William Parkinson

Prediction of falls using a risk assessment tool in the acute care setting

BackgroundThe British STRATIFY tool was previously developed to predict falls in hospital. Although the tool has several strengths, certain limitations exist which may not allow generalizability to a Canadian setting. Thus, we tested the STRATIFY tool with some modification and re-weighting of items in Canadian hospitals.MethodsThis was a prospective validation cohort study in four acute care medical units of two teaching hospitals in Hamilton, Ontario. In total, 620 patients over the age of 65 years admitted during a 6-month period. Five patient characteristics found to be risk factors for falls in the British STRATIFY study were tested for predictive validity. The characteristics included history of falls, mental impairment, visual impairment, toileting, and dependency in transfers and mobility. Multivariate logistic regression was used to obtain optimal weights for the construction of a risk score. A receiver-operating characteristic curve was generated to show sensitivities and specificities for predicting falls based on different threshold scores for considering patients at high risk.ResultsInter-rater reliability for the weighted risk score indicated very good agreement (inter-class correlation coefficient = 0.78). History of falls, mental impairment, toileting difficulties, and dependency in transfer / mobility significantly predicted fallers. In the multivariate model, mental status was a significant predictor (P < 0.001) while history of falls and transfer / mobility difficulties approached significance (P = 0.089 and P = 0.077 respectively). The logistic regression model led to weights for a risk score on a 30-point scale. A risk score of 9 or more gave a sensitivity of 91% and specificity of 60% for predicting who would fall.ConclusionGood predictive validity for identifying fallers was achieved in a Canadian setting using a simple-to-obtain risk score that can easily be incorporated into practice.

Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries

Primary objective: To examine the potential efficacy of a mindfulness-based stress reduction approach to improve quality of life in individuals who have suffered traumatic brain injuries. Research design: Pre-post design with drop-outs as controls. Methods and procedures: We recruited individuals with mild to moderate brain injuries, at least 1 year post-injury. We measured their quality of life, psychological status, and function. Results of 10 participants who completed the programme were compared to three drop-outs with complete data. Experimental intervention: The intervention was delivered in 12-weekly group sessions. The intervention relied on insight meditation, breathing exercises, guided visualization, and group discussion. We aimed to encourage a new way of thinking about disability and life to bring a sense of acceptance, allowing participants to move beyond limiting beliefs. Main outcomes and results: The treatment group mean quality of life (SF-36) improved by 15.40 (SD = 9.08) compared to − 1.67 (SD = 16.65; p = 0.036) for controls. Improvements on the cognitive-affective domain of the Beck Depression Inventory II (BDI-II) were reported (p = 0.029), while changes in the overall BDI-II (p = 0.059) and the Positive Symptom Distress Inventory of the SCL-90R (p = 0.054) approached statistical significance. Conclusions: The intervention was simple, and improved quality of life after other treatment avenues for these participants were exhausted.

Mortality, Independence in Living, and Re-fracture, One Year Following Hip Fracture in Canadians

Abstract Purposes: 1.To determine the one year mortality, institutionalization, and re-fracture rates following hip fractures in Canadians. 2.To compare post-fracture outcomes between those who fracture while living in institutions versus living in the community. 3.To compare Canadian data with that of other countries. Methods: an observational study involved a cohort of 527 men and women aged 50 and older with hip fractures identified by ICD-9 codes. Subjects were contacted 12 months following acute care discharge between April 1, 1995 and March 21, 1996, from four hospitals in Hamilton Ontario. Data on mortality, place of residence, and re-fractures were obtained by telephone contact and searches of re-hospitalization records. Results: data were obtained on 504 of the 527 Patients. Overall, 25.2% of patients died within one year. Among 399 Patients coming from the community, 20.5% died, 5.2% sustained another hip fracture and 19.0% (24.3% of survivors) were institutionalized. Among the 105 patients from institutions, only one returned to the community, 39.0% died, and 5.7% refractured a hip. Of those returning to the community, 62.4% had used home care services for a mean of 154 days (95% CI=129,179). Osteoporosis was noted in the hospital records for only nine of 141 Patients (1.7%). None had bisphosphonates or hormone replacement recorded and only 25 (17.7%) had vitamin D or calcium recorded as discharge medications. Interpretation: rates of mortality and loss of independence in living were similar to those found in other studies whereas hip re-fracture rates were higher (p

Lengthy hospitalization associated with vertebral fractures despite control for comorbid conditions.

Abstract: This study established whether length of hospital stay (LOS) in Canadians 50 years and older is attributable to their vertebral fractures versus comorbid conditions. The study used a case–control design and data in the Canadian Institute for Health Information (CIHI) database on hospital discharges in Ontario, Alberta, and British Columbia between April 1, 1996 and March 31, 1997. Patients with vertebral fractures were identified by International Classification of Diseases (ICD-9) codes. LOS constituted the dependent measure in a multivariate linear regression that calculated the independent contributions to LOS by vertebral fractures while controlling for: age, gender, province, discharged deceased, hip fractures, all other fractures, motor vehicle accidents, all other injuries, and the major disorder classifications in ICD-9. Mean LOS for all patients admitted for vertebral fractures was 10.1 days. LOS attributed solely to vertebral fractures was 4.8 days based on a 50-year-old woman with no comorbid conditions, and 6.1 days based on a 75-year-old woman. Of 18 health conditions, vertebral fractures were among the top 3 in accounting for LOS, along with hip fractures and mental disorders which accounted for 5.9 days and 6.1 days in a 50-year-old woman. Among patients admitted for other problems, comorbid vertebral fractures added 2.1 days. These findings indicate that hospital stays for vertebral fractures are lengthy despite control for comorbidity.

Validity of serum creatine kinase as a measure of muscle injury produced by lumbar surgery.

Background and Purpose Serum creatine kinase (CK) concentrations have historically been used to investigate muscle disease and serious muscle damage, and there is a growing interest in the potential for a biochemical approach to quantifying skeletal muscle injury occurring in orthopedic surgeries and spinal injuries. The wide availability of CK measurement could foster spinal muscle injury research. However, measurement validity has never been systematically demonstrated in clinical settings. In this study, the validity of serum CK concentration elevation as an index of muscle injury was investigated using lumbar decompression surgery (LDS) as a model. Subjects and Methods Blood samples were obtained from 18 research volunteers drawn from the clinical population undergoing LDS. A baseline sample was taken in the preoperative waiting area. Each subjects highest CK concentration between 12 and 48 hours after surgery was used as the biochemical injury response. The surface area of muscle isolated (incision length×depth) and strained by retraction was obtained for concurrent validity testing against biochemical measurement. Results The correlation between highest total CK concentration and muscle surface area was moderate (r=0.60) and significant (P<0.01). Correlations between surface area and CK at specific time points, revealed minimal loss of association at 12 hours (r=0.57) and 24 hours (r=0.58), but weaker correlations at 6 hours (r=0.45) and 48 hours (r=0.28) after injury. Analyses for proportions of each isoenzyme making up the total CK revealed that baseline and peak CK consisted almost exclusively of skeletal muscle CK (CK-MM), with minimal representation by heart muscle (CK-MB), and brain (CK-BB). Conclusions The findings provide support for the validity of serum CK measurement as an index of skeletal muscle injury caused by LDS, and demonstrate that LDS provides a useful model for measurement testing and development studies.

Long-term efficacy of combined relaxation: biofeedback treatments for chronic headache.

&NA; Thirty‐four patients having chronic idiopathic headaches participated in a long‐term study comparing autogenic relaxation training alone (REL) with combinations of relaxation and electromyographic biofeedback (REL + EMG) or relaxation and temperature biofeedback (REL + TEMP). Assignment to treatment conditions was balanced on demographics and clinical characteristics, as well as headache classification according to muscle contraction or vascular headache symptomatology. The results indicate that REL + TEMP produced no additional improvements over REL following the 8‐week treatment program, or at 6‐month, or 12‐month follow‐up. However, REL + EMG produced significantly greater reductions in headache activity measures than the REL and REL + TEMP conditions at all post‐treatment time points. Headache activity continued to improve over the follow‐up period independent of treatment condition. These data indicate that EMG biofeedback augments long‐term clinical improvements in headache patients who undergo autogenic relaxation training.

A 6-Mo Home-Based Exercise Program May Slow Vertebral Height Loss

Twenty-one of 46 postmenopausal women were assigned to a home-based exercise program consisting of 60 min of exercise, 3 d/wk. The 25 nonexercisers continued usual daily activities. Each woman had at least one prevalent vertebral fracture and suffered from osteoporosis as defined by the application of WHO criteria to lumbar spine bone mineral density. Vertebral heights were measured using bone densitometry at baseline and 12 mo later. Vertebrae T9 to L4 were all identified for each of the 46 subjects in both the baseline and end-of-study lateral scans. The change in mean vertebral height over the course of the study was -0.3 mm anteriorly, -0.7 mm at the mid-location, and -0.4 mm posteriorly for the nonexercisers. For the exercisers, the corresponding changes were +0.1 mm anteriorly, -0.3 mm at the mid-location, and +0.2 mm posteriorly. The benefit of exercise in preserving vertebral morphometry in patients with osteoporosis deserves further investigation.

Injury Measurement Properties of Serum Interleukin-6 Following Lumbar Decompression Surgery

BACKGROUND Circulating interleukin-6 (IL-6) is frequently used to study surgical injury and inflammation. Measurement properties of serum IL-6 were examined following lumbar decompression surgery (LDS), including time course, sensitivity, and validity for detecting muscle trauma in comparison to the muscle cytoplasmic protein creatine kinase (CK). MATERIALS AND METHODS Seven women and seven men had serial blood samples taken in the preoperative waiting areas, immediately after surgery, at 6, 12, 24, 48 h, 4 d, and at 6 to 7 d. Lumbar surgeries were single level, decompression, with laminotomy. RESULTS Time to peak serum IL-6 varied across individuals (range 6 to 48 h). However, the higher of two samples drawn within the sensitive time window (6 to 24 h) had a strong correlation with peak IL-6 (r = 0.99, P < 0.001). There was a moderate correlation between the rise in serum IL-6 and rise in serum CK, r = 0.56, P < 0.05. T-tests revealed that group mean IL-6 was significantly elevated at only one serial time point (6 h), whereas group mean CK was significantly elevated at three serial time points (6, 12, 24 h) and approached significant elevation as late as 48 h (P = 0.07). Women had lower CK concentrations at 6 and 24 h but gender differences on IL-6 were not statistically significant. CONCLUSIONS The serum IL-6 response to LDS injury can be captured in a practical manner, despite individual variability in time course. Inclusion of CK measurement may improve sensitivity to the muscle trauma component of an overall injury.

Magnitude and variability of effect sizes for the associations between chronic pain and cognitive test performances: a meta-analysis

Objectives and Methods: A systematic review and meta-analysis were performed to estimate the size and variability of the association between chronic pain (CP) and poorer cognitive test performances as a function of individual tests, pain sub-types, and study sources on 22 studies having (1) a control group, (2) reported means and standard deviations (SDs) and (3) tests studied at least 3 times. Results: CP patients performed significantly poorer with small to moderate effects (d = −.31 to −.57) on Digit Span Backward; STROOP Word; Color and Color-Word; Digit Symbol; Trail Making A and B; Rey Auditory Learning Immediate and Delayed Recall and Recognition. For these 10 measures, single effects (no interaction) were supported (I2 = 0%–8%) and Random and Fixed models yielded similar results. No group differences were found for Corsi Blocks Forward or Wisconsin Cart Sorting Test Categories Achieved, or Perseveration. Effects for the Rey Complex Figure Immediate and Delayed Recall were significant, but effect size was inconclusive, given moderate to high heterogeneity and lack of consistency between Random and Fixed models. For the Paced Auditory Serial Addition Test, there was a homogeneous (I2 = 0%) and significantly lower performance in fibromyalgia (d = −.47), but no effect in diagnostically undifferentiated pain samples, and wide variability across studies of whiplash (d = −.15 to −1.04, I2 = 60%). Conclusion: The magnitude and consistency of the CP – cognition effect depended on the test, pain subgroup and study source. Summary points Among tests showing a chronic pain (CP) – cognition effect, the magnitude of this association was consistently small to moderate across tests. Effect size estimation was inconclusive for Digit Span Forwards, the Paced Auditory Serial Addition Test and the Rey Complex Figure Test. Variance was too heterogeneous for testing cognitive domain specificity of the CP – cognition effect.

Ventromedial hypothalamic lesions eliminate gastric acid secretion elicited by anticipated eating

Electrolytic lesions of the ventromedial hypothalamus (VMH) produce an obesity syndrome characterized, in part, by excessive food intake and adiposity. Several hypotheses suggest that VMH lesion-induced hyperphagia results from elevated parasympathetic tone on the viscera expressed via the vagus nerves. To evaluate this possibility, vagally-mediated gastric acid secretion was measured in control and VMH-lesion rats. Initially, Pavlovian conditioning was used to elicit acid secretion to anticipated eating. VMH lesions eliminated the ability to mobilize acid secretion to the expectation of eating even though other behavioural indices of conditioning indicated that VMH rats still expected the food. The generality of the acid secretory deficit in VMH rats was evaluated by activating vagally-mediated acid secretion pharmacologically with insulin or 2-deoxy-D-glucose (2DG). VMH rats significantly increased acid secretion to insulin, although the response was attenuated compared to controls. Acid secretion stimulated by 2DG was normal. Thus the effects of VMH lesions on vagally-mediated acid secretion depend on the way in which the response is activated. The implications of this finding are discussed.