Temporal Trends in Public Stroke Knowledge, 1995-2021.

BACKGROUND: Outreach campaigns have sought to reduce the burden of stroke by improving knowledge of stroke risk factors (RF) and warning signs (WS). We describe trends in stroke knowledge from 1995 to 2021. METHODS: From 1995 to 2021, 6 separate surveys were conducted in the Greater Cincinnati Northern Kentucky Region. Temporal trends in RF/WS knowledge were analyzed using logistic regression adjusting for Race, sex, age, and education. RESULTS: In 1995, 28.6% of participants (537/1880) could name ≥2 WS, compared with 50.6% (983/1944) in 2021 (trend P<0.0001 after adjustment). In 1995, 44.5% of participants (836/1880) knew ≥2 RF, compared with 56.7% (1103/1944) in 2021 (trend P<0.0001 after adjustment). Although still improved compared with 1995, fewer participants could identify ≥2 RF in 2021 (1103/1944, 56.7%) when compared with 2011 (1287/2036, 63.2%, pairwise P<0.05). This decline in RF knowledge was disproportionately larger in women (odds ratio of 0.67 for knowledge in 2021 compared with 2011 in females, P=0.047 for the interaction between sex and study year). CONCLUSIONS: Although stroke knowledge has overall improved since 1995, there is evidence for lost gains since 2011, particularly in women. Stroke outreach campaigns need ongoing evaluation.

Using Epidemiological Data to Inform Clinical Trial Feasibility Assessments: A Case Study.

BACKGROUND: Clinical trial enrollment and completion is challenging, with nearly half of all trials not being completed or not completed on time. In 2014, the National Institutes of Health StrokeNet in collaboration with stroke epidemiologists from GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) began providing proposed clinical trials with formal trial feasibility assessments. Herein, we describe the process of prospective feasibility analyses using epidemiological data that can be used to improve enrollment and increase the likelihood a trial is completed. METHODS: In 2014, DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trialists, National Institutes of Health StrokeNet, and stroke epidemiologists from GCNKSS collaborated to evaluate the initial inclusion/exclusion criteria for the DEFUSE 3 study. Trial criteria were discussed and an assessment was completed to evaluate the percent of the stroke population that might be eligible for the study. The DEFUSE 3 trial was stopped early with the publication of DAWN (Thrombectomy 6 to 24 Hours After Stroke With a Mismatch Between Deficit and Infarct), and the Wilcoxon rank-sum statistic was used to analyze whether the trial would have been stopped had the proposed changes not been made, following the DEFUSE 3 statistical analysis plan. RESULTS: After initial epidemiological analysis, 2.4% of patients with acute stroke in the GCNKSS population would have been predicted to be eligible for the study. After discussion with primary investigators and modifying 4 key exclusion criteria (upper limit of age increased to 90 years, baseline modified Rankin Scale broadened to 0-2, time since last well expanded to 16 hours, and decreased lower limit of National Institutes of Health Stroke Scale score to <6), the number predicted to be eligible for the trial increased to 4%. At the time of trial conclusion, 57% of the enrolled patients qualified only by the modified criteria, and the trial was stopped at an interim analysis that demonstrated efficacy. We estimated that the Wilcoxon rank-sum value for the unadjusted predicted enrollment would not have crossed the threshold for efficacy and the trial not stopped. CONCLUSIONS: Objectively assessing trial inclusion/exclusion criteria using a population-based resource in a collaborative and iterative process including epidemiologists can lead to improved recruitment and can increase the likelihood of successful trial completion.

Dashboard visualizations: Supporting real-time throughput decision-making.

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

Acceptability of self-sample human papillomavirus testing among medically underserved women visiting the emergency department.

OBJECTIVE: Self-sample human papillomavirus (HPV) testing in public emergency departments (EDs) may be a viable strategy to opportunistically screen women who otherwise do not attend for regular Papanicolaou test-based cervical cancer screening. We describe the acceptability of self-sample HPV testing among women presenting to two high-volume, urban EDs that primarily care for the medically underserved. METHODS: In 2014, a total of 210 women 21 years of age and older were recruited from two public ED waiting areas following a two-stage cluster sampling design. Questionnaire items inquired about demographics, healthcare access and utilization, history of cervical cancer screening, and acceptability of self-sample HPV testing. Descriptive analyses were performed. RESULTS: Overall, 34.8% of participants were considered screening non-attendees based on their adherence to the current guidelines for Pap testing every three years. Acceptability of self-sample HPV testing was high, with over 85% of participants reporting that they would be willing to use the test if available. A smaller proportion (58%) was deemed likely to accept self-sample HPV testing in a public ED restroom setting. Primary concerns expressed by women were that the sampling may not be done correctly (64%) and that they may not know how to perform the sampling (39%). CONCLUSIONS: Opportunistic self-sample HPV testing is acceptable to women seeking care at a high-volume, urban emergency care center. The use of this intervention potentially offers a unique strategy to improve cervical cancer screening among high-risk women who otherwise do not attend for regular screening.

Emotional, Psychological, and Social Well-being Experience of Long-Term Living with Type 1 Diabetes Mellitus: A Patient-Psychiatrist-Endocrinologist Perspective.

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease that impacts blood glucose levels and can also lead to an increased prevalence of psychiatric conditions. Living with T1DM has been associated with a significant impact on a person's social, mental, and psychological quality of life (QoL). Stressors related to T1DM include the demands of managing the condition, acceptance of the diagnosis, and recognition of the sizeable personal responsibility involved in managing the condition. Participating in treatment designed to improve QoL can still take a psychological toll on individuals with T1DM and can lead to a wide range of psychological distress, including anxiety, fear, depression, stress, anger, frustration, and denial (among many others). Ongoing research seeks to investigate the range of psychiatric conditions that are common among people with T1DM. Bringing patient perspectives into research to design and implement workable solutions is the future of a novel holistic approach to managing T1DM-related mental health impact. Connecting with other people living with T1DM, clinicians, counselors/therapists, mental health professionals, and social workers might alleviate some of the challenges of managing the emotional issues and psychological distress associated with T1DM. Here, we provide the perspective of someone with over 33 years of living with T1DM, its impact on his mental health, QoL, the steps undertaken, and the path to successful management. This perspective is complemented by opinions from two expert clinicians-an endocrinologist and a psychiatrist. Sharing the real-life subjective burden experienced by the person living with diabetes could be one step towards increasing awareness of the toll of mental health disorders on people living with T1DM. This patient experience, complemented by expert endocrinologist and psychiatrist opinions, could pave the way for an effective two-way dialogue to manage the condition effectively.

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke.

BACKGROUND AND OBJECTIVES: Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality. METHODS: All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression. RESULTS: We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32). DISCUSSION: Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Vitamin D and orthostatic hypotension.

INTRODUCTION: we aimed to investigate on the potential relationship between vitamin D and orthostatic hypotension (OH) in a case-control model in older adults. METHODS: all participants were community-dwelling adults who were not taking vitamin D supplements. Cases were subjects aged 64 or older who were diagnosed with OH at a Falls and Blackout Unit. Controls were age- (within 5 years) and gender-matched subjects who had no history of blackouts, falls or orthostatic dizziness in the preceding year. OH was defined according to standard criteria and was diagnosed with an active stand test. Serum vitamin D [25(OH)D] was measured by radioimmunoassay. RESULTS: seventy-six subjects were included in the analysis (38 controls and 38 cases). Twenty-four in each group were female and mean age was between 78 and 79 years. Subjects with OH had lower serum 25(OH)D compared to controls (mean difference = 20.6 nmol/l, P = 0.0002). Lower vitamin D status was associated with an increased risk of OH after adjustment for season, body mass index, presence of stroke, diabetes and angina (P = 0.035) but not with impaired orthostatic haemodynamics. DISCUSSION: findings suggest that vitamin D may play a role in the aetiology of OH. Further studies will be required to explore on this relationship.

Making sense: sensor-based investigation of clinician activities in complex critical care environments.

In many respects, the critical care workplace resembles a paradigmatic complex system: on account of the dynamic and interactive nature of collaborative clinical work, these settings are characterized by non-linear, inter-dependent and emergent activities. Developing a comprehensive understanding of the work activities in critical care settings enables the development of streamlined work practices, better clinician workflow and most importantly, helps in the avoidance of and recovery from potential errors. Sensor-based technology provides a flexible and viable way to complement human observations by providing a mechanism to capture the nuances of certain activities with greater precision and timing. In this paper, we use sensor-based technology to capture the movement and interactions of clinicians in the Trauma Center of an Emergency Department (ED). Remarkable consistency was found between sensor data and human observations in terms of clinician locations and interactions. With this validation and greater precision with sensors, ED environment was characterized in terms of (a) the degree of randomness or entropy in the environment, (b) the movement patterns of clinicians, (c) interactions with other clinicians and finally, (d) patterns of collaborative organization with team aggregation and dispersion. Based on our results, we propose three opportunities for the use of sensor technologies in critical care settings: as a mechanism for real-time monitoring and analysis for ED activities, education and training of clinicians, and perhaps most importantly, investigating the root-causes, origins and progression of errors in the ED. Lessons learned and the challenges encountered in designing and implementing the sensor technology sensor data are discussed.

Does crowding influence emergency department treatment time and disposition?

OBJECTIVE: The objective of this study was to determine whether crowding influences treatment times and disposition decisions for emergency department (ED) patients. METHODS: We conducted a retrospective cohort study at 2 hospitals from January 1, 2014, to July 1, 2014. Adult ED visits with dispositions of discharge, admission, or transfer were included. Treatment times were modeled by linear regression with log-transformation; disposition decisions (admission or transfer vs discharge) were modeled by logistic regression. Both models adjusted for chief complaint, Emergency Severity Index (ESI), and 4 crowding metrics in quartiles: waiting count, treatment count, boarding count, and National Emergency Department Overcrowding Scale. RESULTS: We included 21,382 visits at site A (12.9% excluded) and 29,193 at site B (15.0% excluded). Respective quartiles of treatment count increased treatment times by 7.1%, 10.5%, and 13.3% at site A (P < 0.001) and by 4.0%, 6.5%, and 10.2% at site B (P < 0.001). The fourth quartile of treatment count increased estimates of treatment time for patients with chest pain and ESI level 2 from 2.5 to 2.9 hours at site A (20 minutes) and from 3.0 to 3.3 hours at site B (18 minutes). Treatment times decreased with quartiles of waiting count by 5.6%, 7.2%, and 7.3% at site B (P < 0.001). Odds of admission or transfer increased with quartiles of waiting count by 8.7%, 9.6%, and 20.3% at site A (P = 0.011) and for the third (11.7%) and fourth quartiles (27.3%) at site B (P < 0.001). CONCLUSIONS: Local crowding influenced ED treatment times and disposition decisions at 2 hospitals after adjusting for chief complaint and ESI.

Reel psychiatry.

A comprehensive list of good-to-excellent portrayals of psychiatric conditions is presented for major categories of mental illness. Precise numerical codes from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) are provided along with the name of the actor portraying the character of interest, and country and year of release for each film.

Vascular biomarkers of cognitive performance in a community-based elderly population: the Dublin Healthy Ageing study.

BACKGROUND: population studies suggest that cardiovascular risk factors may be associated with cognitive impairment. Epidemiological studies evaluating individual markers of vascular disease as risk factors for cognitive dysfunction have yielded inconsistent results. Homocysteine has emerged as a marker consistently associated with poorer outcomes. Existing studies have largely examined individual vascular risks in isolation and have tended to ignore patient psychological status. OBJECTIVE: to investigate the association between markers of vascular disease and cognition in a community-dwelling non-demented elderly population while adjusting for vascular and non-vascular confounds. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (s.d., 6.06) years. 208 (44.6%) were male. RESULTS: higher levels of homocysteine were consistently associated with poorer performance in tests assessing visual memory and verbal recall. No other vascular biomarker was found to be associated with cognitive performance. Factors such as alcohol use, tea intake, life satisfaction, hypertension and smoking were positively correlated with global cognitive performance. Negative correlations existed between cognitive performance and depression, past history of stroke, intake of fruit and use of psychotropic medication. CONCLUSIONS: homocysteine was the only vascular biomarker associated with poorer function in a number of domains on neuropsychological testing, independent of vascular and non-vascular confounds. Other psychosocial factors may need to be taken into account as potential confounds in future studies investigating cognition.

Interruptions in a level one trauma center: a case study.

BACKGROUND: The emergency department has been characterized as interrupt-driven. Government agencies and patient safety organizations recognize that interruptions contribute to medical errors. The purpose of this study was to observe, record, and contextualize activities and interruptions experienced by physicians and Registered Nurses (RNs) working in a Level One Trauma Center. DESIGN: A case study that relied on an ethnographic study design using the shadowing method. SUBJECTS: A convenience sample of physicians and RNs, each with at least 6 months of experience in the Emergency Department (ED), were asked to participate. In these kinds of detailed qualitative investigations, it is quite common to have a small sample size. Ethical approval: Approval was obtained from institutional ethic committees prior to initiating the study. Community consent was obtained from the ED staff through in-service education. SETTING: All observations were made in the trauma section of the ED of a tertiary teaching hospital. The hospital is situated in a major medical center in the Gulf Coast region of the United States of America (USA). FINDINGS: Five attending ED physicians were observed for a total of 29h, 31min. Eight RNs were shadowed for a total of 40 h, 9min. Interruptions and activities were categorized using the Hybrid Method to Categorize Interruptions and Activities (HyMCIA). Registered Nurses received slightly more interruptions per hour than physicians. People, pagers, and telephones were identified as mediums through which interruptions were delivered. The physical environment was found to contribute to interruptions in workflow because of physical design and when supplies were not available. Physicians and RNs usually returned to the original, interrupted activity more often than leaving the activity unfinished. CONCLUSION: This research provides an enhanced understanding of interruptions in workflow in the ED, the identification of work constraints, and the need to develop interventions to manage interruptions. It is crucial that interruptions be delivered in such a way that there is minimal negative impact on performance. The significance and importance of the interruption must always be weighed against the negative impact that it has on smooth, efficient workflow.

Towards a hybrid method to categorize interruptions and activities in healthcare.

OBJECTIVE: Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD: The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS: The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS: Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Initiators of interruption in workflow: the role of MDs and RNs.

The healthcare environment has been characterized as interrupt-driven with medical doctors (MDs) and registered nurses (RNs) receiving many interruptions during a shift. Previous research studies have focused on the recipient because of the negative impact on task performance. It is equally important to understand the initiator of an interruption to help design strategies to lessen the number of interruptions and the possible negatives consequences. The purpose of this instrumental study was to examine MDs and RNs as initiators of interruptions. Results of this study indicate that MDs and RNs initiate interruptions most often through face-to-face situations and use of the telephone. Strategies to successfully manage interruptions must consider both the role of initiator as well as the recipient in an interruption event.

Ultrasound Screening for Adverse Local Tissue Reaction after Hip Arthroplasty.

Early detection of adverse local tissue reaction (ALTR) to prosthetic hip wear debris is vital to improve the success of revision surgery. Magnetic resonance imaging with metal artefact reduction sequencing (MARS MRI) is considered the modality of choice to provide cross-sectional imaging of the soft tissues. The areas adjacent to the prosthesis are, however, not readily imaged using these protocols. Ultrasound has also been recommended as an imaging modality in the follow-up of hip replacement surgery. We decided to characterise the typical ultrasound findings in a group of patients undergoing routine biennial review of arthroplastic hips with particular reference to the hip capsule, femoral neck and iliopsoas bursa and tendon adjacent to the implant. Fifty-two patients with a mean (±SD) age of 60.4 (±12) y were prospectively recruited. Twelve patients had bilateral hip prostheses, giving 64 hips for analysis. Mean (±SD) age of the prosthesis in situ was 8.2 (±3.3) y. Data were grouped on the basis of the shape of the iliofemoral ligament. The median (range) maximal anteroposterior synovial thickness was 5 (2-8) mm in the normal concave iliofemoral ligament group and 7 (4-56) mm in the abnormal straight/convex iliofemoral ligament group (p = 0.001). The anteroposterior iliopsoas tendon measurement was 5 (3-8) mm in the normal group and 5 (4-8) mm in the abnormal group (p = 0.065). ALTR development in asymptomatic well-functioning prostheses may be recognised earlier using ultrasound rather than MARS MRI by carefully assessing the shape of the iliofemoral ligament. Ultrasound findings of an abnormal straight or convex ligament may be suggestive of early ALTR and warrant streaming of patients to a more frequent surveillance program.