Newborn literacy program effective in increasing maternal engagement in literacy activities: an observational cohort study.

BACKGROUND: Literacy is important for success in school and in adulthood. Book-gift programs at birth exist to help develop these foundations early on. The effectiveness of the Read to Me! Nova Scotia Family Literacy Program (a program where books and literacy materials are given to families in hospital when their baby is born) on the duration and frequency with which mothers engage in reading and other literacy based activities with their newborns was assessed. METHODS: An observational cohort study design was used. Mothers of babies who received the Read to Me! package in Nova Scotia born between January-August 2006 made up the intervention group (N = 1051). Mothers of babies born in Prince Edward Island between December 2006 and March 2008 made up the control group (N = 279) and did not receive any literacy package when their baby was born. A phone questionnaire was conducted consisting of questions regarding frequency and duration of maternal engagement in language and literacy-based activities with their infants. These activities included reading, singing, talking, listening to CDs and the radio and watching TV. Babies were aged 0-10 months at the time of the interview. RESULTS: Mothers who received the Read to Me! literacy package spent significantly more time reading to their babies, 17.9 ± 17.6 min/day compared to controls 12.6 ± 10.7 min/day, (p < 0.0001). CONCLUSIONS: Read to Me! may be an inexpensive, easy to administer and effective intervention which results in increased shared reading of mothers and their newborns.

Forced euvolemic diuresis with mannitol and furosemide for prevention of contrast-induced nephropathy in patients with CKD undergoing coronary angiography: a randomized controlled trial.

BACKGROUND: Contrast-induced nephropathy is common in patients with coronary angiography. Mechanistically, forced euvolemic diuresis with mannitol and furosemide ought to prevent contrast-induced nephropathy. Our objectives are to: (1) undertake a randomized trial testing this hypothesis, and (2) conduct a meta-analysis of our findings with 2 earlier studies. STUDY DESIGN: (1) Randomized allocation-concealed controlled trial with blinded ascertainment of outcomes, and (2) random-effects meta-analysis of 3 trials. SETTING & PARTICIPANTS: Single-center study of consenting adults with serum creatinine level greater than 1.7 mg/dL undergoing coronary angiography; patients unable to tolerate fluid challenge or receiving dialysis were excluded. Two previous trials had randomly assigned 159 patients. INTERVENTION: Forced euvolemic diuresis with saline, mannitol, and furosemide compared with saline hydration controls. All patients were pretreated with at least 500 mL of half-normal saline before angiography; during and 8 hours after, urine output was replaced milliliter per milliliter with half-normal saline. OUTCOMES & MEASUREMENTS: The primary outcome was contrast-induced nephropathy within 48 hours of the procedure, defined as a 0.5-mg/dL absolute or 25% relative increase in creatinine level. RESULTS: Overall, 92 patients were allocated to intervention (n = 46) or control (n = 46). Mean age was 64 +/- 14 (SD) years, 23% were women, 37% had diabetes, 47% used oral furosemide, mean creatinine level was 2.8 +/- 1.6 mg/dL, and most patients (72%) underwent diagnostic catheterization. Patients had a net positive fluid balance (389 +/- 958 mL for intervention versus 655 +/- 982 mL for controls; P = 0.2). Contrast-induced nephropathy occurred in 23 (50%) intervention patients versus 13 (28%) controls (relative risk, 1.77; 95% confidence interval, 1.03 to 3.05; P = 0.03; adjusted odds ratio, 3.73; P = 0.03). Within 48 hours, creatinine level had increased by 0.8 +/- 1.1 mg/dL with intervention versus 0.2 +/- 0.6 mg/dL for controls (P = 0.002). Overall, 11 (12%) patients died or required dialysis, with no difference according to allocation status (P = 0.5). Random-effects meta-analysis of published data (3 trials; 251 patients) suggests furosemide-based interventions lead to significant harm compared with hydration: pooled relative risk, 2.15; 95% confidence interval, 1.37 to 3.37; I(2) = 0%. LIMITATIONS: Small single-center study that cannot determine whether harms were related to furosemide, mannitol, or a combination. CONCLUSIONS: Forced euvolemic diuresis led to a significantly increased risk of contrast-induced nephropathy. This strategy should be abandoned, and our results suggest that oral furosemide therapy perhaps should be held before angiography.

Gaps in patient care practices to prevent hospital-acquired delirium.

OBJECTIVE: To evaluate the current patient care practices that address the predisposing and precipitating factors contributing to the prevention of hospital-acquired delirium in the elderly. DESIGN: Prospective cohort (observational) study. PARTICIPANTS: Patients 65 years of age and older who were admitted to medical teaching units at the University of Alberta Hospital in Edmonton over a period of 7 months and who were at risk of delirium. SETTING: Medical teaching units at the University of Alberta. MAIN OUTCOME MEASURES: Demographic data and information on predisposing factors for hospital-acquired delirium were obtained for all patients. Documented clinical practices that likely prevent common precipitants of delirium were also recorded. RESULTS: Of the 132 patients enrolled, 20 (15.2%) developed hospital-acquired delirium. At the time of admission several predisposing factors were not documented (eg, possible cognitive impairment 16 [12%], visual impairment 52 [39.4%], and functional status of activities of daily living 99 [75.0%]). Recorded precipitating factors included catheter use, screening for dehydration, and medications. Catheters were used in 35 (26.5%) patients, and fluid intake-and-output charting assessed dehydration in 57 (43.2%) patients. At the time of admission there was no documentation of hearing status in 69 (52.3%) patients and aspiration risk in 104 (78.8%) patients. After admission, reorientation measures were documented in only 16 (12.1%) patients. Although all patients had brief mental status evaluations performed once daily, this was not noted to occur twice daily (which would provide important information about fluctuation of mental status) and there was no formal attention span testing. In this study, hospital-acquired delirium was also associated with increased mortality (P < .004), increased length of stay (P < .007), and increased institutionalization (P < .027). CONCLUSION: Gaps were noted in patient care practices that might contribute to hospital-acquired delirium and also in measures to identify the development of delirium at an earlier stage. Effort should be made to educate health professionals to identify the predisposing and precipitating factors, and to screen for delirium. This might improve the prevention of delirium.

Pediatric infective endocarditis: Has Staphylococcus aureus overtaken viridans group streptococci as the predominant etiological agent?

BACKGROUND: Viridans group streptococci (VGS) have traditionally been the most common etiological agents of infective endocarditis (IE). Advances in cardiovascular surgery and the increasing use of long-term central venous catheters may have altered the epidemiology of pediatric IE. METHODS: A chart review of children younger than 17 years of age with IE was completed at the Stollery Children's Hospital (Edmonton, Alberta) between 1985 and 2004. The literature was reviewed to look for changes over time in the most common etiological agents of pediatric IE. RESULTS: There were 31 cases of definite IE and nine cases of possible IE at the Stollery Children's Hospital, 19 of which were nosocomial. Thirty cases (75%) had congenital heart disease. The etiological agents were Staphylocccus aureus (n=16), VGS (n=5), coagulase-negative staphylococci (n=3), enterococcus (n=3), other streptococci (n=8), Enterobacter cloacae (n=1) and Stenotrophomonas maltophilia (n=1), while three cases were culture negative. Two deaths were due to S aureus IE. Review of the literature identified an increasing number of case series in which S aureus was the predominant etiological agent, but VGS still predominated in some recent series. CONCLUSION: Congenital heart disease remains the primary risk factor for pediatric IE. Prospective population-based studies are required to determine whether S aureus has become the predominant pathogen.

Clinical risk scoring beyond initial troponin values: results from a large, prospective, unselected acute chest pain population.

BACKGROUND: Risk stratifying the diverse group of patients who present to hospital with chest discomfort remains challenging. Current clinical risk models, typically derived from selected populations, are limited by their relative complexity and the absence of a well-defined role of troponin. OBJECTIVE: To derive a simple clinical risk score from a large, unselected population of patients with chest discomfort and to delineate the prognostic value of an initial troponin measurement. METHODS: Prospective, consecutive data were collected from patients who presented to a tertiary care hospital. Multivariate analysis was used to identify variables predictive of the primary end point: death, nonfatal myocardial infarction or revascularization at 30 days. Integer values were assigned, generating a risk score to quantify individual patient risk. RESULTS: Among 1054 patients, predictor variables included ST-segment deviation (strongest predictor -- assigned two points), male sex, prior congestive heart failure, three or more cardiac risk factors and prior acetylsalicylic acid use (one point each). There was a progressive increase in events with increasing total score (P<0.0001), with a 15-fold gradient from scores of 0 to 4 and greater. Although a negative troponin measurement was associated with fewer events for all scores, patients with higher scores remained exposed to substantial risk. A negative initial troponin measurement conferred a negative predictive value of 97.3% (95% CI 93.7% to 99.1%) among patients with a risk score of 0. CONCLUSION: Significant 30-day events occurred in patients with elevated risk scores, despite negative initial troponin measurements, emphasizing the importance of clinical risk stratification. This simple clinical risk score, in conjunction with a single troponin I measurement, facilitates triage of patients who present to hospital with chest discomfort.

Economic implications of treatment guidelines for congestive heart failure.

Congestive heart failure (CHF) is the most common cause of cardiovascular hospital admission. A significant proportion of the costs of CHF is due to hospitalizations. The present study evaluated the economic impact of a modest increase in the use of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, spironolactone and digoxin on CHF hospitalizations. Patients with CHF were identified through the Canadian Institute for Health Information (CIHI) database. The efficacy of ACE inhibitors, beta-blockers, spironolactone and digoxin in the first year of treatment were retrieved from the Survival and Ventricular Enlargement (SAVE) trial, a meta-analysis, the Randomized Aldactone Evaluation Study (RALES) and the Digitalis Investigation Group (DIG) trial, respectively. Cost of CHF hospitalization was based on the National List of Provincial Costs. Costs of drug treatment were based on the 2002 Alberta Health and Wellness Drug Benefit list. Physician visits for drug titration were also included in the model. A total of 85,679 patients with CHF were identified with a total of 106,130 hospital discharges. A 10% increase in use of ACE inhibitors, beta-blockers, spironolactone and digoxin would incur in a total cost due to avoidable hospital admissions of 0.4 million dollars, 1.3 million dollars, 3.7 million dollars and 1.2 million dollars, respectively. Similarly, the costs of drug treatment would be 2.2 million dollars, 1.3 million dollars, 0.3 million dollars and 0.5 million dollars, respectively. An increase in the use of the above medications would save 6.6 million dollars due to avoidable hospital admissions. The total cost of drug treatment was 4.3 million dollars, giving a net savings of 2.3 million dollars in the first year. The implementation of evidence-based therapy for CHF treatment is not only clinically efficacious, but also economically attractive.

The use of beta-blockers in a tertiary care heart failure clinic: dosing, tolerance, and outcomes.

BACKGROUND: Little is known about the dosing, tolerability, and impact of beta-blockers in nontrial participants. This study was conducted to evaluate the use and outcomes of beta-blockers in a tertiary care heart failure clinic. METHODS: Analysis of prospectively collected data from a cohort of 1041 patients with heart failure seen at the University of Alberta Heart Function Clinic, Edmonton, from September 1, 1989, through July 1, 2001, with objective measurement of ejection fraction at baseline and prospective collection of data at all subsequent clinic visits. RESULTS: Median age at baseline was 69 years; 65% were male; 75% had systolic dysfunction; mean ejection fraction was 33%; and 51% had New York Heart Association class III or IV symptoms. Median duration of follow-up was 32 months (interquartile range, 13-62 months). Overall, 46% of patients received beta-blockers, but only 18% of these were ultimately prescribed the dosages achieved in the trials (mean maximum dosages achieved, 27 mg/d for carvedilol and 81 mg/d for metoprolol tartrate). Of those patients prescribed beta-blockers, 74% continued to receive them during follow-up. Blood pressure, heart rate, and failure symptomatology did not change appreciably before and after beta-blockers were prescribed, or during the upward titration of the dosage. Although our patients were prescribed lower dosages than those used in trials, Cox multivariate regression revealed that beta-blockers were associated with improved survival, even after adjusting for potential confounders including New York Heart Association class, year of prescription, and concomitant medication use (relative risk, 0.63; 95% confidence interval, 0.50-0.81). CONCLUSIONS: The benefits of beta-blockers seen in randomized trials extend to nontrial participants treated in a tertiary care clinic specializing in heart failure. In our cohort of elderly patients with multiple comorbidities, beta-blockers were well tolerated.

Contemporary burden of illness of congestive heart failure in Canada.

BACKGROUND: Congestive heart failure (CHF) is associated with high morbidity and mortality; however, there is little contemporary Canadian data to quantify the burden of this illness. OBJECTIVE: To report the impact of CHF in Canada, as measured by hospitalizations. METHODS: Data were obtained from the Canadian Institute for Health Information on patients hospitalized with CHF as a most responsible, primary or complication diagnosis during fiscal year 2000/01. RESULTS: There were a total of 106,130 discharges for 85,679 CHF patients in the fiscal year 2000/01. Total in-hospital mortality was 15.8%. In terms of total discharges for CHF, 32.7% were readmissions. On an individual patient basis, 19.9% of patients were rehospitalized once or more during 2000. In terms of burden of illness of CHF compared with other major illnesses, CHF is associated with the second highest total number of hospital days and third highest number of patients affected. CONCLUSIONS: Hospitalization for CHF occurs frequently and accounts for a large number of hospital bed-days in Canada. These figures should signal a call to action for researchers, administrators and health care providers regarding the need for more efficacious therapies, better application of already-proven therapies and patient education.

Complementary and alternative medicine use by pediatric specialty outpatients.

OBJECTIVE: Complementary and alternative medicine (CAM) use is high among children and youth with chronic illnesses. The objective of this study was to assess the prevalence and patterns of CAM use in 10 subspecialty clinics in Canada and to compare CAM use between 2 geographically diverse locations. METHODS: This survey was carried out at 1 Children's Hospital in western Canada (Edmonton) and 1 Children's Hospital in central Canada (Ottawa). Questionnaires were completed by parents in either French or English. RESULTS: Although demographic characteristics of the 2 populations were similar, CAM use at the western hospital was 71% (n = 704) compared with 42% (n = 222) at the central hospital (P < .0001). Most respondents agreed or strongly agreed that they feel comfortable discussing CAM in their clinic. The most common CAM products currently used were multivitamins/minerals, herbal products, and homeopathic remedies. The most common CAM practices currently used were massage, chiropractic, relaxation, and aromatherapy. Eighty adverse effects were reported, and 55 (68.8%) of these were self-assessed as minor. CONCLUSIONS: Results of this study indicate that CAM use is high among pediatric specialty clinic outpatients and is much greater in the western than in the central hospital. Most respondents felt that their CAM use was helpful with few or no harms associated. Many patients, using CAM alongside their conventional medicines, are still not discussing their CAM use with their physicians and are increasing the likelihood for potential interactions and preventable harms.

Identifying patients with AAA with the highest risk following endovascular repair.

INTRODUCTION: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. METHODS: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. RESULTS: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. CONCLUSIONS: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.

Empiric acyclovir for neonatal herpes simplex virus infection.

BACKGROUND: Because neonatal herpes simplex virus (NHSV) infection is difficult to diagnose, there has been a move towards using more empiric acyclovir (ACV). OBJECTIVE: The purpose of this study was to review the use of ACV to optimize future management of NHSV. METHODS: Charts were reviewed for infants started on intravenous ACV up to day 43 of life--January 2001 through February 2007--at five hospitals in Edmonton and Calgary. RESULTS: ACV was started for possible (N = 115) or proven (N = 3) herpes simplex virus (HSV) infection. Six of the infants with possible HSV infection later had proven HSV infection. Seizures (34%), hemodynamic instability (29%) and skin lesions (24%) were the most common indications for ACV. Among the 118 infants, 106 (90%) had cerebrospinal fluid obtained and 82 (69%) had at least one surface swab for HSV but 4 (3%) had no specimens submitted for HSV detection. ACV was continued for 3.9 ± 3.5 days in the infants with no proven HSV disease. Possible nephrotoxicity from ACV was recorded in 3 of these 109 infants and in none of the infants with proven HSV disease. CONCLUSIONS: Clinicians in Alberta primarily consider the diagnosis of NHSV infection when confronted with a neonate with seizures, hemodynamic instability or suspicious skin lesions, but need to consider the diagnosis more often if all cases are to be treated at first presentation. They often perform incomplete investigations to rule out NHSV infection. Adverse events from ACV appear to be uncommon when the drug is used for suspected NHSV disease.

Cardiovascular assessment of diabetic end-stage renal disease patients before renal transplantation.

BACKGROUND: Although consensus guidelines for preoperative cardiovascular (CV) assessment exist, diabetic patients with renal insufficiency (DM/RI) undergoing assessment for renal transplantation are a unique high-risk group that remains poorly investigated. METHODS: A consecutive cohort of DM/RI patients being assessed for renal transplantation was studied. We analyzed the ability of clinical characteristics and noninvasive investigation to predict significant coronary artery disease (CAD) and incidence of major adverse CV events. RESULTS: Baseline characteristics (n = 280) are as follows: mean age 48.6 years (± 11.5 standard deviation), 66% men, diabetes duration 22.6 years (mean ± 8.9 standard deviation), 92% hypertension, 46% hypercholesterolemia, 24% family history CAD, and 21% known CAD. Abnormal myocardial perfusion imaging was found in 27.8%, and 56.5% had CAD more than or equal to 50%. Although positive myocardial perfusion imaging was the only independent predictor of CAD (odds ratio 7.18, 95% confidence interval 2.98-17.3), a poor negative predicted value was observed with normal imaging in 50.3% of patients having CAD more than or equal to 50%, 35.4% CAD more than 70%, and 41.8% Duke angiographic score more than or equal to 4. At mean follow up of 4 years (median 3.9), 76 of 280 patients suffered major adverse cardiovascular events including 17% mortality. Angiographic evidence of CAD (≥ 70% odds ratio 1.81, 95% confidence interval 1.02-3.23) was the only independent predictor of major adverse cardiac events. CONCLUSION: DM/RI patients being assessed for renal transplantation have frequent CV risk factors, high likelihood of CAD, and a 28% incidence of major adverse cardiac events after 4 years. Myocardial perfusion imagining is of little clinical utility as a screening tool for CAD in this population. Only angiographic CAD was predictive of subsequent major adverse cardiac events. Further studies of risk stratification and revascularization in this high-risk population are warranted.

Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) contributes to increased morbidity and mortality. However, its pathophysiology remains incompletely understood. We hypothesized that intra-operative mean arterial pressure (MAP) relative to pre-operative MAP would be an important predisposing factor for CSA-AKI. METHODS: We performed a prospective observational study of 157 consecutive high-risk patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The primary exposure was delta MAP, defined as the pre-operative MAP minus average MAP during CPB. Secondary exposure was CPB flow. The primary outcome was early CSA-AKI, defined by a minimum RIFLE class - RISK. Univariate and multivariate logistic regression were performed to explore for association between delta MAP and CSA-AKI. RESULTS: Mean (± SD) age was 65.9 ± 14.7 years, 70.1% were male, 47.8% had isolated coronary bypass graft (CABG) surgery, 24.2% had isolated valve surgery and 16.6% had combined procedures. Mean (± SD) pre-operative, intra-operative and delta MAP were 86.6 ± 13.2, 57.4 ± 5.0 and 29.4 ± 13.5 mmHg, respectively. Sixty-five patients (41%) developed CSA-AKI within in the first 24 hours post surgery. By multivariate logistic regression, a delta MAP≥26 mmHg (odds ratio [OR], 2.8; 95%CI, 1.3-6.1, p = 0.009) and CPB flow rate ≥54 mL/kg/min (OR, 0.2, 0.1-0.5, p < 0.001) were independently associated with CSA-AKI. Additional variables associated with CSA-AKI included use of a side-biting aortic clamp (OR, 3.0; 1.3-7.1, p = 0.012), and body mass index ≥25 (OR, 4.2; 1.6-11.2, p = 0.004). CONCLUSION: A large delta MAP and lower CPB flow during cardiac surgery are independently associated with early post-operative CSA-AKI in high-risk patients. Delta MAP represents a potentially modifiable intra-operative factor for development of CSA-AKI that necessitates further inquiry.

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: a longitudinal study.

BACKGROUND: Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women. OBJECTIVES: We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively. DESIGN: Longitudinal extension survey following participation in a clinical trial. SETTING: Ten Canadian centres. PARTICIPANTS: Women (222) who participated in the Women's Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview. METHODS: Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants. RESULTS: Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR)=2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR=4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR=2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p=0.017), visit another type of provider (i.e., naturopath or chiropractor, p=0.004), or use any health care service (p<0.0001). CONCLUSIONS: Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.