Astrid B. Schreuder

Relation between short-term fine-particulate matter exposure and onset of myocardial infarction.

Background: Epidemiologic studies have reported increases in the incidence of cardiovascular morbidity and myocardial infarction (MI) associated with increases in short-term and daily levels of fine-particulate matter air pollution, suggesting a role for particulate matter in triggering an MI. Methods: We studied the association between onset time of MI and preceding hourly measures of fine-particulate matter using a case-crossover study of 5793 confirmed cases of acute MI. We linked data from a community-wide database on acute MI from 1988–1994 in King County, Washington, with central site air pollution monitoring data on fine-particulate matter determined by nephelometry. We compared air pollution exposure levels averaged 1 hour, 2 hours, 4 hours, and 24 hours before MI onset to a set of time-stratified referent exposures from the same day of the week in the month of the case event. Results: The estimated relative risk for a 10-μg/m3 increase in fine-particulate matter the hour before MI onset was 1.01 (95% CI = 0.98–1.05). Analyses of pollutant levels at the other time points demonstrated a similar lack of association. No increased risk was found in all cases with preexisting cardiac disease (odds ratio = 1.05; 0.95–1.16). Stratification by known cardiovascular risk factors (hypertension, diabetes, and smoking status) also did not modify the relation between fine-particulate matter and MI onset. Conclusion: Although a very small effect cannot be excluded, there was no consistent association between ambient levels of fine-particulate matter and risk of MI onset.

Association between short term exposure to fine particulate matter and heart rate variability in older subjects with and without heart disease

Background: Short term increases in exposure to particulate matter (PM) air pollution are associated with increased cardiovascular morbidity and mortality. The mechanism behind this effect is unclear, although changes in autonomic control have been observed. It was hypothesised that increases in fine PM measured at the subjects’ home in the preceding hour would be associated with decreased high frequency heart rate variability (HF-HRV) in individuals with pre-existing cardiac disease. Methods: Two hundred and eighty five daily 20 minute measures of HRV (including a paced breathing protocol) were made in the homes of 34 elderly individuals with (n = 21) and without (n = 13) cardiovascular disease (CVD) over a 10 day period in Seattle between February 2000 and March 2002. Fine PM was continuously measured by nephelometry at the individuals’ homes. Results: The median age of the study population was 77 years (range 57–87) and 44% were male. Models that adjusted for health status, relative humidity, temperature, mean heart rate, and medication use did not find a significant association between a 10 μg/m3 increase in 1 hour mean outdoor PM2.5 before the HRV measurement and a change in HF-HRV power in individuals with CVD (3% increase in median HF-HRV (95% CI −19 to 32)) or without CVD (5% decrease in median HF-HRV (95% CI −34 to 36)). Similarly, no association was evident using 4 hour and 24 hour mean outdoor PM2.5 exposures before the HRV measurement. Conclusion: No association was found between increased residence levels of fine PM and frequency domain measures of HRV in elderly individuals.

Ambient Woodsmoke and Associated Respiratory Emergency Department Visits in Spokane, Washington

Abstract Three multivariate receptor algorithms were applied to seven years of chemical speciation data to apportion fine particulate matter to various sources in Spokane, Washington. Source marker compounds were used to assess the associations between atmospheric concentration of these compounds and daily cardiac hospital admissions and/or respiratory emergency department visits. Total carbon and arsenic had high correlations with two different vegetative burning sources and were selected as vegetative burning markers, while zinc and silicon were selected as markers for the motor vehicle and airborne soil sources, respectively. The rate of respiratory emergency department visits increased 2% for a 3.0 μg/m3 interquartile range change in a vegetative burning source marker (1.023,95% CI 1.009–1.038) at a lag of one day. The other source markers studied were not associated with the health outcomes investigated. Results suggest vegetative burning is associated with acute respiratory events.

Translating a Multifactorial Fall Prevention Intervention into Practice: A Controlled Evaluation of a Fall Prevention Clinic

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital‐based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinics first 6 months of operation were compared with outcomes for 86 age‐, sex‐, and race‐matched controls; all persons included in analyses received primary care at the hospitals geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall‐related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow‐up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall‐related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow‐up; differences in fall‐related healthcare use according to study group from baseline to follow‐up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real‐world clinical practice settings on key outcomes, including injurious falls, downstream fall‐related healthcare use, and costs.

Adherence to Guideline-Directed Venous Thromboembolism Prophylaxis Among Medical and Surgical Inpatients at 33 Academic Medical Centers in the United States

This study’s purpose was to describe compliance with established venous thromboembolism (VTE) prophylaxis guidelines in medical and surgical inpatients at US academic medical centers (AMCs). Data were collected for a 2007 University HealthSystem Consortium Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Benchmarking Project that explored VTE in AMCs. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. A total of 33 AMCs from 30 states participated. In all, 48% of patients received guideline-directed prophylaxis—59% were medical and 41% were surgical patients. VTE history was more common among medical patients with guideline-directed prophylaxis. Surgical patients admitted from the emergency department and with higher illness severity were more likely to receive appropriate prophylaxis. Despite guidelines, VTE prophylaxis remains underutilized in these US AMCs, particularly among surgical patients. Because AMCs provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

Improving insulin ordering safely: the development of an inpatient glycemic control program.

This report describes a Glycemic Control Program instituted at an academic regional level-one trauma center. Key interventions included: 1) development of a subcutaneous insulin physician order set, 2) use of a real-time data report to identify patients with out-of-range glucoses, and 3) implementation of a clinical intervention team. Over four years 18,087 patients admitted to non-critical care wards met our criteria as dysglycemic patients. In this population, glycemic control interventions were associated with increased basal and decreased sliding scale insulin ordering. No decrease was observed in the percent of patients experiencing hperglycemia. Hypoglycemia did decline after the interventions (4.3% to 3.6%; p = 0.003). Distinguishing characteristics of this Glycemic Control Program include the use of real-time data to identify patients with out-of-range glucoses and the employment of a single clinician to cover all non-critical care floors.

Using an Electronic Medical Record Tool to Improve Pneumococcal Screening and Vaccination Rates for Older Patients Admitted with Community-Acquired Pneumonia

An electronic medical record tool was developed that determines if a patient meets criteria for screening for the vaccine; it then poses a series of screening questions. Use of the tool has improved performance on pneumococcal vaccination from 44% to more than 90%, with an increase in vaccine units of 305%.

Translating a Multifactorial Fall Prevention Intervention into Practice: A Controlled Evaluation of a Fall Prevention Clinic: FALL PREVENTION CLINIC EVALUATION

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital‐based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinics first 6 months of operation were compared with outcomes for 86 age‐, sex‐, and race‐matched controls; all persons included in analyses received primary care at the hospitals geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall‐related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow‐up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall‐related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow‐up; differences in fall‐related healthcare use according to study group from baseline to follow‐up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real‐world clinical practice settings on key outcomes, including injurious falls, downstream fall‐related healthcare use, and costs.

Translating a multifactorial fall prevention intervention into practice

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital‐based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinics first 6 months of operation were compared with outcomes for 86 age‐, sex‐, and race‐matched controls; all persons included in analyses received primary care at the hospitals geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall‐related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow‐up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall‐related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow‐up; differences in fall‐related healthcare use according to study group from baseline to follow‐up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real‐world clinical practice settings on key outcomes, including injurious falls, downstream fall‐related healthcare use, and costs.