In 2001, the Ontario Ministry of Health and Long-Term Care introduced the Ontario Stroke Strategy by designating regional stroke centres across the province. The primary role of these centres is to coordinate stroke care within the region and across the care continuum in keeping with best practices. Concurrently, Trillium Health Centre was identifying best practice projects to support its ongoing quest for excellence. With Trillium designated as a regional stroke centre, acute ischemic stroke care was an obvious choice for a best practice project. The aim of the project was to improve access to care and quality of care for stroke patients from emergency through acute care to in-patient rehabilitation. The team chose the rapid cycle change methodology. This approach to quality improvement advocates the testing of a series of small changes (i.e., process improvement ideas) in tandem with measurements to assess the impact of the change to drive further process improvements. The project was deemed a success, resulting in significant improvements in the timeliness and quality of care.
Fall risk is a major contributor to fracture risk; implementing fall reduction programmes remains a challenge for health professionals and policy-makers.
We aimed to (1) ascertain whether the care received by 54 older adults after an emergency department (ED) fall presentation met internationally recommended 'Guideline Care', and (2) prospectively evaluate this cohort's 6-month change in fall risk profile. Participants were men and women aged 70 years or older who were discharged back into the community after presenting to an urban university tertiary-care hospital emergency department with a fall-related complaint. American Geriatric Society (AGS) guideline care was documented by post-presentation emergency department chart examination, daily patient diary of falls submitted monthly, patient interview and physician reconciliation where needed. Both at study entry and at a 6-month followup, we measured participants physiological characteristics by Lord's Physiological Profile Assessment (PPA), functional status, balance confidence, depression, physical activity and other factors.
We found that only 2 of 54 (3.7%) of the fallers who presented to the ED received care consistent with AGS Guidelines. Baseline physiological fall risk scores classified the study population at a 1.7 SD higher risk than a 65-year-old comparison group, and during the 6-month followup period the mean fall-risk score increased significantly (i.e. greater risk of falls) (1.7+/-1.6 versus 2.2+/-1.6, p=0.000; 29.5% greater risk of falls). Also, functional ability [100 (15) versus 95 (25), p=0.002], balance confidence [82.5 (44.4) versus 71.3 (58.7), p=0.000] and depression [0 (2) versus 0 (3), p=0.000] all worsened over 6 months. Within 6 months of the index ED visit, five participants had suffered six fall-related fractures.
We conclude that this group of community-dwelling fallers, who presented for ED care with a clinical profile suggesting a high risk of further falls and fracture, did not receive Guideline care and worsened in their fall risk profile by 29.5%. This gap in care, at least in one centre, suggests further investigation into alternative approaches to delivering Guideline standard health service.
A cautious outlook towards neck injuries has been the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries.
This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs for suspected neck injuries were included in the study. Data on patient demographics, high risk & low risk factors as per the Canadian Cervical Spine rule and cervical spine radiography results were collected and analysed.
28 patients were included in the high risk category according to the Canadian Cervical Spine rule. 86 patients fell into the low risk category. If the Canadian Cervical Spine rule was applied, there would have been a significant reduction in cervical spine radiographs as 86/114 patients (75.4%) would not have needed cervical spine radiograph. 2/114 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied.
Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients would have reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and health care costs.
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The paper presents guidelines for assessing regional exposure factors (EFs) according to the results of a questionnaire survey of about two thousand persons, including urban workers and/or adult students of the Central Federal District (CFD) and Siberian Federal District (SFD) of Russia. It has been ascertained that in CFD, annual exposure (324 days/year) is less than the standard value defaulted in Guidelines P 18.104.22.1680-04 (350 days/year), which causes a reduction in the chronic average daily dose. Town-dwellers spend the bulk of a day indoors (86 and 87% in CFD and SFD, respectively); 8 and 3% of a day on transport in CFD and SFD, and 7 and 10% indoors in these districts. The findings are in agreement with the data obtained by Russian and foreign investigators and suggest that the daily distribution of a microenvironmental load should be taken into account when health exposures and risks are estimated. The average daily tap water consumption in CFD (2.2 l/day) and SFD (1.7 l/day) is close to 90% percentile of the values recommended by the U.S. EPA (2.4 l/day) and the WHO or less than the value used in the calculation of the Russian maximum permissible concentrations for water (3.0 l/day). The time spent on water procedures by town-dwellers is 36.4 min/day in CFD and 37.6 min/day in SFD (while 29.2 min/day in rural dwellers in SFD) with the standard value of 30 min/day. The findings suggest that the use of the regional values of water-associated EFs increases the chronic average daily dose and therefore a risk upon oral, dermal, and inhalational exposure. The regional features of FEs have been kept in mind on assessing the risk upon multienvironmental exposures to the characteristic components of emission caused by aluminum works in CFD.
Implementing the European Renal Best Practice Guidelines suggests that prediction equations work well to differentiate risk of end-stage renal disease vs. death in older patients with low estimated glomerular filtration rate.
Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Nephrology, St. Olav Hospital, Trondheim, Norway. Electronic address: firstname.lastname@example.org.
Recent European guidelines suggest using the kidney failure risk equation (KFRE) and mortality risk equation for kidney disease (MREK) to guide decisions on whether elderly patients with chronic kidney disease should be referred early for dialysis preparation. However, the concurrent use of the two risk equations has not been validated. To do so we evaluated 1,188 individuals over five years with estimated glomerular filtration rate (eGFR) under 45ml/min/1.73m2 and age over 65 years from the Norwegian population based HUNT study. Forty-two patients started renal replacement therapy and 462 died as their first clinical event. The KFRE was well calibrated (mean risk estimate 4.9% vs observed 3.5%) with high diagnostic accuracy (C-statistics 0.93). The MREK underestimated death risk in those with lower risk (mean risk estimate 30.1% vs observed 38.9%) and had moderate diagnostic accuracy (C-statistics 0.71). Only 31 individuals had estimated end stage kidney disease (ESRD) risk greater than death risk, and most experienced ESRD before death. Only two of 598 patients over 80 years old, and ten of 1,063 with eGFR 25-45ml/min/1.73m2 at baseline experienced ESRD. Decision curve analysis demonstrated that for risk adverse patients, deferring ESRD preparation may be appropriate until predicted ESRD risk exceeds predicted death risk. For those preferring a more aggressive approach, referral when eGFR is under 25 ml/min/1.73m2 may be beneficial if age remains under 80 years. Thus, the risk of ESRD is low compared to the risk of death in many older patients with chronic kidney disease stage 3b or worse, and combination of predicted ESRD and death risks, eGFR levels, age, and the patient`s valuations of harm and benefit can be helpful for deciding when to start dialysis preparations.
Risk assessments of contaminated land often involve the use of generic bioconcentration factors (BCFs), which express contaminant concentrations in edible plant parts as a function of the concentration in soil, in order to assess the risks associated with consumption of homegrown vegetables. This study aimed to quantify variability in BCFs and evaluate the implications of this variability for human exposure assessments, focusing on cadmium (Cd) and lead (Pb) in lettuce and potatoes sampled around 22 contaminated glassworks sites. In addition, risks associated with measured Cd and Pb concentrations in soil and vegetable samples were characterized and a probabilistic exposure assessment was conducted to estimate the likelihood of local residents exceeding tolerable daily intakes. The results show that concentrations in vegetables were only moderately elevated despite high concentrations in soil, and most samples complied with applicable foodstuff legislation. Still, the daily intake of Cd (but not Pb) was assessed to exceed toxicological thresholds for about a fifth of the study population. Bioconcentration factors were found to vary more than indicated by previous studies, but decreasing BCFs with increasing metal concentrations in the soil can explain why the calculated exposure is only moderately affected by the choice of BCF value when generic soil guideline values are exceeded and the risk may be unacceptable.
Studies on the precise impact of environmental pollutants on human health are difficult to undertake and interpret, because many genetic and environmental factors influence health at the same time and to varying degrees. Our chapter in the AMAP report was based on new approaches to describe risks and future needs. In this paper, we will introduce the issues associated with risk assessment of single chemicals, and present suggestions for future studies as well as a summary of lessons learned during the health-related parts of the European Union-funded FP7 project ArcRisk (Arctic Health Risks: Impacts on health in the Arctic and Europe owing to climate-induced changes in contaminant cycling, 2009-2014; www.arcrisk.eu).
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