ABSTRACT
Background and aims Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada (CWC), aims to address unnecessary care and tests through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five tests, procedures, and treatments to question within the emergency department setting. The Canadian CT-scan Head Rule (CCHR) has been found to be the most effective clinical decision rule in adults with minor head injuries. This study aimed to better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center in Halifax, Nova Scotia. Materials and methods Our mixed methods design included a narrative literature review, a retrospective chart audit, and a qualitative audit-feedback component with physicians who work in the emergency department (ED). The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Results Analysis of qualitative data is included here, in parallel with in-depth analysis to contextualize findings from the chart audit. A total of 302 charts of patients presenting to the surveyed site were retrospectively reviewed for this study. Of the 37 cases where the CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated as per the CCHR, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusions Our review revealed that the CCHR was adhered in 87.8% of cases at the surveyed ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical to achieving the goal of reducing unnecessary CTs. This work will be presented to the physician group to engage and understand factors that are enablers in the process of ED minor head injury care.
ABSTRACT
OBJECTIVE: West African crystalline maculopathy (WACM) is characterized by the presence of macular hyperrefractile crystal-like deposits. Although the underlying pathophysiology has not been elucidated, a few biologic drivers have been proposed. We analyzed a large WACM case series to gain a more robust understanding of its features and etiology. DESIGN: Prospective, cross-sectional cohort study. SUBJECTS: Participants with WACM were selected from the large cohort recruited in the Ghana Age-Related Macular Degeneration Study. METHODS: Demographic and detailed medical histories, full ophthalmic examinations, digital color fundus photographs, and OCT images were obtained. All cases with WACM were evaluated by 3 retina experts. Crystal numbers, location, and distribution were determined. Associations between WACM and White age-related macular degeneration (AMD) risk variants were assessed using Firth's bias-reduced logistic regression, including age and sex as covariates. MAIN OUTCOME MEASURES: Phenotypic features of, and genetic associations with, WACM. RESULTS: West African crystalline maculopathy was identified in 106 eyes of 53 participants: 22 were bilateral and 24 were unilateral. Grading for AMD was not possible in 1 eye in 7 participants with WACM; therefore, laterality was not assessed in these subjects. Thirty-eight participants were women and were 14 men; sex was unrecorded for 1 participant. The mean age was 68.4 years (range, 45-101 years). Typical WACM crystals were demonstrated on OCT, which were more easily identified at high contrast and predominantly located at the inner limiting membrane. In eyes with copathology, crystals localized deeper in the inner retina, with wider retinal distribution over copathology lesions. There was no association with age or sex. A significant association was observed between the complement factor H (CFH) 402H risk variant and WACM. CONCLUSIONS: This study confirms the localization of crystals adjacent to the inner limiting membrane and distribution over lesions in eyes with copathology. The evaluation of OCT images under high contrast allows improved identification. West African crystalline maculopathy may be associated with the CFH-CFHR5 AMD risk locus identified among Whites; however, it is also possible that the combination of crystals and the CFH 402H allele increases the risk for developing late AMD. Further analyses using larger sample sizes are warranted to identify causalities between genotype and WACM phenotype.