The use of a work-related asthma screening questionnaire in a primary care asthma program: an intervention trial.

OBJECTIVES: The work-related asthma screening questionnaire (long-version) (WRASQ(L)) is a 14-item tool designed to increase the recognition of work-related asthma (WRA) in primary care. The purpose of this study was to assess whether the WRASQ(L) provided additional information about a patient's likelihood of WRA, beyond what was collected in standard care, and to assess the use of the WRASQ(L) in the primary care setting. METHODS: This was an intervention study involving two Ontario primary care sites. Standard care for asthma patients in these sites involved completing the Asthma Care Map (ACM), a template for asthma management that includes seven WRA screening items. Participation in this study involved completing an electronic WRASQ(L) at each visit for participants and prompted care providers to record details related to WRA investigations. Ethics approval was obtained from an Institutional Review Board. RESULTS: The study sample (N = 37) was predominantly female (73.0%), with a mean age of 46.3 years (SD, 10.9). The use of WRASQ(L) identified additional work-related symptoms in 38% and exposures in 60% of participants over and above those identified by the ACM. Two participants were newly suspected of WRA during the study period. CONCLUSIONS: The WRASQ(L) provided added information about possible WRA over standard care. The use of the questionnaire's results by care providers was limited due to barriers encountered in incorporating the use of electronic version of the WRASQ(L) into clinical practice. Once validated and implemented in practice, the WRASQ(L) has the potential to increase the recognition of WRA.

The development and test re-test reliability of a work-related asthma screening questionnaire.

OBJECTIVE: Work-related asthma (WRA) is under-recognized and delays in recognition contribute to long-term morbidity. The objective of the project was to develop a WRA screening questionnaire for use by primary care providers in the assessment of individuals with asthma, and to evaluate the respondent burden, test re-test reliability and face validity of the questionnaire. METHODS: A literature search was undertaken and an expert advisory committee was convened. A questionnaire was drafted and assessed for feasibility of use and content validity. The study enrolled patients with asthma attending outpatient clinics and an asthma education center. Participants were asked to respond to the questionnaire on two occasions, and comment on the content (face validity) and ease of completion (respondent burden). Ethics approval was obtained from an institutional review board. RESULTS: A 14-item self-administered screening questionnaire was created. Thirty-nine participants were recruited, and 26 participants completed a second administration of the questionnaire. The items on the relation of asthma symptoms to work demonstrated substantial agreement between testings. The workplace exposures items were found to have good reproducibility. The majority of participants denied that items were repetitive, not useful or difficult to understand. CONCLUSIONS: We have developed a WRA screening questionnaire designed to aid primary care providers in the recognition of possible WRA. The tool exhibited content and face validity, good test re-test reliability and low respondent burden. Participant feedback is being considered in revisions of the questionnaire.

Development and implementation of an electronic asthma record for primary care: integrating guidelines into practice.

RATIONALE: Evidence-based practice may be enhanced by integrating knowledge translation tools into electronic medical records (EMRs). We examined the feasibility of incorporating an evidence-based asthma care map (ACM) into Primary Care (PC) EMRs, and reporting on performance indicators. METHODS: Clinicians and information technology experts selected 69 clinical and administrative variables from the ACM template. Four Ontario PC sites using EMRs were recruited to the study. Certified Asthma Educators used the electronic ACM for patient assessment and management. De-identified data from consecutive asthma patients were automatically transmitted to a secure central server for analysis. RESULTS: Of the four sites recruited, two sites using "stand-alone" EMR systems were able to incorporate the selected ACM variables into an electronic format and participate in the pilot. Data were received on 161 visits by 130 patients aged 36.5 ± 26.9 (mean ± SD) (range 2-93) years. Ninety-four percent (65/69) of the selected ACM variables could be analyzed. Reporting capabilities included: individual patient, individual site and aggregate reports. Reports illustrated the ability to measure performance (e.g. number of patients in control, proportion of asthma diagnoses confirmed by an objective measure of lung function), benchmark and use EMR data for disease surveillance (e.g. number of smokers and the individuals with suspected work-related asthma). CONCLUSIONS: Integration of this evidence-based ACM into different EMRs was successful and permitted patient outcomes monitoring. Standardized data definitions and terminology are essential in order for EMR data to be used for performance measurement, benchmarking and disease surveillance.

Comparison of asthma control criteria: importance of spirometry.

AIMS: To compare the measurements of asthma control using Canadian Thoracic Society (CTS) Asthma Management Consensus Summary and Global Initiative for Asthma (GINA) guidelines composite indices with and without spirometry. METHODS: Asthma control parameters were extracted from electronic medical records (EMRs) of patients ≥6 years old at two primary care sites. Asthma control ratings calculated according to CTS and GINA criteria were compared. RESULTS: Data were available from 113 visits by 93 patients, aged 6-85 years (38.7 ± 24.8; mean ± SD). The proportion of visits at which individuals' asthma was completely controlled was 22.1% for CTS symptoms only and 9.7% for CTS with spirometry (p < .01); and 17.7% versus 14.1% for GINA symptoms only versus symptoms with spirometry (p = .125). CONCLUSIONS: Asthma control ratings using GINA and CTS criteria are discordant in more than half of the patients deemed "in control" by at least one scale. Differences in the spirometry criterion threshold are primarily responsible for this discordance. Failure to include spirometry as part of the control index consistently overestimates asthma control and may underestimate future risk of exacerbations.

A cross-national profile of bullying and victimization among adolescents in 40 countries.

OBJECTIVES: (1) To compare the prevalence of bullying and victimization among boys and girls and by age in 40 countries. (2) In 6 countries, to compare rates of direct physical, direct verbal, and indirect bullying by gender, age, and country. METHODS: Cross-sectional self-report surveys including items on bullying and being bullied were obtained from nationally representative samples of 11, 13 and 15 year old school children in 40 countries, N = 202,056. Six countries (N = 29,127 students) included questions about specific types of bullying (e. g., direct physical, direct verbal, indirect). RESULTS: Exposure to bullying varied across countries, with estimates ranging from 8.6% to 45.2% among boys, and from 4.8% to 35.8% among girls. Adolescents in Baltic countries reported higher rates of bullying and victimization, whereas northern European countries reported the lowest prevalence. Boys reported higher rates of bullying in all countries. Rates of victimization were higher for girls in 29 of 40 countries. Rates of victimization decreased by age in 30 of 40 (boys) and 25 of 39 (girls) countries. CONCLUSION: There are lessons to be learned from the current research conducted in countries where the prevalence is low that could be adapted for use in countries with higher prevalence.

Social environments and physical aggression among 21,107 students in the United States and Canada.

BACKGROUND: Physical aggression is an important issue in North American populations. The importance of students' social environments in the occurrence of physical aggression requires focused study. In this study, reports of physical aggression were examined in relation to social environment factors among national samples of students from Canada and the United States. METHODS: Students in grades 6-10 from the United States (n = 14,049) and Canada (n = 7058) who had participated in the Health Behaviour in School-aged Children Survey (HBSC) were studied. Rates of students' physical aggression were compared between the 2 countries. School, family, socioeconomic, and peer-related factors were considered as potential risk factors. A simple social environment risk score was developed using the US data and was subsequently tested in the Canadian sample. RESULTS: Risks for physical aggression were consistently higher among United States versus Canadian students, but the magnitude of these differences was modest. The relative odds of physical aggression increased with reported environmental risk. To illustrate, US boys in grades 6-8 reporting the highest social environment risk score (5+) experienced a relative odds of physical aggression 4.02 (95% CI 2.7-5.9) times higher than those reporting the lowest score (adjusted OR for risk scores 0 through 5+ was 1.00, 1.19, 2.10, 2.01, 3.71, and 4.02, respectively, p(trend) < .001). CONCLUSIONS: Unexpectedly, rates of physical aggression and associations between social environments and students' aggression were remarkably similar in Canada and the United States. Family, peer, and school social environments serve as risk or protective factors, with significant cumulative impact on physical aggression in both countries. Given the observed high rates and the many negative effects of aggression on long-term health, school policies aimed at the reduction of such behavior remain a clear priority.

Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction.

OBJECTIVE: Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI. METHODS: Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann-Whitney U test and presented graphically with Kaplan-Meier curves. RESULTS: Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67-108) preprotocol to 62 minutes (IQR 40-80) postprotocol (p < 0.001). CONCLUSION: In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

Hospitalized head injuries in agricultural settings: who are the vulnerable groups?

OBJECTIVES: The goal of this study was to identify subgroups of the farm population that are particularly vulnerable to head injury. METHODS: A retrospective case series of hospitalized head injuries was assembled from a national registry of agricultural injuries. Vulnerable subgroups were identified based on a priori criteria and the causes and consequences of their injuries were profiled. RESULTS: Three distinct subgroups of farm people were identified as being vulnerable: (1) farm children under the age of 10, injured most frequently by a fall from a structural height (42.5%); (2) females 10-19 years, injured most frequently by large animals (68.8%), mainly horses, and (3) men over age 60 years, who were injured by a diversity of mechanized and animal-related external causes. CONCLUSION: This identification of vulnerable groups provides foundational information from which to develop and direct prevention efforts.

Application of novel communication technologies to the study of farm families: a randomized controlled trial.

OBJECTIVE: The objective of this pilot study was to evaluate the efficacy of three different communication technologies for collection of health outcomes from farm households. METHODS: A randomized controlled trial was conducted in central Saskatchewan, Canada in 2006. The 94 farms completing the baseline questionnaire were randomly assigned to follow-up by regular mail (n=30), computer telephony (n=32), or their choice of regular mail, computer telephony, or e-mail follow-up (n=32). The primary endpoints were absolute differences in the proportions of farms using the assigned method to provide follow-up data, 2 months post-recruitment. RESULTS: Of the total study population, 51 (54.3%) provided follow-up information. Farms in the regular mail arm were more likely to submit follow-up data than farms in the other arms (27/30 regular mail vs. 23/32 choice vs. 2/32 computer telephony). The differences in proportions between the computer telephony and other study arms were highly significant (e.g., absolute difference between regular mail and computer telephony 83.7% [95% CI: 70.1%, 97.3%; p<0.001]). CONCLUSION: The optimal method for health outcome data collection from farm households in our study is regular mail. Despite their novelty and attractiveness, caution is warranted when adopting modern communication technologies in population health research.

Rugby injury in Kingston, Canada: a ten-year study.

Rugby is a high-contact sport with an elevated risk for injury. While many studies have examined the epidemiology of rugby injury, there are no surveillance-based injury studies from North America. The objective of this study was to profile the scope and nature of injuries experienced during the sport of rugby. We analyzed emergency department injury surveillance data over a decade (1993-2003) from the Kingston sites of the Canadian Hospital Injury Reporting and Prevention Program. Rugby injuries were examined by mechanism, nature and anatomical site of injury, with stratification according to sex and age. A total of 1,527 injuries was observed (mean of 153 per year). Results show the tackling phase of play accounted for the highest number of injuries (506/1,527; 33.1 percent). The most common natures of injury were sprains and strains (426/1,527; 27.9 percent), while the leading anatomical location of injury was the face (294/1,527; 19.3 percent). Target patterns of injury were identified as priorities for prevention, based on injury frequency and severity.

Pediatric fall injuries in agricultural settings: a new look at a common injury control problem.

OBJECTIVES: Children on farms experience high risks for fall injuries. This study characterized the causes and consequences of fall injuries in this pediatric population. METHODS: A retrospective case series was assembled from registries in Canada and the United States. A new matrix was used to classify each fall according to initiating mechanisms and injuries sustained on impact. RESULTS: Fall injuries accounted for 41% (484/1193) of the case series. Twenty percent of the fall injuries were into the path of a moving hazard (complex falls), and 91% of complex falls were related to farm production. Sixty-one percent of complex falls from heights occurred while children were not working. Fatalities and hospitalized injuries were overrepresented in the complex falls. CONCLUSIONS: Pediatric fall injuries were common. This analysis provides a novel look at this occupational injury control problem.

Influence of multiple risk behaviors on physical activity-related injuries in adolescents.

OBJECTIVE: The study objectives were to (1) examine the relationship between physical activity and physical activity injuries in youth, (2) determine whether this relationship is modified by the engagement in multiple risk behaviors, and (3) determine whether this relationship is modified by the setting of the injury (school versus outside of school). METHODS: We examined associations between physical activity and multiple risk behaviors with physical activity injuries occurring at and outside of school. The study population consisted of a representative sample of 5559 Canadian youth in grades 6 through 10 who participated in the 2001/2002 Health Behavior in School-Aged Children Survey. The exposure and outcome measures were determined from a classroom-based survey. RESULTS: Irrespective of grade, there were strong gradient relations between physical activity participation and related injuries outside of school. Conversely, there were modest relations between physical activity participation and related injuries at school. In students in grades 6 to 8, there was no relation between multiple risk behaviors and physical activity injuries at school and a curvilinear relation between multiple risk behaviors and physical activity injuries outside of school. The opposite pattern of relationships between multiple risk behaviors and injuries was observed in students in grades 9 to 10. Irrespective of grade and setting of injury, there was no significant interaction between physical activity and multiple risk behaviors on injury risk. The results were consistent by severity of injury and for structured/organized and unstructured/informal forms of physical activity. CONCLUSIONS: The environment moderated the relation between physical activity and related injuries in that strong risk gradients only existed outside of the school setting. Unexpectedly, there were no consistent gradients between the engagement in multiple risk behaviors and physical activity injuries or any interaction effect between physical activity exposure and multiple risk behaviors. These findings suggest that optimizing the environment would be a preferred strategy for preventing physical activity injuries compared with selectively targeting youth who engage in multiple risk behaviors.

Stages of development and injury patterns in the early years: a population-based analysis.

BACKGROUND: In Canada, there are many formal public health programs under development that aim to prevent injuries in the early years (e.g. 0-6). There are paradoxically no population-based studies that have examined patterns of injury by developmental stage among these young children. This represents a gap in the Canadian biomedical literature. The current population-based analysis explores external causes and consequences of injuries experienced by young children who present to the emergency department for assessment and treatment. This provides objective evidence about prevention priorities to be considered in anticipatory counseling and public health planning. METHODS: Four complete years of data (1999-2002; n = 5876 cases) were reviewed from the Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), an ongoing injury surveillance initiative. Epidemiological analyses were used to characterize injury patterns within and across age groups (0-6 years) that corresponded to normative developmental stages. RESULTS: The average annual rate of emergency department-attended childhood injury was 107 per 1000 (95% CI 91-123), with boys experiencing higher annual rates of injury than girls (122 vs. 91 per 1000; p < 0.05). External causes of injury changed substantially by developmental stage. This lead to the identification of four prevention priorities surrounding 1) the optimization of supervision; 2) limiting access to hazards; 3) protection from heights; and 4) anticipation of risks. CONCLUSION: This population-based injury surveillance analysis provides a strong evidence-base to inform and enhance anticipatory counseling and other public health efforts aimed at the prevention of childhood injury during the early years.

Cross-national study of fighting and weapon carrying as determinants of adolescent injury.

OBJECTIVES: We sought to (1) compare estimates of the prevalence of fighting and weapon carrying among adolescent boys and girls in North American and European countries and (2) assess in adolescents from a subgroup of these countries comparative rates of weapon carrying and characteristics of fighting and injury outcomes, with a determination of the association between these indicators of violence and the occurrence of medically treated injury. DESIGN AND SETTING: Cross-sectional self-report surveys using 120 questions were obtained from nationally representative samples of 161082 students in 35 countries. In addition, optional factors were assessed within individual countries: characteristics of fighting (9 countries); characteristics of weapon carrying (7 countries); and medically treated injury (8 countries). PARTICIPANTS: Participants included all consenting students in sampled classrooms (average age: 11-15 years). MEASURES: The primary measures assessed included involvement in physical fights and the types of people involved; frequency and types of weapon carrying; and frequency and types of medically treated injury. RESULTS: Involvement in fighting varied across countries, ranging from 37% to 69% of the boys and 13% to 32% of the girls. Adolescents most often reported fighting with friends or relatives. Among adolescents reporting fights, fighting with total strangers varied from 16% to 53% of the boys and 5% to 16% of the girls. Involvement in weapon carrying ranged from 10% to 21% of the boys and 2% to 5% of the girls. Among youth reporting weapon carrying, those carrying handguns or other firearms ranged from 7% to 22% of the boys and 3% to 11% of the girls. In nearly all reporting countries, both physical fighting and weapon carrying were significantly associated with elevated risks for medically treated, multiple, and hospitalized injury events. CONCLUSIONS: Fighting and weapon carrying are 2 common indicators of physical violence that are experienced by young people. Associations of fighting and weapon carrying with injury-related health outcomes are remarkably similar across countries. Violence is an important issue affecting the health of adolescents internationally.

A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions.

STUDY DESIGN: Concealed allocation, multicenter, single-blind, randomized controlled clinical trial. OBJECTIVE: To assess the efficacy of an educational video in the tertiary prevention of persistent WAD symptoms following rear-end motor vehicle collisions (MVCs). SUMMARY OF BACKGROUND DATA: Whiplash-associated disorders (WAD) are an important and costly health problem. There is a lack of high quality evidence surrounding efficacy of treatments for WAD. Existing research supports active interventions and early return to regular activities. METHODS: Consecutive patients presenting to four tertiary care emergency departments following rear-end MVCs were eligible. Following informed consent, patients were allocated, using central randomization, to receive an educational video plus usual care or usual care alone. The video provided reassurance, and advice about posture, return to regular activities, exercises, and pain-relief methods. Data were collected by telephone using standardized questionnaires. The primary outcome was presence of Persistent WAD Symptoms at 24 weeks postinjury, based on the frequency and severity of neck, shoulder, or upper back pain. The absolute difference in proportion of patients with persistent WAD symptoms and rate ratios were calculated. Changes in pain scores were compared using the Mann-Whitney U test. RESULTS: The intervention (n = 206) and control (n = 199) groups were similar at baseline (mean age 38.4 years; 64% female). Overall, the proportion of subjects with Persistent WAD Symptoms decreased from 89.1% at baseline to 33.6% at 24 weeks after injury. At 24 weeks, the proportion of subjects with persistent WAD symptoms in the intervention group was 7.9% (95% CI, -2.0, 17.8) lower than the control group. The median improvement in pain score at 24 weeks was 3 for the intervention group and 2 for the control group (P = 0.016). CONCLUSION: The presence of persistent WAD symptoms following simple rear-end MVCs was high in this sample. The video group demonstrated a trend toward less severe WAD symptoms. We recommend evaluating other educational interventions that could reduce WAD symptoms.