Relationships Between Wheelchair Services Received and Wheelchair User Outcomes in Less-Resourced Settings: A Cross-Sectional Survey in Kenya and the Philippines.

OBJECTIVE: To explore the relationships between wheelchair services received during wheelchair provision and positive outcomes for users of wheelchairs. DESIGN: Secondary analysis of cross-sectional data. SETTING: Urban and periurban communities in Kenya and the Philippines. PARTICIPANTS: Adult basic manual wheelchair users (N=852), about half of whom reported having received some wheelchair services with the provision of their current wheelchairs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed a survey that included questions related to demographic, clinical, and wheelchair characteristics. The survey also included questions about the past receipt of 13 wheelchair services and 4 positive outcomes for users of wheelchairs. The relationships between individual services received and positive outcomes were assessed using logistic regression analyses. In addition to assessing individual services and outcomes, we analyzed a composite service score (the total number of services received) and a composite outcome score (≥3 positive outcomes). RESULTS: The top 3 individual services from the perspective of relationships with the composite outcome score were "provider did training" (P=.0009), "provider assessed wheelchair fit while user propelled the wheelchair" (P=.002), and "peer group training received" (P=.033). The composite service score was significantly related to "daily wheelchair use" (P<.0001), "outdoor unassisted wheelchair use" (P<.0001), "high performance of activities of daily living" (P=.046) and the composite outcome score (P=.005), but not to the "absence of serious falls" (P=.73). CONCLUSIONS: The receipt of wheelchair services is associated with positive outcomes for users of wheelchairs, but such relationships do not exist for all services and outcomes. These findings are highly relevant to ongoing efforts to optimize wheelchair service delivery.

Urban-Rural Differences in Cardiac Arrest Outcomes: A Retrospective Population-Based Cohort Study.

Background: Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas. Methods: This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms. Results: A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3). Conclusions: Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

Contexte: Environ 10 % des personnes qui subissent un arrêt cardiaque en milieu extrahospitalier (ACEH), traité par des intervenants paramédicaux, survivent jusqu'à leur congé de l'hôpital. Le taux de survie peut différer de 19,2 % entre les centres urbains et les régions rurales. Notre étude visait à étudier les différences en matière de survie après un ACEH entre les centres urbains et les régions rurales. Méthodologie: Il s'agissait d'une étude de cohorte rétrospective portant sur des patients ayant subi un ACEH traité par les services médicaux d'urgence de la Nouvelle-Écosse en 2017. Les cas d'ACEH traumatique, prévu et non cardiaque ont été exclus. Les données ont été recueillies à partir du système de dossiers électroniques de soins aux patients des services médicaux d'urgence et de la Base de données sur les congés des patients. L'analyse du système d'information géographique a classé les cas selon qu'ils sont survenus dans un centre urbain (population de plus de 1 000 personnes) ou dans une région rurale, en utilisant les limites du recensement canadien de 2016. Le principal paramètre d'évaluation était la survie à la sortie de l'hôpital. Les covariables utilisées dans la régression logistique multivariée étaient l'âge, le sexe, la réanimation effectuée par des témoins si présents lors de l'arrêt cardiaque, l'emplacement public et les symptômes précédents. Résultats: Au total, 510 ACEH traités par les services médicaux d'urgence de la Nouvelle-Écosse ont été inclus aux fins de l'analyse. En tout, 12 % (n = 62) des sujets ont survécu jusqu'à leur congé hospitalier. Les patients ayant subi un ACEH dans un centre urbain étaient 107 % plus susceptibles de survivre que ceux ayant subi un ACEH dans une région rurale (rapport de cotes ajusté : 2,1; intervalle de confiance à 95 % : 1,1 ­ 3,8; p = 0,028). Le temps moyen de délivrance d'un choc lors d'un ACEH avec rythme défibrillable est significativement plus court (11,2 ± 6,2 minutes) dans un centre urbain que dans une région rurale (17,5 ± 17,3 minutes). Conclusions: La Nouvelle-Écosse fait état d'une disparité dans les soins de l'ACEH entre les régions urbaines et les régions rurales, que l'on observe également dans les villes densément peuplées. La survie est plus longue dans les centres urbains. Il est possible de prolonger davantage la survie globale, en particulier dans les régions rurales, en sensibilisant la communauté à l'ACEH et en optimisant la prestation des soins de santé.

Left ventricular growth after 1 year of haemodialysis does not correlate with arteriovenous access flow: a prospective cohort study.

BACKGROUND: The incidence of congestive heart failure is 3-fold greater than that of acute coronary syndrome in haemodialysis (HD) patients. The purpose of this study was to determine if blood flow through an arteriovenous (AV) access contributes to an increase in left ventricular mass (LVM) that may increase the risk of congestive heart failure. METHODS: We conducted a 1-year prospective cohort study at two Canadian centres of HD patients at high risk for congestive heart failure who had a first AV access created. Patients underwent echocardiography and measurement of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels before and 1-year post-AV access creation. Access flows were measured within the first month of access maturation and 1-year post-access creation. Data were analysed using descriptive statistics, Student's t-test, correlation coefficients and regression. RESULTS: One-year post-AV access creation, LVM increased by 12.2 +/- 32% (P = 0.025) and plasma NT-proBNP levels increased by 170 +/- 465% (P = 0.02). The average AV access blood flow did not correlate with an increase in LVM or NT-proBNP levels. CONCLUSIONS: In patients on chronic HD after 1 year, AV access flow does not correlate with increases in LVM by echocardiography or plasma levels of NT-proBNP.

Survey of Australian and Canadian Community Pharmacists' Experiences With Patients at Risk of Suicide.

OBJECTIVE: The study's objective was to examine Canadian and Australian community pharmacists' experiences with people at risk of suicide. METHODS: A survey was developed and administered online. Countries were compared by Fisher's exact and t tests. Multivariable logistic-regression analysis was used to identify variables associated with preparedness to help someone in a suicidal crisis. RESULTS: The survey was completed by 235 Canadian and 161 Australian pharmacists. Most (85%) interacted with someone at risk of suicide at least once, and 66% experienced voluntary patient disclosure of suicidal thoughts. More Australians than Canadians had mental health crisis training (p<0.001). Preparedness to help in a suicidal crisis was negatively associated with being Canadian, having a patient who died by suicide, lacking training and confidence, and permissive attitudes toward suicide. CONCLUSIONS: Several perceived barriers impede pharmacists' abilities to help patients who voluntarily disclose suicidal thoughts. Gatekeeper and related suicide prevention strategy training for community pharmacists is warranted.

A survey of Canadian and Australian pharmacists' stigma of suicide.

BACKGROUND: There is limited information available regarding community pharmacists' stigma of suicide. Pharmacists regularly interact with people at risk of suicide and stigmatizing attitudes may impact care. OBJECTIVE: To measure community pharmacists' stigma of suicide. METHOD: Pharmacists in Canada and Australia completed an online survey with the Stigma of Suicide Scale-Short Form. Data were analysed descriptively and with univariate and multivariate analyses. RESULTS: Three hundred and ninety-six pharmacists returned completed surveys (Canada n = 235; Australia n = 161; female 70%; mean age = 38.6 ± 12.7 years). The rate of endorsement of stigmatizing terms was low overall. Canadian and Australian pharmacists differed (p < 0.05) for several variables (e.g. age, friend or relative with a mental illness, training in mental health crisis). Pharmacists without someone close to them living with a mental illness were more likely to strongly agree/agree with words describing those who die by suicide as pathetic, stupid, irresponsible, and cowardly. Those without a personal diagnosis of mental illness strongly agreed/agreed with the terms immoral, irresponsible, vengeful, and cowardly. More Australian pharmacists strongly agreed/agreed that people who die by suicide are irresponsible, cowardly, and disconnected. Independent variables associated with a higher stigma were male sex, Australian, and negative perceptions about suicide preventability. CONCLUSION: Community pharmacists frequently interact with people at risk of suicide and generally have low agreement of stigmatizing terms for people who die by suicide. Research should focus on whether approaches such as contact-based education can minimize existing stigma.

The factor XIII Val34Leu polymorphism: is it protective against idiopathic venous thromboembolism?

The substitution of leucine for valine at amino acid position 34 of the factor XIII gene is commonly referred to as FXIII Val34Leu polymorphism. The homozygous leucine/leucine genotype has been reported to confer protection against venous thromboembolism, but previous studies have not evaluated a population limited to those with idiopathic venous thromboembolism. The primary objective of the study was to determine whether the FXIII Val34Leu polymorphism is independently associated with the occurrence of idiopathic venous thromboembolism. We prospectively enrolled consecutive patients with at least one objectively confirmed idiopathic venous thromboembolism. Friends of cases were recruited as controls and matched to cases by sex, ethnicity, and age. All participants were tested for the FXIII Val34Leu polymorphism in addition to several well-known thrombophilias. Data from 309 cases and 306 controls were analyzed. The FXIII leucine/leucine genotype was present in 4.9% of cases and 6.5% of controls. An adjusted odds ratio of 0.59 (95% confidence interval, 0.25-1.38) was found for the recessive model and 0.69 (95% confidence interval, 0.46-1.02) for the dominant model. Our results do not support an independent association of the FXIII Val34Leu polymorphism with idiopathic venous thromboembolism in our Caucasian Canadian study population.

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic.

OBJECTIVES: 1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic. METHODS: Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission. RESULTS: Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p=0.048). CONCLUSION: The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.

Factor XIII Val34Leu variant is protective against venous thromboembolism: a HuGE review and meta-analysis.

It has been suggested that a G-to-T transition in exon 2 of the factor XIIIA gene resulting in a substitution of leucine for valine at amino acid 34 (FXIII Val34Leu) protects against venous thromboembolism (VTE). However, the evidence to date is insufficient to incorporate testing for the FXIII Val34Leu variant into clinical practice. To determine whether genotypes with the FXIII Val34Leu variant are protective against VTE, the authors performed a meta-analysis of 12 studies with genotyping for the FXIII Val34Leu variant (3,165 objectively diagnosed VTE cases and 4,909 controls). When a random-effects model was used, the combined odds ratios for VTE were 0.63 (95% confidence interval: 0.46, 0.86) for the homozygotes of the FXIII Val34Leu variant, 0.89 (95% confidence interval: 0.80, 0.99) for the heterozygotes, and 0.85 (95% confidence interval: 0.77, 0.95) for the homozygotes and heterozygotes combined. Potential sources of heterogeneity and potential bias were explored. The meta-analysis provided evidence that the FXIII Val34Leu variant has a small, but significant protective effect against VTE. Since VTE is a complex disorder, this information, along with results of ongoing studies to identify additional genetic factors underlying VTE, will be crucial in developing accurate risk profiles to identify individuals at higher risk of VTE.