Asthma exacerbations constitute one of the most common causes of emergency department (ED) attendance in most developed countries. While severe asthma often requires hospitalization, variability in admission practices has been observed.
To describe the factors associated with admission to Canadian hospitals for acute asthma after ED treatment.
Subjects 18 to 55 years of age treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview (n=695) and telephone interview two weeks later.
The median age of the patients was 30 years, and the majority were women (62.8%). The admission rate was 13.1% (95% CI 10.7% to 15.8%). Admitted patients were older, more often receiving oral or inhaled corticosteroids at presentation, and more frequently receiving systemic corticosteroids and magnesium sulphate in the ED. Similar proportions received beta-2 agonists and/or ipratropium bromide within 1 h of arrival. On multivariable analyses, factors associated with admission included age, previous admission in the past two years, more than eight beta-2 agonist puffs in the past 24 h, a Canadian Triage and Acuity Score of 1 to 2, a respiratory rate of greater than 22 breaths/min and an oxygen saturation of less than 95%.
The admission rate for acute asthma from these Canadian EDs was lower than reported in other North American studies. The present study provides insight into practical factors associated with admission for acute asthma and highlights the importance of history and asthma severity markers on ED decision making. Further efforts to standardize ED management and expedite admission decision-making appear warranted.
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To determine changes in helmet use in cyclists following the introduction of a bicycle helmet law for children under age 18.
Cyclists were observed by two independent observers from July to August 2004 (post-legislation) in Edmonton, Alberta. The data were compared with a similar survey completed at the same locations and days in July to August 2000 (pre-legislation). Data were collected for 271 cyclists in 2004 and 699 cyclists in 2000.
The overall prevalence of helmet use increased from 43% (95% CI 39 to 47%) in 2000 to 53% (95% CI 47 to 59%) in 2004. Helmet use increased in those under 18, but did not change in those 18 and older. In the cluster adjusted multivariate Poisson regression model, the prevalence of helmet use significantly increased for those under age 18 (adjusted prevalence ratio (APR) 3.69, 95% CI 2.65 to 5.14), but not for those 18 years and older (APR 1.17, 95% CI 0.95 to 1.43).
Extension of legislation to all age groups should be considered.
To determine the prevalence of helmet use, compliance with helmet-wearing recommendations and attitudes to bicycle helmet legislation in a northern Ontario community.
Prospective roadside survey of pedal cyclists.
Cyclists riding in the city of Sudbury completed a survey and trained interviewers examined helmet fit.
Of 1134 cyclists encountered at 28 locations; 472 (42%) completed surveys. Males predominated and the mean age was 19.7 years. Overall, helmet use was 20% but helmet ownership was higher (32%). Only 49% of helmets were worn correctly. Support for legislation for those under the age of 16 (81%) and for all ages (57%) was high.
Helmet use in this community is low; one third of helmet owners were found not to be using helmets regularly. Efficacy was reduced by nonadherence to helmet-wearing standards. Education aimed at correcting these findings should be included in safety campaigns.
Bicycle helmets reduce fatal and non-fatal head and face injuries. This study evaluated the effect of mandatory bicycle helmet legislation targeted at those less than 18 years old on helmet use for all ages in Alberta.
Two comparable studies were conducted two years before and four years after the introduction of helmet legislation in Alberta in 2002. Bicyclists were observed in randomly selected sites in Calgary and Edmonton and eight smaller communities from June to October. Helmet wearing and rider characteristics were recorded by trained observers. Poisson regression adjusting for clustering by site was used to obtain helmet prevalence (HP) and prevalence ratio (PR) (2006 vs. 2000) estimates.
There were 4002 bicyclists observed in 2000 and 5365 in 2006. Overall, HP changed from 75% to 92% among children, 30% to 63% among adolescents and 52% to 55% among adults. Controlling for city, location, companionship, neighborhood age proportion
To identify bicyclist and environmental factors associated with fatal bicycle-related trauma in Ontario.
Information was extracted from the provincial coroner's reports on 212 people who had died of bicycle-related injuries in Ontario between 1986 and 1991.
Age, sex and helmet use of the bicyclist, time and place of the event, type of bicyclist or motorist error(s) and use of alcohol by bicyclist or motorist.
Only 32% of the deaths involved bicyclists under 15 years of age. The male-female ratio was 3.5. Over 75% of the cases involved head injury; however, only 8 (4%) of the bicyclists had been wearing a helmet. In 91% of the cases death occurred as the result of a bicycle-motor vehicle collision. Most (65%) of the deaths for which the time was known occurred between 4 pm and 8 am. Bicyclist error was the main cause of crash for 26 (79%) of the children less than 10 years old; it was also the main cause of crash among the bicyclists aged 10 to 19 years (43 [55%]) and those aged 45 years or more (15 [44%]). However, motorist error was the most common cause of collision in the group of cyclists 20 to 44 years of age (42 [63%]). Alcohol was detected in the blood of 7% of the bicyclists killed; alcohol had been consumed by 30% of the motorists who claimed not to have seen the cyclist.
Bicycle-related deaths result from factors that are generally avoidable. Identifiable risk factors other than lack of helmet use suggest that additional research is required to determine the benefits of preventive interventions aimed at reducing the number of such deaths. Age-specific strategies appear warranted.
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To integrate new evidence into the Canadian Asthma Management Continuum diagram, encompassing both pediatric and adult asthma.
The Canadian Thoracic Society Asthma Committee members, comprised of experts in pediatric and adult respirology, allergy and immunology, emergency medicine, general pediatrics, family medicine, pharmacoepidemiology and evidence-based medicine, updated the continuum diagram, based primarily on the 2008 Global Initiative for Asthma guidelines, and performed a focused review of literature pertaining to key aspects of asthma diagnosis and management in children six years of age and over, and adults.
In patients six years of age and over, management of asthma begins with establishing an accurate diagnosis, typically by supplementing medical history with objective measures of lung function. All patients and caregivers should receive self-management education, including a written action plan. Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages. When asthma is not controlled with a low dose of ICS, the literature supports the addition of long-acting beta2-agonists in adults, while the preferred approach in children is to increase the dose of ICS. Leukotriene receptor antagonists are acceptable as second-line monotherapy and as an alternative add-on therapy in both age groups. Antiimmunoglobulin E therapy may be of benefit in adults, and in children 12 years of age and over with difficult to control allergic asthma, despite high-dose ICS and at least one other controller.
The foundation of asthma management is establishing an accurate diagnosis based on objective measures (eg, spirometry) in individuals six years of age and over. Emphasis is placed on the similarities and differences between pediatric and adult asthma management approaches to achieve asthma control.
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To describe the patient characteristics, circumstances and community response in cases of out-of-hospital cardiac arrest; to evaluate the effect on survival of the introduction of prehospital defibrillation; and to identify factors that predict survival.
Population-based before-and-after clinical trial.
Five Ontario communities: London, Sudbury, the Greater Niagara region, Kingston and Ottawa.
A consecutive sample of 1510 primary cardiac arrest patients who were transported to hospital by ambulance over 2 years.
The use of defibrillators by ambulance attendants.
Patient characteristics (sex and age), circumstances of arrest (place, whether arrest was witnessed and cardiac rhythm), citizen response (whether cardiopulmonary resuscitation [CPR] was started by a bystander, time to access to emergency medical services and time to initiation of CPR), emergency medical services response (ambulance response time, time to initiation of CPR and time to rhythm analysis with defibrillator) and survival rates.
A total of 92.1% of the patients were 50 years of age or older, and 68.3% were men. Overall, 79.6% of the arrests occurred in the home. The average ambulance response time for witnessed cases was 7.8 minutes. The overall survival rate was 2.5%. The survival rates before and after defibrillators were introduced were similar, and the general functional outcome of the survivors did not differ significantly between the two phases. Factors predicting survival included patient's age, ambulance response time and whether CPR was started before the ambulance arrived.
The survival rate was lower than expected. The availability of prehospital defibrillation did not affect survival. To improve survival rates after cardiac arrest ambulance response times must be reduced and the frequency of bystander-initiated CPR increased. Once these changes are in place a beneficial effect from advanced manoeuvres such as prehospital defibrillation may be seen.
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Current theories of post-traumatic stress disorder (PTSD) place considerable emphasis on the role cognitive distortions such as self-blame, hopelessness or preoccupation with danger play in the etiology and maintenance of the disorder. Previous studies have shown that cognitive distortions in the early aftermath of traumatic events can predict future PTSD severity but, to date, no studies have investigated the neural correlates of this association.
We conducted a prospective study with 106 acutely traumatized subjects, assessing symptom severity at three time points within the first 3 months post-trauma. A subsample of 20 subjects additionally underwent a functional 4-T magnetic resonance imaging (MRI) scan at 2 to 4 months post-trauma.
Cognitive distortions proved to be a significant predictor of concurrent symptom severity in addition to diagnostic status, but did not predict future symptom severity or diagnostic status over and above the initial symptom severity. Cognitive distortions were correlated with blood oxygen level-dependent (BOLD) signal strength in brain regions previously implicated in visual processing, imagery and autobiographic memory recall. Intrusion characteristics accounted for most of these correlations.
This investigation revealed significant predictive value of cognitive distortions concerning concurrent PTSD severity and also established a significant relationship between cognitive distortions and neural activations during trauma recall in an acutely traumatized sample. These data indicate a direct link between the extent of cognitive distortions and the intrusive nature of trauma memories.
Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.
To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.
A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.
Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P
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The continuous measurement of arterial oxygen saturation using pulse oximetry (SpO2) has become popular for critically ill hospitalized patients. Its use in the ambulance transfer of similarly ill patients has been infrequently documented. This study examines the use of prehospital pulse oximetry, with special reference to the ability of ambulance attendants to recognize hypoxemia. Using a prospective single-blind case series method, a convenience sample of adult patients transferred by ambulance designated Code 3 (serious but not life threatening) or Code 4 (serious and life threatening) to a regional base hospital were examined for the presence of hypoxemia. An Ohmeda finger pulse oximeter probe was attached to all patients. Prior to the study, oxygen treatment was reviewed and ambulance personnel were instructed on the use of the instrument. The continuous oxygen saturation record was not revealed to the attendant(s) during the cell. Administration of oxygen was monitored, and a study form was completed by the attendant at the completion of the call. Overall, 50 patients were included in the study. The most common complaints were chest pain 21 (37%) and shortness of breath 15 (27%). The average age was 64 years, with a range of 32-82. Hypoxemia, defined as SpO2 of less than 90% for more than 1 minute, was detected in 14 patients. Attendants recognized hypoxemia on clinical grounds in only 4 patients (sensitivity = 28%). Forty-one (82%) patients received various amounts of supplemental oxygen; many patients remained hypoxemic despite therapy.(ABSTRACT TRUNCATED AT 250 WORDS)