Ischaemic stroke on anticoagulation therapy and early recurrence in acute cardioembolic stroke: the IAC study.

BACKGROUND AND PURPOSE: A subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH). METHODS: We included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve). RESULTS: Among 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641). CONCLUSION: AF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.

Caring Cards: Preventing Patient Harm Through the Heart of Nursing.

The use of "Caring Cards" is a unique innovation, which builds on reliable Lean processes. It adds the way we emotionally care for people to a Lean methodology. This article describes how the foundational constructs of nursing theory are paired with aspects of universal fall precautions. In a pilot prioritizing Caring Cards, conversations between leaders and staff provide a way for the nurse to describe his or her critical thinking about fall prevention that is individualized to a patient. Leaders collect information on barriers to care and demonstrate follow-up actions to staff members who raise concerns. The system allows for structured leader and staff interactions that are coaching and mentoring in nature. These support an environment where nurses care for patients, while leaders also care for staff. By partnering Lean methodology with the heart of nursing, patient care can be improved. The pilot project utilizing this methodology was performed on a neurological unit. It resulted in a dramatic reduction in falls. The unassisted patient fall rate per 1000 patient-days dropped from 11.60 to 5.81 falls, a 50% reduction.

Developing a Marketing Orientation in Hospital Library Services: A Case Report.

When the four Providence Health & Services libraries in Oregon regionalized services and resources, the transition, which was originally met with apprehension from some library users, turned out to be a resounding success. Despite a loss of two-thirds of the professional staff and a decreased budget, the new regionalized library experienced an increase in business and recognition. While many factors contributed to the success, a creative marketing and outreach campaign was a key component. This column describes the steps taken to promote regionalized library reference services and online resources.

Heat illness and death among workers - United States, 2012-2013.

Exposure to heat and hot environments puts workers at risk for heat stress, which can result in heat illnesses and death. This report describes findings from a review of 2012‒2013 Occupational Safety and Health Administration (OSHA) federal enforcement cases (i.e., inspections) resulting in citations under paragraph 5(a)(1), the "general duty clause" of the Occupational Safety and Health Act of 1970. That clause requires that each employer "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees". Because OSHA has not issued a heat standard, it must use 5(a)(1) citations in cases of heat illness or death to enforce employers' obligations to provide a safe and healthy workplace. During the 2-year period reviewed, 20 cases of heat illness or death were cited for federal enforcement under paragraph 5(a)(1) among 18 private employers and two federal agencies. In 13 cases, a worker died from heat exposure, and in seven cases, two or more employees experienced symptoms of heat illness. Most of the affected employees worked outdoors, and all performed heavy or moderate work, as defined by the American Conference of Governmental Industrial Hygienists. Nine of the deaths occurred in the first 3 days of working on the job, four of them occurring on the worker's first day. Heat illness prevention programs at these workplaces were found to be incomplete or absent, and no provision was made for the acclimatization of new workers. Acclimatization is the result of beneficial physiologic adaptations (e.g., increased sweating efficiency and stabilization of circulation) that occur after gradually increased exposure to heat or a hot environment. Whenever a potential exists for workers to be exposed to heat or hot environments, employers should implement heat illness prevention programs (including acclimatization requirements) at their workplaces.

Strategies and Lessons Learned from a Home Delivery Food Prescription Program for Older Adults.

Food insecurity (FI) is a growing health problem, worsening during the COVID-19 pandemic. Fresh food prescription programs (FFRx) have been shown to increase healthy eating and decrease FI, but few FFRx are community-informed, or theory based. Our FFRx was a delivery program developed to alleviate FI for older adults. It was implemented in an academic medical center and guided by the Capabilities, Opportunities, Motivations, and Behaviors and Theoretical Domains Framework. We tested impacts of the program on FI, Fruit and Vegetable (FV) intake, depression, and loneliness at six-month intervals. During the FFRx, 31 people completed surveys every six months. FI decreased by an average of 2.03 points (p = <.001) while FV intake increased from a mean of 2.8 servings per day to 2.9 servings per day (p = .53). Depression and loneliness scores stayed stable. Preliminary data from this FFRx program, a partnership between an academic medical center and community partners, had positive impacts on FI.

Attempted Suicide Among Adolescents in Military Families: The Mediating Role of Adverse Childhood Experiences.

Research has shown that adolescents in military families have higher rates of suicidal behaviors compared to their nonmilitary peers. This is typically attributed to military-specific stressors, but exposure to adverse childhood experiences (ACEs) may also play a role. Our primary research objective was to determine whether cumulative exposure to ACEs mediates the relationship between military family involvement and attempted suicide. A two-stage cluster random sampling design was used to randomly sample 5,336 students from 98 high schools. Students were asked whether a parent or other adult in their home was serving on active duty in the military and attempted suicide in the past 12 months was assessed. Six measures of childhood abuse and household dysfunction were summed, and the ACE score was categorized as 0, 1, 2, and 3-6 ACEs. Weighted logistic regression and multinomial regression were used to assess differences in ACEs and attempted suicide, controlling for sex, age, race/ethnicity, rurality, and qualification for free/reduced lunch. To investigate potential mediation effects of ACEs on the relationship between military family and attempted suicide, we conducted path analyses controlling for demographics. Compared to their peers, students in military families had higher exposure to ACEs (1 ACE: adjusted odds ratio [AOR] = 1.49, 95% confidence interval [CI] = [0.88, 2.53], 2 ACEs: AOR = 2.07, 95% CI = [1.23, 3.48], and 3-6 ACEs: AOR = 2.57, 95% CI = [1.54, 4.27]) and twice the odds of attempting suicide in the past 12 months (AOR = 2.16, 95% CI = [1.30, 3.61]). Mediation analyses showed that cumulative exposure to ACEs completely mediated the relationship between military family involvement and attempted suicide. The study results highlight the need for trauma-informed approaches to mental health promotion with military families.

Kidney Check Point-of-Care Testing-Furthering Patient Engagement and Patient-Centered Care in Canada's Rural and Remote Indigenous Communities: Program Report.

PURPOSE OF PROGRAM: Access to health care services remains a significant barrier for many Indigenous people's living in rural and remote regions of Canada. Driven by geographical isolation and compounded by socioeconomic and environmental disparities, individuals living under these circumstances face disproportionately poor health outcomes. Kidney Check is a comprehensive screening, triage, and treatment initiative working to bring culturally safe preventive care to rural and remote Indigenous communities across Manitoba, Ontario, BC, Alberta, and Saskatchewan. The project's patient-oriented approach addresses concerns raised by kidney patients and their caregivers using culturally safe practices. Using the various expertise of their multidisciplinary team, Kidney Check seeks to further collaborative efforts to improve access to preventive health care for these groups. Meaningful engagement with patients, communities, and local health care stakeholders ensures Indigenous voices are heard and incorporated into the project in a way that promotes shared decision-making and sustainability. SOURCES OF INFORMATION: As an affiliate program of the Can-SOLVE CKD Network, Kidney Check's guiding priorities were developed over 3 years of patient consultation and finalized during 2 workshops held with more than 30 patients, caregivers, Indigenous peoples, researchers, and policy makers using a modified Delphi process. Today, patients continue to participate in project development via 2 governing bodies: The Patient Governance Circle and the Indigenous Peoples Engagement and Research Council (IPERC). METHODS: Modeled after the Indigenous-led 2015 FINISHED project in Manitoba, Kidney Check employs point-of-care testing to identify diabetes, hypertension, and chronic kidney disease (CKD) in individuals, ages 10 and above, regardless of pre-existing risk factors. The Kidney Check team consists of 4 working groups: project leadership, provincial management, local community partners, and patient partners. By using and building on existing relationships between local and provincial health care stakeholders and various Indigenous communities, the program furthers collaborative efforts to bridge gaps in health equity. KEY FINDINGS: The Kidney Check program has established an infrastructure that integrates patient engagement at all stages of the program from priority setting to deployment and dissemination strategies. LIMITATIONS: While we encourage and offer screening services to all, many still choose not to attend for a variety of reasons which may introduce selection bias. Kidney Check uses patient engagement as a foundational component of the program; however, there is currently a limited amount of research documenting the benefits of patient engagement in health care settings. More formal qualitative evaluations of these activities are needed. In addition, as the COVID-19 pandemic has halted screening procedures in most communities, we currently do not have quantitative data to support the efficacy of the Kidney Check program. IMPLICATIONS: For many Indigenous people, lack of accessibility to health care services is compounded by sociopolitical barriers that disrupt relationships between patients and providers. Meaningful engagement presents one opportunity to ensure the voices and perspectives of Indigenous patients and communities are incorporated into health services. In addition, this screening paradigm has shown to be cost effective as shown by analyses done on the FINISHED screening program.

OBJECTIFS DU PROGRAMME: L'accès aux services de santé demeure un obstacle important pour de nombreuses populations autochtones vivant dans les régions rurales et éloignées du Canada. En raison de l'isolement géographique et de disparités environnementales et socio-économiques, les personnes vivant dans ces situations sont confrontées à de pauvres conditions de santé. Kidney Check est une initiative complète de dépistage, de triage et de traitement qui vise à offrir des soins préventifs et respectueux de leurs valeurs culturelles aux communautés autochtones rurales et éloignées du Manitoba, de l'Ontario, de la Colombie-Britannique, de l'Alberta et de la Saskatchewan. L'approche axée sur le patient répond aux préoccupations soulevées par les patients atteints de néphropathies et leurs soignants grâce à des pratiques adaptées à leur culture. En exploitant les compétences d'une équipe multidisciplinaire, Kidney Check s'efforce de poursuivre les efforts de collaboration visant l'amélioration de l'accès à des soins de santé préventifs pour ces groupes. Un engagement significatif des patients, des communautés et des acteurs locaux du secteur de la santé garantit que les voix autochtones sont entendues et intégrées dans le projet d'une manière qui favorise la pérennité et la prise de décision partagée. SOURCES: Kidney Check étant un programme affilié du réseau CAN-SOLVE CKD, ses priorités directrices ont été élaborées à partir d'une consultation de 3 ans auprès des patients et finalisées au cours de deux ateliers utilisant une version modifiée de la méthode Delphi et réunissant plus d'une trentaine de patients, soignants, membres des communautés autochtones, chercheurs et décideurs. Les patients continuent à ce jour de participer au développement du projet par l'entremise de deux organes directeurs: le Conseil des patients et le Conseil de la recherche et de l'engagement des peuples autochtones (IPICER). MÉTHODOLOGIE: Inspiré du projet de dépistage FINISHED mené en 2015 auprès des Autochtones du Manitoba, Kidney Check utilise des tests au point de service pour dépister le diabète, l'hypertension et l'insuffisance rénale chronique chez les personnes âgées de 10 ans et plus, quels que soient les facteurs de risque préexistants. L'équipe de Kidney Check se compose de quatre groupes de travail: direction du projet, gestion provinciale, partenaires communautaires locaux et patients partenaires. En utilisant et en s'appuyant sur les relations existantes entre les intervenants locaux et provinciaux du secteur de la santé et les diverses communautés autochtones, le programme favorise les efforts de collaboration pour combler les écarts en matière d'équité en santé. PRINCIPAUX RÉSULTATS: Le programme Kidney Check a mis en place une infrastructure impliquant la participation des patients à toutes les étapes du programme, de l'établissement des priorités aux stratégies de déploiement et de diffusion. LIMITES: Nous encourageons et offrons ces services de dépistage à tous, mais, pour diverses raisons, beaucoup choisissent de ne pas y participer, ce qui peut introduire un biais de sélection. La participation des patients est un élément fondamental du programme Kidney Check; néanmoins, les avantages d'un engagement des patients dans les établissements de soins de santé demeurent peu documentés. Davantage d'évaluations qualitatives formelles de ces activités sont donc nécessaires. De plus, la pandémie de COVID-19 ayant interrompu les procédures de dépistage dans la plupart des collectivités, nous ne disposons pas actuellement de données quantitatives pour soutenir l'efficacité du programme. CONCLUSION: Pour de nombreuses populations autochtones, le manque d'accessibilité aux services de santé est aggravé par des obstacles sociopolitiques qui perturbent les relations entre les patients et les fournisseurs de soins. La participation significative des patients et des communautés autochtones permet d'assurer que leurs voix et perspectives soient intégrées dans les services de santé. En outre, ce paradigme de dépistage s'est révélé rentable, comme le montrent les analyses effectuées sur le programme de dépistage FINISHED.