load is independently associated with worse prognosis in SARS, and Mortality data for patients with SARS should be interpreted in light of age, comorbidity and viral load.
Abstract: Background: Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus. It may progress to respiratory failure, and a significant proportion of patients die. Preliminary data suggest that a high viral load of the SARS coronavirus is associated with adverse outcomes in the intensive care unit, but the relation of viral load to survival is unclear. Methods: We prospectively studied an inception cohort of 133 patients with virologically confirmed SARS who were admitted to 2 general acute care hospitals in Hong Kong from Mar. 24 to May 4, 2003. The patients were followed until death or for a minimum of 90 days. We used Cox proportional hazard modelling to analyze potential predictors of survival recorded at the time of presentation, including viral load from nasopharyngeal specimens (measured by quantitative reverse transcriptase polymerase chain reaction [PCR] of the SARS-associated coronavirus). Results: Thirty-two patients (24.1%) met the criteria for acute respiratory distress syndrome, and 24 patients (18.0%) died. The following baseline factors were independently associated with worse survival: older age (61–80 years) (adjusted hazard ratio [HR] 5.24, 95% confidence interval [CI] 2.03–13.53), presence of an active comorbid condition (adjusted HR 3.36, 95% CI 1.44–7.82) and higher initial viral load of SARS coronavirus, according to quantitative PCR of nasopharyngeal specimens (adjusted HR 1.21 per log 10 increase in number of RNA copies per millilitre, 95% CI 1.06–1.39). Interpretation: We found preliminary evidence that higher initial viral load is independently associated with worse prognosis in SARS. Mortality data for patients with SARS should be interpreted in light of age, comorbidity and viral load. These considerations will be important in future studies of SARS.
TL;DR: Depending on which measures of effect authors choose, the impact of an intervention may appear very large or quite small, even though the impact may be small in comparison with other interventions.
Abstract: Physicians, patients and policy-makers are influenced not only by the results of studies but also by how authors present the results.[1][1],[2][2],[3][3],[4][4] Depending on which measures of effect authors choose, the impact of an intervention may appear very large or quite small, even though the
TL;DR: The effort to control illicit drug use in Vancouver's Downtown Eastside did not alter the price of drugs or the frequency of use, nor did it encourage enrolment in methadone treatment programs.
Abstract: Background: Law enforcement is often used in an effort to reduce the social, community and health-related harms of illicit drug use by injection drug users (IDUs). There are, however, few data on the benefits of such enforcement or on the potential harms. A large-scale police “crackdown” to control illicit drug use in Vancouver9s Downtown Eastside provided us with an opportunity to evaluate the effect. Methods: As part of our ongoing prospective cohort study of IDUs in Vancouver, we examined data collected from 244 IDUs in the 3 months before the police crackdown and from 142 IDUs in the 3 months after the start of the crackdown, on Apr. 7, 2003. All study subjects were active drug users. We also examined external data on needle exchanges and syringe disposal. Results: The 2 groups of IDUs were statistically similar: they were mainly young (mean age 39 years) and male (63%), and they had injected illicit drugs for 13 years on average. Ethnic background and the proportion homeless were also similar. There were no statistically significant reported differences (all p > 0.1) in the street price of heroin, cocaine or “crack” in the 2 periods. In the 3-month periods before and after the crackdown, respectively, the rates of daily heroin injection were 27.9% and 26.8%, daily cocaine injection 28.7% and 27.5%, and daily crack use 59.4% and 60.6% (all p > 0.1). The proportions of study subjects receiving methadone treatment, 41.0% and 44.4% ( p = 0.516), did not differ. However, the proportions reporting a change in where drugs were used, 22.5% and 33.8% ( p p p = 0.002) and the monthly average number of used syringes found in public boxes for the safe disposal of syringes decreased from 865 to 502 ( p = 0.018). Interpretation: The effort to control illicit drug use did not alter the price of drugs or the frequency of use, nor did it encourage enrolment in methadone treatment programs. Several measures indicated displacement of injection drug use from the area of the crackdown into adjacent areas of the city, which has implications for both recruitment of new initiates into injection drug use and HIV prevention efforts.
TL;DR: Screening for this infection should be considered mandatory for patients who have a history of travel or residence in a disease-endemic area and risk factors for disseminated disease (e.g., corticosteroid use and human T-lymphotropic virus type I infection).
Abstract: STRONGYLOIDIASIS, WHICH IS CAUSED by the nematode Strongyloides stercoralis, is a common and persistent infection, particularly in developing countries. In the setting of compromised cellular immunity, it can result in fulminant dissemination with case-fatality rates of over 70%. The majority of new Canadian immigrants come from countries where Strongyloides is highly endemic; therefore, the burden of Strongyloides may be underappreciated in Canada. Because early diagnosis and therapy can have a marked impact on disease outcome, screening for this infection should be considered mandatory for patients who have a history of travel or residence in a disease-endemic area and risk factors for disseminated disease (e.g., corticosteroid use and human T-lymphotropic virus type I infection).
TL;DR: Patients in whom TIA is diagnosed in the emergency department have high immediate and short-term risks of stroke, however, their condition is underinvestigated and undertreated compared with stroke: many do not receive the minimum recommended diagnostic tests within 30 days.
Abstract: Background: Canadian data on the characteristics, management and outcomes of patients with transient ischemic attack (TIA) are lacking. We studied prospectively a cohort of consecutive patients presenting with TIA to the emergency department of 4 regional stroke centres in Ontario. Methods: Using data from the Ontario Stroke Registry linked with provincial administrative databases, we determined the short-term outcomes after TIA and assessed patient management in the emergency department and within 30 days after the index TIA. We compared the TIA patients with a cohort of patients who had ischemic stroke. Results: Three-quarters of the TIA patients were discharged from the emergency department. After discharge, the 30-day stroke risk was 5% (13/265) overall and 8% (13/167) among those with a first-ever TIA; the 30-day risk of stroke or death was 9% (11/127) among the TIA patients with a speech deficit and 12% (9/76) among those with a motor deficit. Half of the cases of stroke occurred within the first 2 days after the TIA. Diagnostic investigations were underused in hospital and on an outpatient basis within 30 days after the index TIA, the rates being as follows: CT scanning, 58% (211/364); carotid Doppler ultrasonography, 44% (162/364); echocardiography, 19% (70/364); cerebral angiography, 5% (19/364); and MRI, 3% (11/364). Antithrombotic therapy was not prescribed for more than one-third of the patients at discharge. Carotid endarterectomy was performed in 2% within 90 days. Interpretation: Patients in whom TIA is diagnosed in the emergency department have high immediate and short-term risks of stroke. However, their condition is underinvestigated and undertreated compared with stroke: many do not receive the minimum recommended diagnostic tests within 30 days. We need greater efforts to improve the timely delivery of care for TIA patients, along with investigation of treatments administered early after TIA to prevent stroke.
TL;DR: This guideline is designed to provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy (PMRT).
Abstract: Objective: To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy (PMRT). Outcomes: Locoregional control, disease-free survival, overall survival and treatment-related toxicities. Evidence: This guideline is based on a review of all meta-analyses, consensus statements and other guidelines published between 1966 and November 2002. Searches of MEDLINE and CANCERLIT for English-language randomized controlled trials published between 1995 and November 2002 were also conducted to supplement the literature previously reviewed by the American Society of Clinical Oncology (ASCO) Health Services Research Committee panel in its published guideline. A nonsystematic review of the literature was continued through June 2003. Recommendations: Locoregional PMRT is recommended for women with an advanced primary tumour (tumour size 5 cm or greater, or tumour invasion of the skin, pectoral muscle or chest wall). Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes. The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear. These women should be offered the opportunity to participate in clinical trials of PMRT. Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes. Other patient, tumour and treatment characteristics, including age, histologic grade, lymphovascular invasion, hormone receptor status, number of axillary nodes removed, axillary extracapsular extension and surgical margin status, may affect locoregional control, but their use in specifying additional indications for PMRT is currently unclear. PMRT should encompass the chest wall and the supraclavicular, infraclavicular and axillary apical lymph node areas. To reduce the risk of lymphedema, radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes. A definite recommendation regarding the inclusion of the internal mammary lymph nodes in PMRT cannot be made because of limited and inconsistent data. The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure, particularly to the cardiac and pulmonary structures. Common short-term side effects of PMRT, including fatigue and skin erythema, are generally tolerable and not dose-limiting. Severe long-term side effects, including lymphedema, cardiac and pulmonary toxicities, brachial plexopathy, rib fractures and secondary neoplasms, are relatively rare. The optimal sequencing of PMRT and systemic therapy is currently unclear. Regimens containing anthracyclines or taxanes should not be administered concurrently with radiotherapy because of the potential for increased toxicity. Validation: The authors9 original text was submitted for review, revision and approval by the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Subsequently, feedback was provided by 11 oncologists from across Canada. The final document was approved by the steering committee. Sponsor: The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. Completion date: November 2003.
TL;DR: Second-generation antipsychotic drugs, which are felt to have fewer extrapyramidal adverse effects than the first-generation drugs, are sometimes used to control behavioural disturbances in elderly patients with dementia.
Abstract: Reason for posting: Second-generation antipsychotic drugs, which are felt to have fewer extrapyramidal adverse effects than the first-generation drugs,[1][1] are sometimes used to control behavioural disturbances in elderly patients with dementia. However, similar to warnings issued in the last 2
TL;DR: The predictive values of ApoE ε4 genotype do not support its utility as a diagnostic test for predicting progression from CIND to AD, but it may be useful in research studies to enrich study samples that have a higher rate of progression to AD.
Abstract: Background: Apolipoprotein E (ApoE) e4 genotype is a well-established risk factor for Alzheimer9s disease (AD). However, its effect on predicting conversion from normal to “cognitive impairment, no dementia” (CIND) and from CIND to AD is less clear. Methods: We used a nested case–control design from the population-based Canadian Study of Health and Aging (CSHA) to examine the effect of ApoE e4 genotype on the conversion of subjects from normal to CIND and from CIND to AD. We also contrasted these findings with incident cases of AD and vascular dementia (VaD) in the CSHA cohort. Results: The ApoE e4 genotype was a significant risk factor for conversion from CIND to AD and from normal to AD and VaD. However, it was not a significant risk factor for conversion from normal to CIND. This effect is robust to adjustment for age, sex and education level. There is significant interaction between the ApoE e4 genotype and age for AD and for conversion from CIND to AD. No interaction between ApoE e4 genotype, sex, age, ethnicity and education level was found in other subgroup analyses. The positive predictive value of ApoE e4 for predicting CIND conversion to AD was 0.48, and the negative predictive value was 0.65. Interpretation: Possession of an ApoE e4 allele increases the risk of AD developing from CIND. It is also associated with a decrease in the age at onset of AD. Its predictive values do not support its utility as a diagnostic test for predicting progression from CIND to AD, but it may be useful in research studies to enrich study samples that have a higher rate of progression to AD.
TL;DR: Diabetic patients with symptomatic atherosclerotic disease are undertreated with medications known to reduce cardiovascular morbidity and mortality, perhaps because of a “glucocentric” view of diabetes.
Abstract: Background: Given that most deaths among patients with diabetes mellitus are due to cardiovascular disease, we sought to determine the extent to which medications proven to reduce cardiovascular mortality are prescribed for patients with type 2 diabetes who have symptomatic atherosclerosis (i.e., coronary artery disease [CAD], cerebrovascular disease [CBVD] or peripheral arterial disease [PAD]). Methods: Administrative records from Saskatchewan Health were used to evaluate the use of antiplatelet agents, statins and angiotensin-converting enzyme (ACE) inhibitors by people with treated type 2 diabetes with and without symptomatic atherosclerosis. CAD and CBVD were defined by International Classification of Diseases (ninth revision) codes, and PAD was defined on the basis of pentoxifylline use or lower limb amputation. Multivariate logistic regression analysis was used to compare medication use in patients with and without PAD, with adjustments for differences in age, sex and comorbidity. Results: In this cohort of 12 106 patients with type 2 diabetes (mean age 64 years, 55% male, mean follow-up 5 years), fewer than 25% received an antiplatelet agent or statin, and fewer than 50% received an ACE inhibitor. Although patients with CAD were more likely to receive antiplatelet agents, statins or ACE inhibitors than people without CAD ( p Interpretation: Diabetic patients with symptomatic atherosclerotic disease are undertreated with medications known to reduce cardiovascular morbidity and mortality, perhaps because of a “glucocentric” view of diabetes. Programs to improve the quality of cardiovascular risk reduction in these high-risk patients are needed.
TL;DR: The results indicate that a high proportion of children aged 3–5 years in Newfoundland and Labrador are overweight or obese, and it appears that prevention measures should begin before the age of 3 years.
Abstract: Background: More and more school-aged children in Canada and elsewhere are becoming overweight or obese. Many countries are now reporting a similar trend among preschool children. However, little information is available on the prevalence of overweight and obesity among preschool children in Canada. In addition, available data are based on reported rather than measured heights and weights. We conducted this study to determine the prevalence of overweight and obesity, using measured heights and weights, in the 1997 cohort of children aged 3–5 years born in Newfoundland and Labrador. Methods: We calculated the body mass indices (BMIs) using heights and weights measured by public health nurses during the province-wide Preschool Health Check Program conducted between October 2000 and January 2003. Descriptive data on the children9s BMIs and prevalence estimates were generated and analyzed by sex and age with the use of the classification system recommended by the International Obesity Task Force. Results: Data were available for 4161 of the 5428 children born in 1997; boys and girls were equally represented (50.1% and 49.9% respectively). Overall, 25.6% of the preschool children in the cohort were overweight or obese. The rates did not differ significantly by sex or age group Interpretation: These results indicate that a high proportion of children aged 3–5 years in Newfoundland and Labrador are overweight or obese. It appears that prevention measures should begin before the age of 3 years.