Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial.

Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor. INTRODUCTION: To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture. METHODS: Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients. RESULTS: By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not. CONCLUSION: While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income. TRIAL REGISTRATION: ClinicalTrials.gov : NCT01401556.

Workers' recovery from concussions presenting to the emergency department.

BACKGROUND: The emergency department (ED) is the first point of care for many patients with concussion, and post-concussion syndrome can impact vocational outcomes like successful return to work. Evaluation of concussion in general adult populations is needed. AIMS: To document the occurrence and outcomes of work-related concussion presenting to the ED for treatment. METHODS: This study enrolled adults presenting with concussion to three urban Canadian EDs. Baseline ED interviews, physician questionnaires and patient phone interviews at 30 and 90 days documented work-related events, ED management, discharge advice, patient adherence and symptom severity. Work-related injury and return to work were modelled using logistic or linear regression, as appropriate. RESULTS: Overall, 172 enrolled workers completed at least one follow-up. Work-related concussions were uncommon (n = 28). Most employees (80%) missed at least 1 day of work (median = 7; interquartile range: 3-14). Most (91%) employees returned to work within 90 days, while 41% reported persistent symptoms. Manual labour and self-reported history of attention deficit hyperactivity disorder were associated with work-related concussion, while days of missed work increased with marital status (divorced), history of sleep disorder and physician's advice to avoid work. CONCLUSION: Work-related concussions are infrequent; however, most workers who sustain a concussion will miss work, and many return while still experiencing symptoms. Work-related concussion and days of missed work are mainly affected by non-modifiable factors. Workers, employers and the workers' compensation system should take necessary precautions to ensure that workers return to work safely and successfully following a concussion.

Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment.

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced. INTRODUCTION: Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year. METHODS: We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison. RESULTS: We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time. CONCLUSIONS: The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.

Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews.

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.

Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials.

UNLABELLED: Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers. INTRODUCTION: In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors. METHODS: Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year. RESULTS: Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment. CONCLUSIONS: The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.

Air pollution and emergency department visits for epistaxis.

OBJECTIVES: This study aimed to evaluate the association between outdoor ambient air pollution and emergency department (ED) visits for epistaxis. DESIGN: Cross-sectional study, case-crossover design. SETTING: ED visit data were obtained for Edmonton, Alberta, Canada, for a period of 10 years starting 1 April 1992 and ending March 31st of 2002. The data on ED visits were supplied by Capital Health for the five major acute care hospitals in the Edmonton area. PARTICIPANTS: The analysis was performed for the population as a whole (N = 15 038) and split by sex: males (N = 8587) and females (N = 6451). MAIN OUTCOME MEASURES: We explored associations between ambient concentrations of air pollutants (CO, NO2 , SO2 , O3 , PM10 , PM2.5 ) lagged by 0-4 days and ED visits for epistaxis in Edmonton, Alberta, Canada. RESULTS: Odds ratios (ORs) and their 95% confidence intervals (CI) were reported for an increase in an interquartile range (IQR) of pollutant concentration. We obtained positive and statistically significant results for all patients with epistaxis; exposure to O3 with IQR = 14 ppb, OR = 1.05 (95% CI: 1.00-1.09, lag 0), and for males (age < 25 years), OR = 1.16 (1.03-1.30), lag 4; and to PM10 with IQR = 15 µg/m(3) , OR = 1.02 (1.00-1.05, lag 3). These results were stronger for older (age > 24 years) females. CONCLUSIONS: These findings suggest that there may be an association between air pollutant exposure, specifically ozone and PM10 , and the number of ED visits for epistaxis.

Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10.

BACKGROUND: The international classification of diseases version 10 (ICD-10) uses alphanumeric expanded codes and external cause of injury codes (E-codes). OBJECTIVE: To examine the reliability and validity of emergency department (ED) coders in applying E-codes in ICD-9 and -10. METHODS: Bicycle and pedestrian injuries were identified from the ED information system from one period before and two periods after transition from ICD-9 to -10 coding. Overall, 180 randomly selected bicycle and pedestrian injury charts were reviewed as the reference standard (RS). Original E-codes assigned by ED coders (ICD-9 in 2001 and ICD-10 in 2004 and 2007) were compared with charts (validity) and also to ICD-9 and -10 codes assigned from RS chart review, to each case by an independent (IND) coder (reliability). Sensitivity, specificity, simple, and chance-corrected agreements (κ statistics) were calculated. RESULTS: Sensitivity of E-coding bicycle injuries by the IND coder in comparison with the RS ranged from 95.1% (95% CI 86.3 to 99.0) to 100% (95% CI 94.0 to 100.0) for both ICD-9 and -10. Sensitivity of ED coders in E-coding bicycle injuries ranged from 90.2% (95% CI 79.8 to 96.3) to 96.7% (95% CI 88.5 to 99.6). The sensitivity estimates for the IND coder ranged from 25.0% (95% CI 14.7 to 37.9) to 45.0% (95% CI 32.1 to 58.4) for pedestrian injuries for both ICD-9 and -10. CONCLUSION: Bicycle injuries are coded in a reliable and valid manner; however, pedestrian injuries are often miscoded as falls. These results have important implications for injury surveillance research.

Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture.

UNLABELLED: In a randomized trial, a multifaceted intervention tripled rates of osteoporosis treatment in older patients with wrist fracture. An economic analysis of the trial now demonstrates that the intervention tested "dominates" usual care: over a lifetime horizon, it reduces fracture, increases quality-adjusted life years, and saves the healthcare system money. INTRODUCTION: In a randomized trial (N = 272), we reported a multifaceted quality improvement intervention directed at older patients and their physicians could triple rates of osteoporosis treatment within 6 months of a wrist fracture when compared with usual care (22% vs 7%). Alongside the trial, we conducted an economic evaluation. METHODS: Using 1-year outcome data from our trial and micro-costing time-motion studies, we constructed a Markov decision-analytic model to determine cost-effectiveness of the intervention compared with usual care over the patients' remaining lifetime. We took the perspective of third-party healthcare payers. In the base case, costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. One-way deterministic and probabilistic sensitivity analyses were conducted. RESULTS: Median age of patients was 60 years, 77% were women, and 72% had low bone mineral density (BMD). The intervention cost $12 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients receiving the intervention, three fractures (one hip fracture) would be prevented, 1.1 quality-adjusted life year gained, and $26,800 saved by the healthcare system over their remaining lifetime. The intervention dominated usual care across numerous one-way sensitivity analyses: with respect to cost, the most influential parameter was drug price; in terms of effectiveness, the most influential parameter was rate of BMD testing. The intervention was cost saving in 80% of probabilistic model simulations. CONCLUSIONS: For outpatients with wrist fractures, our multifaceted osteoporosis intervention was cost-effective. Healthcare systems implementing similar interventions should expect to save money, reduce fractures, and gain quality-adjusted life expectancy.

Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study.

UNLABELLED: Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care). INTRODUCTION: Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6 months of fracture). More effective strategies are needed. METHODS: We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs. RESULTS: Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n = 21) or multifaceted intervention (n = 25). Median age was 60 years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1-11.5, p = 0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1-2.4, p = 0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0-4.2, p = 0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention. CONCLUSIONS: A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care. TRIAL REGISTRY: clinicaltrials.gov identifier: NCT00152321.

Cognitive distortions in an acutely traumatized sample: an investigation of predictive power and neural correlates.

BACKGROUND: Current theories of post-traumatic stress disorder (PTSD) place considerable emphasis on the role cognitive distortions such as self-blame, hopelessness or preoccupation with danger play in the etiology and maintenance of the disorder. Previous studies have shown that cognitive distortions in the early aftermath of traumatic events can predict future PTSD severity but, to date, no studies have investigated the neural correlates of this association. METHOD: We conducted a prospective study with 106 acutely traumatized subjects, assessing symptom severity at three time points within the first 3 months post-trauma. A subsample of 20 subjects additionally underwent a functional 4-T magnetic resonance imaging (MRI) scan at 2 to 4 months post-trauma. RESULTS: Cognitive distortions proved to be a significant predictor of concurrent symptom severity in addition to diagnostic status, but did not predict future symptom severity or diagnostic status over and above the initial symptom severity. Cognitive distortions were correlated with blood oxygen level-dependent (BOLD) signal strength in brain regions previously implicated in visual processing, imagery and autobiographic memory recall. Intrusion characteristics accounted for most of these correlations. CONCLUSIONS: This investigation revealed significant predictive value of cognitive distortions concerning concurrent PTSD severity and also established a significant relationship between cognitive distortions and neural activations during trauma recall in an acutely traumatized sample. These data indicate a direct link between the extent of cognitive distortions and the intrusive nature of trauma memories.

A prospective review of the use of ketamine to facilitate endotracheal intubation in the helicopter emergency medical services (HEMS) setting.

INTRODUCTION: Ketamine is a dissociative agent used for sedation and intubation in various clinical settings. Despite its proven haemodynamic safety, ketamine has not been widely used in prehospital medicine. This study examined the use of ketamine in helicopter emergency medical services (HEMS). METHODS: This prospective cohort study enrolled all patients transported by a single HEMS program in whom ketamine was used to facilitate intubation. Data were collected using standard forms by two independent trained research staff. Demographics, medical condition, intubation conditions, vital signs (pre and post drug administration) and complications were recorded. Proportions, medians with IQR, change scores and CIs are reported; differences were compared using paired t tests. RESULTS: During the 2-year study period, 71 patients received ketamine to facilitate endotracheal intubation. Ketamine was used most often in men (52 (73%)), and the median age was 49 years (IQR: 31, 69). Most patients were adults (70 (99%)) with medical illnesses (42 (59%)); 37 (52%) intubations were performed at the sending hospital, and 30 (42%) were performed on scene. A paramedic performed the intubation in 58 cases (82%). The median ketamine dose was 80 mg (IQR: 60, 100; ~ 1mg/kg); 53 (75%) patients also received a paralytic agent. Mean arterial pressure (2.3 mmHg; 95% CI: -8.0 to 3.3) and heart rate (0.45 beats/min, 95% CI: -4.9 to 4.0) changes failed to reach statistical or clinical significance. No differences were found between patients with suspected concomitant head injury and other patients with respect to ketamine dose, changes in vital signs and complications. Complications included: one (1.4%) interstitial IV, five (7%) failed intubations, five (7%) hypotension and four (6%) hypertension episodes, one (1%) bradycardia, two (3%) tachycardia and five (7%) deaths. CONCLUSIONS: Ketamine is an effective agent in facilitating intubation in a HEMS environment. Complications are similar to use in the controlled Emergency Department setting.

Factors associated with incorrect bicycle helmet use.

BACKGROUND: Incorrect bicycle helmet use increases head injury risk. OBJECTIVE: To evaluate the patterns of incorrect helmet use based on unobtrusive field observations. METHODS: Two observational surveys conducted in Alberta in 2000 and 2006 captured information on cyclist characteristics, including correct helmet use. Prevalence of correct helmet use was compared across multiple factors: age, gender, riding companionship, and environmental factors such as riding location, neighbourhood median family income, and region. Poisson regression analysis was used to relate predictor variables to the prevalence of incorrect helmet use, adjusting for clustering by site of observation. RESULTS: Among helmeted cyclists (n=5862), 15.3% were wearing their helmet incorrectly or were using a non-bicycle helmet. Children (53%) and adults (51%) tended to wear their helmet too far back, while adolescents tended not have their straps fastened (48%). Incorrect helmet use declined approximately 50% over the study period for children and adolescents, but 76% (95% CI 68% to 82%) in adults. Children were 1.8 times more likely to use their helmets incorrectly in 2000 compared with adults, but this effect increased to 3.9 (95% CI 2.9 to 5.4) in 2006. Adolescents were more likely to use their helmets incorrectly in 2006 compared with adults (prevalence ratio 2.76; 95% CI 1.9 to 4.02). Children and adolescents cycling alone, compared with adults cycling alone, cycling at non-school sites and cycling in Edmonton, was associated with incorrect helmet use. CONCLUSIONS: Important factors not previously identified were associated with incorrect bicycle helmet use. This information can be used to target interventions to increase correct use.

A systematic review of correct bicycle helmet use: how varying definitions and study quality influence the results.

BACKGROUND: Bicycle helmets effectively reduce the risk of bicycle-related head injuries and trauma; however, they must fit properly to be effective. Little is known about the prevalence of correctly worn helmets and factors associated with proper helmet use. OBJECTIVE: To examine proper bicycle helmet use through a systematic review. METHODS: Comprehensive searches of electronic medical databases were performed, and completed by grey literature and reference list checks to identify eligible studies. Studies eligible for inclusion had to involve cyclists and report on the prevalence of correct or incorrect helmet use. Two reviewers independently selected studies and data were extracted regarding the prevalence and factors influencing proper helmet wearing of cyclists. RESULTS: An inclusive search strategy led to 2285 prescreened citations; 11 of the studies were finally included in the review. Overall, correct helmet use varied from 46% to 100%, depending on the criteria used by researchers to define proper helmet use; stricter criteria reduced the proportion of properly worn helmets. Adulthood, female sex and educational interventions were associated with correct helmet use in some studies. Self-reported poor helmet fit (OR = 1.96; 95% CI 1.10 to 3.75), posterior positioning of helmet (OR = 1.52; 95% CI 1.02 to 2.26) and helmet loss in crash (OR = 3.25; 95% CI 1.82 to 5.75) increased the risk of head injury. In addition, educational programmes on helmet use in schools increased correct helmet use among schoolchildren. CONCLUSIONS: This systematic review outlines the current state of the literature including the variability in research methodology and definitions used to study proper helmet-wearing behaviour among cyclists.

Vaccines for preventing influenza in people with asthma.

BACKGROUND: Influenza vaccination is recommended for asthmatic patients in many countries as observational studies have shown that influenza infection can be associated with asthma exacerbations, but influenza vaccination itself has the potential to adversely affect pulmonary function. A recent overview concluded that there was no clear benefit of influenza vaccination in patients with asthma but this conclusion was not based on a systematic search of the literature. OBJECTIVES: Whilst influenza may cause asthma exacerbations, there is controversy about the use of influenza vaccinations, since they may precipitate an asthma attack in some people. The objective of this review was to assess the efficacy of influenza vaccination in children and adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and checked reference lists of articles. The last search was carried out in September 2007. SELECTION CRITERIA: Randomised trials of influenza vaccination in children (over two years of age) and adults with asthma. Studies involving people with chronic obstructive pulmonary disease were excluded. DATA COLLECTION AND ANALYSIS: Inclusion criteria and assessment of trial quality were applied by two reviewers independently. Data extraction was done by two reviewers independently. Study authors were contacted for missing information. MAIN RESULTS: Nine trials were initially included. Four of these trials were of high quality. Six further articles have been included in three updates (Bueving 2003; Castro 2001; Fleming 2006; Redding 2002; Reid 1998). The included studies covered a wide diversity of people, settings and types of influenza vaccination, but data from the more recent studies that used similar vaccines have been pooled. BENEFITS: Bueving 2003 studied 696 children with asthma and did not demonstrate a significant reduction in influenza related asthma exacerbations (Risk Difference 0.01; 95% confidence interval -0.02 to 0.04). HARMS: The pooled results of two trials involving 2306 people with asthma did not demonstrate a significant increase in asthma exacerbations in the two weeks following influenza vaccination (Risk Difference 0.00; 95% confidence interval -0.02 to 0.02). AUTHORS' CONCLUSIONS: Uncertainty remains about the degree of protection vaccination affords against asthma exacerbations that are related to influenza infection. Evidence from recently published trials indicates that there is no significant increase in asthma exacerbations immediately after vaccination (at least with inactivated influenza vaccination). There is concern regarding possible increased wheezing and hospital admissions in infants given live intranasal vaccination.

Heparin versus placebo for acute coronary syndromes.

BACKGROUND: Acute coronary syndromes (ACS) represent a spectrum of disease including unstable angina (UA) and non-ST segment myocardial infarction (NSTEMI). Despite treatment with aspirin, beta-blockers and nitroglycerin, UA/NSTEMI is still associated with significant morbidity and mortality. Although emerging evidence suggests that low molecular weight heparin (LMWH) is more efficacious compared to unfractionated heparin (UFH), there is limited data to support the role of heparins as a drug class in the treatment of ACS. OBJECTIVES: To determine the effect of heparins (UFH and LMWH) compared with placebo for the treatment of patients with ACS. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (issue 4, 2002), MEDLINE (1966 to May 2002), EMBASE (1980 to May 2002) and CINAHL (1982 to May 2002). Authors of included studies and pharmaceutical industry representatives were contacted to determine if unpublished studies which met the inclusion criteria were available. SELECTION CRITERIA: Randomized controlled trials of parenteral UFH or LMWH versus placebo in people with ACS (UA or NSTEMI). DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed quality of studies. Data were extracted independently by two reviewers. Study authors were contacted to verify and clarify missing data. MAIN RESULTS: Eight studies (3118 participants) were included in this review. We found no evidence for difference in overall mortality between the groups treated with heparin and placebo (RR = 0.84, 95% CI 0.36 to 1.98). Heparins reduced the occurrence of MI (RR = 0.40, 95% CI 0.25 to 0.63, NNT = 33). An increase in the incidence of minor bleeds (RR = 6.80, 95% CI 1.23 to 37.49, NNH = 17). AUTHORS' CONCLUSIONS: Compared to placebo, patients treated with heparins had similar risk of mortality, revascularization, recurrent angina, major bleeding and thrombocytopenia. However, those treated with heparins had decreased risk of MI and a higher incidence of minor bleeding.

Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation.

INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs. OBJECTIVES: To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive. METHODS: A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression. RESULTS: Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack-years of smoking (45 pack-years versus 53 pack-years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta-agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001). CONCLUSIONS: Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

Increasing the use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map.

PURPOSE: Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs). METHODS: Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST(1)) and the 18 months after POST(1) (POST(2)). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge. RESULTS: A total of 387 patient charts were included (PRE, n=150; POST(1), n=150; POST(2), n=87). Patient characteristics in the three groups were similar; however, patients in POST(1) and POST(2) showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST(1) and 70% during POST(2). The use of peak expiratory flow (PEF) was high during the PRE, POST(1) and POST(2) periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST(1) and 75% POST(2); P<0.01) in the POST(1,2) periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST(1) and 69% POST(2); P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST(1) and 61% POST(2); P<0.001) in the POST(1,2) periods. Discharge without any corticosteroids decreased over the three periods (32% PRE, 21% POST(1) and 17% POST(2); P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST(1) and 265 min POST(2); P<0.01) and admissions were infrequent (9% PRE, 13% POST(1) and 6% POST(2); P=0.50). CONCLUSIONS: The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

Education interventions for adults who attend the emergency room for acute asthma.

BACKGROUND: The use of educational and behavioural interventions in the management of chronic asthma have a strong evidence base. There may be a role for educative interventions following presentation in an emergency setting in adults. OBJECTIVES: To assess the effectiveness of educational interventions administered following an acute exacerbation of asthma leading to presentation in the emergency department. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register. Study authors were contacted for additional information. Searches are current to November 2006. SELECTION CRITERIA: Randomised, parallel group trials were eligible if they recruited adults (> 17 years) who had presented at an emergency department with an acute asthma exacerbation. The intervention of interest was any educational intervention (for example, written asthma management plan). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Twelve studies involving 1954 adults were included. Education significantly reduced subsequent admission to hospital (relative risk 0.50; 95% confidence interval 0.27 to 0.91); however, did not significantly reduce the risk of re-presentation at emergency departments (ED) the study follow up (relative risk 0.69; 95% confidence interval 0.40 to 1.21). The lack of statistically significant differences between asthma education and control groups in terms of peak flow, quality of life, study withdrawal and days lost were hard to interpret given the low number of studies contributing to these outcomes. One study from the early 1990s measured cost and found no difference for total costs and costs related to physician visits and admissions to hospital. If data were restricted to emergency department treatment, education led to lower costs than control. AUTHORS' CONCLUSIONS: This review found that educational interventions applied in the emergency department reduce subsequent asthma admissions to hospital. The interventions did not significantly reduce ED re-presentations; while the trend in effect favours educational interventions, the pooled results were not statistically significant. The impact of educational intervention in this context on longer term outcomes relating to asthma morbidity is unclear. Priorities for additional research in this area include assessment of health-related quality of life, lung function assessment, exploration of the relationship between socio-economic status and asthma morbidity, and better description of the intervention assessed.

Corticosteroids for preventing relapse following acute exacerbations of asthma.

BACKGROUND: Acute asthma is responsible for many emergency department (ED) visits annually. Between 12 to 16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation. OBJECTIVES: To determine the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register and reference lists of articles. In addition, authors of all included studies were contacted to locate unpublished studies. The most recent search was run in October 2006. SELECTION CRITERIA: Randomized controlled trials comparing two types of corticosteroids (oral, intra-muscular, or inhaled) with placebo for outpatient treatment of asthmatic exacerbations in adults or children. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Six trials involving 374 people were included. One study used intramuscular corticosteroids, five studies used oral corticosteroids. The review was split into two reviews and although the latest search yielded no additional placebo controlled trials an additional IM study was included. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (Relative risk (RR) 0.38; 95% confidence interval (CI) 0.2 to 0.74). This favourable effect was maintained over the first 21 days (RR 0.47; 95% CI 0.25 to 0.89) and there were fewer subsequent hospitalizations (RR 0.35; 95% CI 0.13 to 0.95). Patients receiving corticosteroids had less need for beta(2)-agonists (mean difference (MD) -3.3 activations/day; 95% CI -5.6 to -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI -0.47 to 0.56) and side effects (SMD 0.03; 95% CI -0.38 to 0.44) in the first 7 to 10 days, while rarely reported, showed no significant differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. From these results, as few as ten patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. AUTHORS' CONCLUSIONS: A short course of corticosteroids following assessment for an asthma exacerbation significantly reduces the number of relapses to additional care, hospitalizations and use of short-acting beta(2)-agonist without an apparent increase in side effects. Intramuscular and oral corticosteroids are both effective.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

BACKGROUND: Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and use of an external support (e.g. ankle brace), and surgical repair or reconstruction. OBJECTIVES: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings. MAIN RESULTS: Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants. The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I(2) statistics showed the remaining trials to be more homogeneous. The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. AUTHORS' CONCLUSIONS: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomised controlled trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.