Search

Summary: We compared medication prescription and initiation proportions among high-risk Fracture Screening and Prevention Program patients with multiple chronic conditions. Patients with two conditions were more likely to receive prescriptions and initiate prescribed medication than those with none. Post hoc analysis showed that patients with ≥ 3 conditions were less likely to be prescribed and to initiate medication, compared to those with two conditions. Tailored interventions are important for improving post-fracture care outcomes. Purpose: To investigate the association between the number of chronic conditions and pharmacological treatment outcomes in high-risk patients who were screened through the Fracture Screening and Prevention Program (FSPP). Methods: A retrospective cohort study was employed to determine the association between the number of chronic conditions and treatment outcomes. All high-risk patients who were enrolled in the FSPP between June 1, 2017, and June 30, 2022, were included in the study. The number of self-reported chronic conditions available in the FSPP data was classified into four categories: (1) 0 condition; (2) 1 condition; (3) 2 conditions; and (4) ≥ 3 conditions. Multivariable logistic regression models were created with prescription and initiation as outcomes. Results: In total, 11,245 patients were identified as high-risk for future fracture. Patients with two chronic conditions demonstrated a 26% higher odds of receiving a medication prescription, and those with two chronic conditions and prescribed bone-active medication had a 57% increased odds of initiating the treatment compared to individuals without chronic conditions. No significant differences in medication prescription or initiation were seen in those with 1 or ≥ 3 chronic conditions compared to those without chronic conditions. In post hoc testing, we saw a 25–30% significantly lower odds of medication prescription and initiation in patients reporting ≥ 3 chronic conditions when compared to those who reported only two chronic conditions. Conclusion: The findings suggest that a large provincial secondary fracture prevention program resulted in higher odds of prescription and initiation of treatment in patients with two chronic conditions compared to those having no chronic conditions. Potential inequities in these treatment outcomes were found with a threshold of three or more chronic conditions. This highlights the need for tailored interventions and comprehensive support systems to improve fracture prevention outcomes for high-risk patients with multiple chronic conditions. [ABSTRACT FROM AUTHOR]

Background: Multimodal analgesia (MMA) combines opioids with nonopioid analgesics (NOAs) to mitigate opioid‐related adverse events and development of opioid use disorders. Although MMA has become the standard for orthopedic perioperative pain management, guidance is less clear for the approximately 15% of patients who go on to require inpatient orthopedic rehabilitation (IOR) postoperatively. The IOR population tends to be older and frailer and hence likely more vulnerable to adverse events. Little research has been done to shed light on how NOAs are used in this population. Objective: To characterize NOA prescribing in older versus younger adults during IOR admissions and to determine predictors of NOA prescribing in an older IOR population. Design: Retrospective case–control study. Setting: Two IOR wards at an academic rehabilitation hospital in Toronto, Canada. Patients: All patients aged ≥50 years admitted for an orthopedic indication between November 2019 and June 2021; the patients aged <65 group was included for comparative characterization of NOA prescribing versus older peers. Interventions: Not applicable. Main Outcome Measures: Medication use and adverse events, pain, and rehabilitation outcomes such as the Functional Independence Measure, discharge destination, and length of stay. Results: A total of 643 patient encounters were included; 48.2% used NOA. Age (odds ratio [OR]: 0.97; confidence interval [CI]: 0.95–0.99, p <.001) and prior NOA use (OR: 3.15; CI: 2.0–4.9, p <.001) were associated with NOA prescribing. Other positively associated factors included body mass index, psychiatric history, elective surgery, and admission from a specific referring hospital. Adverse events between NOA users and nonusers were similar. Conclusions: NOA prescribing is heterogeneous and declines with age in IOR. This points to an opportunity to explore integrating NOA into opioid‐sparing MMA protocols tailored to older IOR patients, along with further study of the safety and benefit of these regimens. [ABSTRACT FROM AUTHOR]

Introduction: Point-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study explores a new method to assess diaphragmatic motion by measuring the excursion of the uppermost point of the zone of apposition (ZOA) at the mid-axillary line using a high-frequency linear ultrasound probe and compares it with two previously established methods: the assessment of the excursion of the dome of the diaphragm (DOD) and the thickening ratio at the ZOA. Methods: This is a single-centre, prospective comparative study on elective surgical patients with normal diaphragmatic function. Following research ethics board approval and patient written consent, 75 elective surgical patients with normal diaphragmatic function were evaluated preoperatively. Three ultrasound methods were compared: (1) assessment of the excursion of the DOD using a curvilinear probe through an abdominal window; (2) assessment of the thickening fraction of the ZOA; and (3) assessment of the excursion of the ZOA. The last two methods performed with a linear probe on the lateral aspect of the chest. Results: Seventy-five patients were studied. We found that the evaluation of the excursion of the ZOA was more consistently successful (100% bilaterally) than the evaluation of the excursion of the DOD (98.7% and 34.7% on the right and left sides, respectively). The absolute values of the excursion of the ZOA were greater than and well correlated with the values of the DOD. Conclusion: Our preliminary data from this exploratory study suggest that the evaluation of the excursion of the ZOA on the lateral aspect of the chest using a linear probe is consistently successful on both right and left sides. Future studies are needed to establish the distribution of normal values and suggest diagnostic criteria for diaphragmatic paresis or paralysis. [ABSTRACT FROM AUTHOR]

Objective: To identify which components of maternal vascular malperfusion (MVM) pathology are associated with adverse pregnancy outcomes and to investigate the morphological phenotypes of MVM placental pathology and their relationship with distinct clinical presentations of pre‐eclampsia and/or fetal growth restriction (FGR). Design: Retrospective cohort study. Setting: Tertiary care hospital in Toronto, Canada. Population: Pregnant individuals with low circulating maternal placental growth factor (PlGF) levels (<100 pg/mL) and placental pathology analysis between March 2017 and December 2019. Methods: Association between each pathological finding and the outcomes of interest were calculated using the chi‐square test. Cluster analysis and logistic regression was used to identify phenotypic clusters, and their association with adverse pregnancy outcomes. Cluster analysis was performed using the K‐modes unsupervised clustering algorithm. Main outcome measures: Preterm delivery <34+0 weeks of gestation, early onset pre‐eclampsia with delivery <34+0 weeks of gestation, birthweight <10th percentile (small for gestational age, SGA) and stillbirth. Results: The diagnostic features of MVM most strongly associated with delivery <34+0 weeks of gestation were: infarction, accelerated villous maturation, distal villous hypoplasia and decidual vasculopathy. Two dominant phenotypic clusters of MVM pathology were identified. The largest cluster (n = 104) was characterised by both reduced placental mass and hypoxic ischaemic injury (infarction and accelerated villous maturation), and was associated with combined pre‐eclampsia and SGA. The second dominant cluster (n = 59) was characterised by infarction and accelerated villous maturation alone, and was associated with pre‐eclampsia and average birthweight for gestational age. Conclusions: Patients with placental MVM disease are at high risk of pre‐eclampsia and FGR, and distinct pathological findings correlate with different clinical phenotypes, suggestive of distinct subtypes of MVM disease. [ABSTRACT FROM AUTHOR]

Background and aimThe large regional variation in survival after treatment of out-of-hospital cardiac arrest (OHCA) is incompletely explained. Communities respond to OHCA with differing number of emergency medical services (EMS) personnel who respond to the scene. The effect of different numbers of EMS personnel on-scene upon outcomes is unclear. We sought to evaluate the association between number of EMS personnel on-scene and survival after OHCA.MethodsWe performed a retrospective review of prospectively collected data on 16,122 EMS-treated OHCA events from December 1, 2005 to May 31, 2007 from a combined population over 21 million people residing in an area of over 33,000 square miles in Canada and the United States. Number of EMS personnel on-scene was defined as the number of EMS personnel who responded to the scene of OHCA within 15 min after 9-1-1 call receipt and prior to patient death or transport away from the scene. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models.ResultsCompared to a reference number of EMS personnel on-scene of 5 or 6, 7 or 8 EMS personnel on-scene was associated with a higher rate of survival to hospital discharge, adjusted odds ratio [OR], 1.35 (95% CI: 1.05, 1.73). There was no significant difference in survival between 5 or 6 personnel on-scene versus fewer.ConclusionMore EMS personnel on-scene within 15 min of 9-1-1 call was associated with improved survival of out-of-hospital cardiac arrest. It is unlikely that this finding was mediated solely by earlier CPR or earlier defibrillation.